collaborative leadership literature review

Effects of collaborative leadership on organizational performance

• January 2019
• 6(1):138-144

• American international University kuwait

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Collaborative Leadership in an Organizational Context: A Research Agenda

2022, Journal of Human Resource & Leadership

Organizations not only exist to make a profit and be financially sustainable but also to make a difference and have a meaningful legacy using specific business models adopted. To achieve that outcome organizations must establish effective authority relationships to work together efficiently. This is what entails collaborative relationships and leadership. The literature on collaborative leadership despite having significant developments over the last two decades has been faulted. There have been vast perspectives from scholars with minimal consensus on what constitutes acceptable dimensions of collaborative leadership and how that fits in an organizational context. These misalignments have resulted in challenges to the full realization of the benefits of collaborative leadership as a result of its skewed implementation and application in an organizational context. The result is a lack of appreciation and belief by business practitioners and organization leaders on the implications of collaborative leadership application on their organization’s financial sustainability. This effect goes deeper in that organization leaders are not very clear on the impact of their organization's business model and their role in facilitating successful collaborative leadership. This conceptual paper aimed to bridge that gap by reviewing and integrating extant conceptual, theoretical, and empirical literature on collaborative leadership and present a case for the development of a new theoretical model suitable for the expansion of the current understanding of deployment of collaborative leadership in an organizational context. The paper reviewed 397 articles from various journals, which were searched through the google search engine. 132 articles were finally used in the development of this paper sieved by the year of publication from 2001-2021. The findings lead to the development of a proposed and integrated conceptual framework model linking collaborative leadership to financial sustainability as an organizational outcome while acknowledging the significance of the role played by the organization’s business model and top echelon support in the relationship. Several propositions are presented for consideration and validation through empirical work. The study calls on future research to consider the adoption of the proposed model in extending research on leadership to new frontiers.

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Collaborative Leadership and Health: A Review of the Literature

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Publication Date:

Publisher: Turning Point National Program Office at the University of Washington

Author(s): C. Larson; C. Sweeney; A. Christian; L. Olson

Research Area: Health

Type: Report

This literature search on collaborative leadership used six key terms and covered 10 databases (ABI/Inform, Academic Universe/Medical, Communication Abstracts, ERIC, Expanded Academics/Health Reference Center, Medline, Periodical Abstracts, PsychInfo, SocWork Abstracts, and WorldCat). It covered literature from 1985 to the present and returned 37,323 titles. In addition to this systematic search, the review includes sources known to the four-member research team. It covers six areas:(1) Leadership and health outcomes: collaborative forms of leadership are good strategies for affecting public health outcomes.(2) Skills, competencies and capacities: while we may expect too much of individual leaders, collaborative leadership provides a way to share the skills and capacities of many people.(3) Best practices: include competent leadership, communication skills, building relationships, a shared vision, and recognizing crisis as opportunity.(4) Conditions and contingencies: While politics and differences among stakeholders may be impediments to collaborative leadership, shared planning, provision of resources, creating a vision, and trust are characteristics likely to promote such leadership. These characteristics promote empowerment, which is a key to successful leadership.(5) Leadership development strategies and methods: Developing leaders is not a static activity, and multiple strategies are needed. No one approach will work with everyone.(6) Collaborative technologies: Technology is a key part of leadership development and public health leadership, and currently includes videoconferencing, distance learning, the Internet, and multiple software packages.

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Are You a Collaborative Leader?

by Herminia Ibarra and Morten T. Hansen

Summary .   

Reprint: R1107D

Social media and technologies have put connectivity on steroids and made collaboration more integral to business than ever. But without the right leadership, collaboration can go astray. Employees who try to collaborate on everything may wind up stuck in endless meetings, struggling to reach agreement. On the other side of the coin, executives who came of age during the heyday of “command and control” management can have trouble adjusting their style to fit the new realities.

In their research on top-performing CEOs, Insead professors Ibarra and Hansen have examined what it takes to be a collaborative leader. They’ve found that it requires connecting people and ideas outside an organization to those inside it, leveraging diverse talent, modeling collaborative behavior at the top, and showing a strong hand to keep teams from getting mired in debate. In this article, they describe tactics that executives from Akamai, GE, Reckitt Benckiser, and other firms use in those four areas and how they foster high-performance collaborative cultures in their organizations.

Watching his employees use a new social technology, Marc Benioff, the CEO of Salesforce.com, had an epiphany. His company had developed Chatter, a Facebook inspired application for companies that allows users to keep track of their colleagues and customers and share information and ideas. The employees had been trying it out internally, not just within their own work groups but across the entire organization. As Benioff read the Chatter posts, he realized that many of the people who had critical customer knowledge and were adding the most value were not even known to the management team.

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• Cabinet Office
• National Leadership Centre
• Leadership College for Government

A Literature Review on Effective Leadership Qualities for the NLC by Dr Martin King and Professor Rob Wilson

Published 15 December 2020

© Crown copyright 2020

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/nlc-public-service-leadership-literature-reviews/a-literature-review-on-effective-leadership-qualities-for-the-nlc-by-dr-martin-king-and-professor-rob-wilson

Executive summary

The review conducted did not produce evidence for a distinct ‘qualities approach’ drawing on the five identified qualities applied consistently across the literature. This is because the review presented a field of research into leadership that is characterised by fragmentation and conflicting nomenclature. These inconsistencies in the findings prevent us from drawing strong conclusions across the literature. Nevertheless, organising the various strands of debate into clusters that capture shared ways of talking about leadership across different theories in the literature can be helpful. The evidence that the five qualities as defined by the National Leadership Centre (NLC) are the most relevant ones is mixed. We summarise the evidence on this and suggestions on how to potentially adapt the descriptions on the five qualities in Section 2. In Section 3, we turn to a discussion about the challenges of a ‘qualities approach’ to the study of leadership. We describe three main clusters of theories in the literature (explained in more detail in the glossary in Appendix II) that challenge the notion that leadership derives exclusively from properties of the individual. These clusters can provide inspiration for an expansion of the NLC understanding of leadership. We then turn to the issue of the outcomes and goals that leadership is measured against in the literature in Section 4. Finally, in Section 5 we report the questions that emerged from this literature review and suggest ways in which the NLC could explore these, including co-productive and qualitative research methods.

Table of contents

• Our approach to this literature review
• The evidence of the five qualities in the literature
• Critiques of a ‘qualities approach’ to leadership
• Measuring leadership impact
• Conclusions and recommendations for future research Appendix I: Search terms and key results Appendix II: Glossary Appendix III: Bibliography

1. Our approach to this literature review

The NLC identified five qualities of leadership based on a preliminary review of the leadership literature: ‘adaptive’, ‘connected’, ‘purposeful’, ‘questioning’, and ‘ethical’. The purpose of the brief was to undertake a wider review of the literature exploring the evidence base on public leadership and examining the support for the NLC five key qualities approach. The brief sought to address the following key questions:

• To what extent does the evidence base support the NLC’s assertion that there are five qualities exhibited by effective public service leaders?
• How could the NLC’s articulation and definition of the key attributes of effective public service leaders be iterated or improved to better reflect the evidence base?

Based on the questions in the brief, we approached the ‘rapid’ literature review through a general search and then separate ones for each of the five qualities. This review involved six searches of abstracts repeated across five academic databases capturing discussions of leadership across academic fields and disciplines. The results of these searches were analysed through an abstract review. The searches included keywords such as synonyms to capture wider discussion of the qualities, and additional phrases to capture discussion of leadership in the context of public services and under conditions of complexity or uncertainty. The searches returned 9318 results. These results were then filtered further to 575 papers based on the preferences expressed by the NLC, including a broad scope review capturing wider research into leadership qualities; a preferred focus on studies based in the UK and similar regional contexts; discussion of public administration at a senior level in the context of collaboration across sectors and organisations; and a focus on complex or ‘wicked problems’ in the public sector. A full breakdown of the search terms, databases, and results can be found in Appendix I, while the findings of each of the searches can be found in the separate Abstract Search documents.

The search produced results across disciplines (e.g. public administration studies, leadership studies), across theories and methodological approaches (e.g. transformational leadership, distributed leadership), and at different levels of focus (from abstract discussions of the nature of leadership to discussions specific to particular professions). In our review of the abstracts we summarised key themes and findings emerging from the literature, including findings relevant to specific qualities, additional ways of talking about leadership present in the literature, ideals and outcomes, methodological approaches, and theoretical models of leadership. The results of each search presented in the Abstract Search documents include an overall summary, collected themes, referenced papers, and a full list of abstracts. The process revealed a number of trends in the literature, notably a diversity of theoretical perspectives on leadership and a wealth of studies exploring leadership in relation to specific outcomes and goals. The full implications presented by these developments were not apparent through review of the abstracts alone. Therefore, in addition to the abstract review, we conducted deep dives into key papers. We draw out the conclusions from these studies in this paper. In addition, we provide a glossary in Appendix II that defines prominent leadership theories and related concepts featured in the literature.

2. The evidence of the five qualities in the literature

The literature review did not produce evidence for a distinct ‘qualities approach’ drawing on the five identified qualities applied consistently across the literature. The review presented a field of research into leadership that is characterised by fragmentation and conflicting nomenclature. While there was evidence of studies using the same terms outlined in the NLCs discussion of qualities, they were not necessarily writing from a self-consciously ‘qualities approach to leadership’, and there was a lack of unified understanding underpinning the debate. Many studies would talk about the attributes of leadership in terms of style, traits, skills, and competencies. Furthermore, while studies might be interpreted as interested in the quality of connectedness, they might talk about it and understand it in different ways, for example, talking instead of empathy or emotional intelligence. Additionally, studies may import broader theoretical frameworks in describing leadership attributes. Influential frameworks include ‘transformational leadership’, ‘charismatic leadership’, ‘collaborative leadership’, ‘authentic leadership’, ‘servant leadership’, ‘network leadership’, ‘place-based leadership’, and ‘complex leadership theory’, all of which are described in detail in Appendix II. These approaches frame discussion of qualities, meaning that people may use different words for the same concept, or the same word for different concepts, making it hard to assess the evidence available on specific qualities.

It does not necessarily follow from these findings that the five NLC qualities are not a helpful way of understanding leadership. Indeed, the review demonstrates that there is a lack of clarity and coherence in the debate on leadership that might be helpfully navigated by organising the various strands of debate into clusters that capture shared ways of talking about what is valued in leadership that cut across different theories and frameworks in the literature. There is mixed evidence that the five qualities might provide such a useful framework. In the case of ethical and adaptive leadership, there is direct evidence for discussion of these qualities, although there is variation in how they are understood. In the case of connected and purposeful, there is more indirect evidence for discussion of these qualities, and perhaps a need to adapt the articulation of these qualities to better reflect the direction of the literature. Discussion of the quality of questioning is arguably the weakest, or at least a case where there is a lot of overlap with other qualities. We discuss the findings of each individual quality in the tables below.

NLC definition

Adaptive leaders are able to change proactively and constantly learn in a complex, uncertain and volatile world. Number of abstracts reviewed: 141

Summary of findings

Adaptive leadership and the need to learn in the face of complex challenges featured prominently in the literature. The review revealed a more formalised understanding of ‘adaptive leadership’ presented in Appendix II. It should be noted that the discussions of this quality often encouraged a less individualistic understanding of adaptation, in some cases talking of adaptive organisations, relationships and cultures, and organisational agility.

In order to build on this the NLCs definition, it may be helpful to further explore the more specific understandings of adaptive leadership, as well as the relationship between individual adaptiveness and organizational-level adaptiveness.

Trends in the literature

• Discussion of adaptive leaders was common, including a formalised understanding of ‘adaptive leadership’, adaptive behaviours, and an adaptive leadership framework. Further ways of talking about this quality in the context of leadership included ‘learning’, ‘leaders as learners’, and related concepts included ‘self monitoring’.
• In addition to talking about adaptiveness as a quality of individual leaders, the literature also included discussion of adaptive organisations, relationships, and organisational agility.
• There was also some overlap with other qualities discussed in the brief, suggesting for example that in order to be an adaptive leader one also has to exhibit other qualities, such as attributes related to ethical leadership (e.g. trustworthy, authentic, purposeful, forward looking, visionary).

Ethical leaders consistently behave in ways that create trust, and they take a long-term, sustainable approach to fulfilling the organisation’s public service mission. Number of abstracts reviewed: 123

Ethical leadership featured prominently in the literature revealed the complex and multifaceted nature of the relationship between ethics and leadership. It was frequently discussed in the context of more formalised concepts such as ‘servant leadership’ and ‘authentic leadership’. The literature illustrated how the ethical implications of leadership can vary greatly depending on the professional context in which it is applied, and how leadership presents ethical dilemmas and potential tensions between the professional and ethical norms of leadership and what might be commonly perceived to be good.

Given the multi-faceted nature of ethical leadership, there may be a case for crafting a more specific definition, with thought given to how abstract-level definitions of ethical leadership interact with context-specific understandings of ethics.

• Ethical leadership was by far the most discussed quality of leadership, often in relation to frameworks of ‘servant leadership’ and ‘spiritual leadership’. It should be noted that ethics represents a much broader set of concerns than we might reasonably expect from the other qualities.
• Abstract-level discussions of the good leader can be contrasted with more context-specific discussions of leadership, including ethical frameworks, norms, and dilemmas encountered by specific professions such as nursing.
• Within the literature, there is a lot of focus on ‘building trust’ as outlined in the NLC definition with a focus on supporting others. There was some discussion around ‘sustainable’, ‘long-term’, and ‘public service ethos’, which is similar to public service mission.
• Some concepts that were mentioned in the literature that are not in the NLC definition include ‘integrity’, ‘credible leadership’, ‘authentic leadership’, ‘values’, and ‘self-efficacy’.
• Ethical leadership is also contrasted with administrative evil, mistrust, and narcissism.

Connected leaders are empathic, collaborative thinkers who consistently work across organisational boundaries to build strategic relationships across the public service. Number of abstracts reviewed: 127

Connected was not frequently discussed in the literature, however the elements of this quality described in the NLC definition were heavily discussed in relation to leadership. It was more common to talk of this quality in terms of empathy, while emotional intelligence can be interpreted as a related concept that features prominently in the research.

The results of the review present two general questions. The first is whether the NLC definition of connectedness is too rich as it encompasses both notions of empathy and collaboration. The second question is whether the notion of ‘collaborative thinkers’ captures the way in which the literature is talking about collaborative approaches as it potentially challenges the qualities approach (discussed in more depth in Section 3 of this paper). This is an area that would be helpful to explore further.

• Although connected leaders might be a helpful, more holistic way of talking about this quality of leadership, it was more common for this quality to be discussed in other terms including those listed such as ‘empathetic leadership’, but also through concepts like ‘emotional intelligence’ (although this terms obviously relates to a much more specific and contested concept).
• The description of ‘collaborative leaders’ who build strategic relationships is potentially relevant to a significant portion of the literature that deals with collaborative approaches and relational understandings of leadership (see for example the description of ‘network leadership’ and ‘collaborative leadership’ in Appendix II).

Purposeful leaders display absolute clarity about their mission and purpose, and they are able to see beyond the problems and pressures of the present. Number of abstracts reviewed: 36

Compared to other searches, such as ‘adaptive’ and ‘ethical’, ‘purposeful’ leadership did not return many results. This could be due to the fact that ‘adaptive’ and particularly ‘ethical’ are terms with much wider applications that are likely to be used in research. It may also be that the notion of purposeful leadership is not widely recognised or applied in the literature, even if related concepts feature more frequently.

The NLC could consider linking the idea of purposefulness with the ideas discussed in the literature of ‘boldness’ and ‘motivation’ on top of those of ‘mission’ and ‘clarity’ that are already present in the definition.

• Purposeful leadership is often discussed in terms of boldness, clarity, clear communication, clear goals, and planning. Related terms include ‘being bold’, ‘having vision’, and ‘thinking outside the box’. Studies also consider the relationship between these qualities and narcissism as a personality trait and charismatic leadership as a leadership type.
• One might argue though, that the notion of ‘purposeful leadership’ is implicit in the way people frame talk of ‘transformational leadership’ and ‘public service motivation’ (see Appendix II for more details)

Questioning

Questioning leaders are open minded and seek to understand the views and experiences of others. Number of abstracts reviewed: 42

There was little evidence to support ‘questioning’ as a distinct quality of leadership within the literature. It may be helpful to consider the purpose of distinguishing this quality from the ideas of ‘adaptive’ and ‘connected’ and what might be lost by merging it to these other attributes.

• Compared to other searches, such as ‘adaptive’ and ‘ethical’, ‘questioning’ leadership did not return many results. Those that it produced, emphasised the importance of ‘curiosity’ and the use of questions (rather than the quality per se) as a means of building trust, respect, constructing authority, and developing and building relationships. ‘Vigilance’ also appeared as a related concept.
• The concept description shares similarities to the description of ‘connected’ and ‘adapted’. For example, a person who is open minded and seeks to understand the views and experiences of others might be described as ‘empathetic’ in some contexts or perhaps receptive to change and capable of learning and adapting in other contexts. In this sense it may be that the literature tends to discuss these features in ways more aligned with that language.

3. Critiques of a ‘qualities approach’ to leadership

Stepping beyond the discussion of the evidence of individual qualities, the literature reviewed presented a number of challenges to taking a ‘qualities approach’ to the study of leadership altogether. Recent trends in the literature tend to depart from an understanding of leadership as deriving exclusively from properties of the individual. Based on deeper exploration of the key papers in this area, we explain the evolution of leadership studies towards less individualistic theories and the implications of these developments for a ‘qualities approach’ in the section below.

3.1 The evolution of leadership studies

Over the past fifty years, the understanding of public administration and governance in the literature has become increasingly nuanced and complex (Bussu and Galanti 2018, Horwath and Morrison 2007, Heifetz et al 2009). Many recent studies observe a shift from hierarchical, command and control mechanisms to coproduction and/or collaborative action across sectors, organisations and disciplines (Silvia 2011, Avolio et al 2009). In parallel to this, the study of leadership also evolved and branched out in this direction. Heroic, great-man theories that focused on traits and qualities unique to the leader used to be predominant, while now the literature presents more expansive understandings of leadership and its challenges that attend to the relational, situational, and context-specific elements (Bass and Bass 2008).

The shift to this more nuanced understanding of leadership is also a response to criticism of exclusively leader-centred approaches. Accounts of ‘charismatic’, and later ‘transformational leadership’, which emphasise the capacity of leaders to inspire and motivate followers to excel in their work and enhance performance (see Appendix II for more details), have been criticised for being too individualistic in their understanding of leadership. Stogdill (1948 in Bass and Bass 2008) argues that the qualities, characteristics, and skills required of a leader are determined to a large extent by the demands of the situation. Therefore, analysis of leadership cannot be abstracted from the context in which it occurs.

3.2 Three challenges to the qualities approach

As a result of these criticisms, there have been efforts to move beyond an individualistic account of leadership, resulting in a rich diversity of theories and models. These can broadly be grouped into three clusters of literature.

The first cluster (Bussu and Galanti 2018, Horwath and Morrison 2007, Tong et al 2018) responds to the increasingly horizontal and collaborative nature of public administration by rejecting heroic leadership approaches and encouraging us to reframe the leader’s role in terms of those around them. The unit of analysis remains individuals but rather than talking of leaders inspiring followers, these discussions will talk of leaders empowering others, fostering communication, building trust, and enhancing accountability. ‘Authentic’ and ‘servant’ theories of leadership belong to this strand of the literature (see Appendix II for more details).

A second cluster of the literature (Cullen-Lester and Yammarino 2016, Uhl-Bien and Marion 2009, Fairhurst 2007) rejects the individual as a focus of leadership, departing from talk of properties of individuals to properties of relationships, organisations, networks, and systems. Therefore we might talk of adaptive organisations rather than adaptive leaders, or we might think of qualities emerging through an intersubjective process of collaboration or relationship building. For example, the ‘leader member exchange’ theory (Dionne et al 2010) focuses on the relationship between leaders and followers where the quality of the relationship, not the qualities of leaders, determines effectiveness. Other examples of this strand are ‘distributed’ models of leadership (see Appendix II for more details), which consider the potential for leadership to emerge amongst different members of an organisation or network, regardless of their managerial role or seniority. The more extreme examples of this body of literature seek to transcend person-centred approach by focusing on sources of leadership outside of individual people (Ospina 2017). These approaches see leadership as an emergent process and practice intended to cultivate group members’ capacity to navigate to complexity, where leadership can emerge through relationships, system properties, networks as well as individual action. Theories that follow this approach include ‘network leadership theory’, ‘complexity leadership theory’, and ‘collective leadership’ (Ospina 2017, Bryson, Crosby and Stone 2015, Mandell and Keast 2009, Morse 2010) (see Appendix II for more details). These theories offer valuable insights and highlight the limitations of individualistic approaches, however they raise challenges of their own. Some of these more radical approaches are criticised in the literature for stretching the concept of leadership beyond any natural sense of the word, undermining the explanatory value of the term, and inviting one to consider whether such theories are meaningfully talking about leadership at all (Morrison 2010).

Finally, the third cluster of the literature departs entirely from grand theory of leadership altogether, focusing instead on specific types of challenges and barriers leaders face, as well as more specific goals and outcomes (Heifetz et al 2009, Ekstrom and Idvall 2015, Corazzini et al 2014). A prominent approach that belongs to this strand is ‘adaptive leadership theory’ (see Appendix II for more details). This is described not as a theory of leadership per se, but as a practice that mobilises people to tackle tough challenges and thrive (Heifetz et al 2009). The theory is oriented around specific types of challenges that have no ready answers and cannot be addressed with existing procedures and expertise. The activities recommended in the adaptive leadership theory literature may not be necessary or even desirable in other contexts. This approach draws our attention to the possibility that general theories of leadership may be too abstract to be helpful in understanding what is required in response to challenges that leaders face. A general leadership theory narrows our focus to a particular set of challenges anticipated by the theory, and this may neglect other barriers that might be experienced in practice.

An example of where this literature identifies challenges that might not be captured by general leadership theories is highlighted by Ekstrom and Idvall (2015). They discuss leadership challenges experienced by nursing staff, and the implications this has for retention of staff. A challenge the study highlights is the issue of nurses disassociating from their leadership role, concerned that they may appear lazy or bossy, and feeling uncomfortable in their role and therefore job. The discussion presents a specific challenge (the experience of disassociation) and its consequences for a specific outcome (staff retention). While this could be reinterpreted using the language of ‘transformational leadership’ or ‘leader member exchange’, it is not clear this would give us a better understanding of the problem or its potential solutions, rather it might obscure and over-complicate the issue. Intuitively this level of analysis is more helpful to understanding leadership in the context of nursing than the broader understanding introduced by general leadership theories. Further literature highlights the particular ethical dilemmas and frameworks for understanding ethics of leadership within particular professions, as these might present context-specific features (Storch et al 2013, Broussine and Miller 2005, Curtis and Hodge 1995). These discussions suggest a need to pay further attention to what is usefully gained, and also what is lost, by moving from the specific context to much more general understandings of leadership and leadership qualities.

3.3 Implications for the NLC’s qualities approach

To conclude, there is certainly a push from the literature to look beyond individual qualities of leaders and acknowledge the importance of the context and systems within which they operate. This doesn’t reject the validity of a ‘qualities approach’ but it calls for an expansive understanding of the qualities, which acknowledges that these may manifest in various ways and emerge from different sources other than the traditional leader. In this sense, in addition to thinking of adaptive qualities of individuals, the NLC could also consider how cultures or organisations demonstrate these qualities. Additionally, the literature would also suggest that attention needs to be paid to the situation in which leaders operate, including the specific challenges and barriers experienced by members of a system, and the specific goals or outcomes that would be desirable in a given professional context.

4. Measuring leadership impact

The discussion in the previous section considered sources of variety in how leadership is conceptualised and different approaches to understanding the challenges that leaders encounter. It is important to also reflect on variety in how good leadership is measured, and more specifically, the intended purpose of leadership — the goals and outcomes that leadership is judged against. The literature talks about leadership in the context of various outcomes, from the abstract to the context-specific, from outcomes relating to work output to satisfaction amongst employees or the wider public. The findings suggest a need to consider the compatibility and potential tensions between different goals and outcomes and therefore the need to understand the priorities of leadership in a given context, and the nature of the relationship between leadership style and particular outcomes.

4.1 Approaches to leadership outcomes

The impact of leadership is approached from a wide variety of theoretical perspectives and in many cases different theories are accompanied by specific methods of empirical measurement. For example, ‘authentic leadership’ has been approached through a leader authenticity scale and authentic leadership questionnaires (Avolio et al 2009). Nevertheless, it is helpful to note the presence of goals or outcomes that are applied across these different theoretical approaches as a measure of the impact of good leadership. We have captured numerous examples of these at the top of the Abstract Search documents, however the main ones identified in the literature reviewed are summarised in the table below.

This overview shows that the literature has explored leadership in relation to various outcomes. The measures of outcomes can vary; for example, Kotze and Venter (2011) measure an individual’s effectiveness by asking the individual and four colleagues to rate them, while Uster et al (2018) link effectiveness to external measures of performance. Some of the measures are easily verifiable (such as staff retention rates) to other outcomes such as trust or creativity that are more intangible and thus rely on more contested measures and indicators. Outcomes such as trust can be treated as a dependent variable by some studies (Agote et al 2016) and an independent variable by others (Lee et al 2010).

Finally outcomes are measured within different theoretical perspectives. For example, retention of staff has been explored from different theoretical frameworks, notably ‘leader member exchange’ and ‘transformational leadership’ (See Appendix II for more details). Joo (2010) and Joo (2012) both find a correlation between high-quality relationships between leaders and followers and staff retention in studies that utilise leader member exchange theory. Additionally, Wang et al (2018) explore the impact of transformational leadership and emotional intelligence on the retention of nursing staff, finding that transformational leadership and emotional intelligence were significant predictors of nurse intent to stay, with emotional intelligence found to partially mediate the relationship between transformational leadership and intent to stay.

In order to judge the significance of these findings, we would need to be able to establish the validity of the individual studies and the comparability of measures applied across studies to allow for meaningful comparisons, which is beyond the scope of this paper. An important consideration for the purpose of strengthening our understanding of leadership qualities is the extent to which the findings support a causal relationship between a given attribute of leadership and a given outcome, or whether they only establish correlation.

4.2 Implications for the NLC’s qualities approach

These examples from the literature illustrate multiple layers of variety in the research, from how leadership is understood and measured, to the variety of outcomes that are understood to be the desired goals of good leadership. It is beyond the scope of this paper to analyse the strength and validity of individual methodological approaches, the extent to which these studies establish a causal link between a given quality of leadership and a given outcome, or the most effective route to developing these qualities in leaders. Nevertheless, these questions are of importance to our understanding of a ‘qualities approach’ to leadership. For example, is the key to understanding how connected leaders are able to retain staff or enhance creativity emotional intelligence? If so, discussion on leadership development that focus specifically on enhancing emotional intelligence would be an important direction for further exploration. The developments in the literature suggest a need to think about the desired outcomes for leadership and the extent to which these are shared by different leaders, for example, whether particular outcomes are more relevant for particular fields, or specific challenges. Once there is a clearer sense of the desired outcomes and goals of leadership, it is possible to explore leadership attributes relevant to those outcomes and the strength of that research and potential for leader development.

5. Conclusions and recommendations for future research

The review undertaken here provides a wide ranging overview of leadership (with elements similar to a scoping review approach to the literature) through the lens of the NLC five qualities using the academic literature as its basis. Its strength is the breadth of the review and the broad grounding of the five qualities in relation to academic knowledge. The obvious weakness is the depth to which this review has been able to go into the details of the theoretical linkage of the literature with each quality. Another weakness is the limit of the academic literature generally — the context and contemporaneity — which are comparative strengths of the ‘grey’ literature. Literature reviews by their nature are prone to degrees of imprecision, particularly in an area as ambiguous as leadership and a context as complex as the public sector. Different approaches to reviews will always be prone to exaggerating aspects of a phenomenon and occluding others. Given these inevitable constraints, the key question is what to do with the knowledge base that this literature review provides.

Based on the findings and conversations with the NLC team, the following questions emerged as potential areas for future exploration that can advance both the NLC understanding of leadership and its goals as an organisation:

• What is the most useful balance of considerations between the individual qualities of leaders and the wider relational and contextual elements of leadership in public service contexts?
• How can the NLC make use of the plethora of theories of leadership that exist within the literature and judge the ways in which these may be helpfully applied in practice?
• How should the NLC understand the desired outcomes of leadership, how these might change depending on the context and how to navigate tensions between them?
• To what extent do findings and recommendations on leadership support leaders in interpreting challenges and providing effective leadership in practice?
• How can leadership qualities be usefully identified, learned, and practised through training?
• How can the NLC evolve their understanding of leadership overtime to ensure it accounts for the challenges and experiences of today’s leaders and supports their practice?

These are difficult questions and the first step in addressing them is identifying where the relevant knowledge can be found. The review provides a helpful resource to direct further exploration of the existing evidence base relevant to the issues raised by these questions. Further in-depth academic research could yield useful results, potentially in conjunction with ‘grey’ literature. However, the people best placed to provide the answers to these questions are the leaders themselves. Academic research helps to frame the debate but understanding the value of these theoretical insights, where and how they can be improved, requires closer collaboration and co-production with leaders and those who will translate these lessons into practice.

The NLC is uniquely positioned to tap into the knowledge of its network of public service leaders and gain primary insights into the challenges and attributes of leadership. It has the opportunity to genuinely co-produce with leaders the generation of insights into the way they operate in public service contexts and bring about better outcomes. This could be achieved through introducing co-production into the delivery of its programme or through using qualitative/participatory research methods. Using these methods would build the findings of this and other reviews and connect what is a rich but fragmented literature with the practice of leadership in a complex and ambiguous reality.

Appendix I: Search terms and key results

Appendix II: Glossary

The literature review revealed how the study of leadership has been approached from a wide variety of theoretical perspectives appealing to specialised concepts and understandings of leadership and governance. The glossary below provides an introductory summary of the most prominent theoretical perspectives and concepts that were identified in the review. In each case, the definition is accompanied by a table providing references to papers discussing the theory, where the columns indicate where the theory has been applied in general leadership literature and in discussion of the five NLC qualities. The specific papers referenced in the columns can be found in the six Abstract search documents.

As for notation, papers are referenced by a number (e.g. [17]), where this refers to where the abstract appears in the search documents. An ‘! indicates a particularly important or relevant paper (e.g. [17!]), an ‘n’ indicates where no abstract was present (e.g. [17n]), a ‘-’ indicates limited information available (e.g. [17-]).

Charismatic leadership

Until the 1940s study of leadership primarily focused on individual traits. ‘Great-man’ theories and the ‘warrior model of leadership’ (see Machiavelli, Suntzu) understood leadership, as well as much historical and social progress, as attributable to the qualities of extraordinary individuals. Max Weber introduced the religious concept of ‘charisma’ into social sciences to describe leaders with extraordinary abilities and this notion of charismatic leadership has proven an influential modern continuation of the individual traits approach to leadership. Charismatic leaders are expressive, articulate and emotionally appealing. They are self-confident, determined, active and energetic. They have a positive effect on their followers who identify with them and have complete faith in them. House (1997) presented a theory of charismatic leadership resulting in renewed interest and empirical study of the concept.

Although theories that focus purely on traits have fallen out of favour and have been modified and adapted in recent literature. Charismatic leadership can be understood as a significant modern example of this approach to leadership. It has been influential on further developments such as ‘transformational’ and ‘authentic leadership’ (see p.23 and p.25 respectively), and remains part of the language of the study of leadership.

Transformational leadership

Transformational leadership is a theory of leadership that highlights a leader’s capacity to inspire their followers and thus enhance motivation, morale and performance. This is commonly understood to involve acting as a role model for followers, encouraging followers to act beyond their own self-interest and work for the good of the group, organisation or cause, take greater ownership for their work, to excel and self-actualise. It is commonly contrasted with ‘transactional leadership (see p.24) in which leaders rely on extrinsic rewards and punishments to produce more short term change in behaviour.

Transformational leadership was first mentioned by Downton (1973 in Bass and Bass 2008) and formalised in Burns (1978 in Bass and Bass 2008). Most articulations of transformational leadership treat charismatic leadership as an important dimension of transformational leadership, while including other elements such as inspirational leadership, intellectual stimulation and individualised consideration. Transformational leadership has also been understood to co-exist and indeed augment the results of transactional leadership. Scholars have noted limitations to transformational leadership, principally that the focus on leaders and followers is individualistic and represents only one way to understand and perform leadership (Ospina 2017). Furthermore the framework may be limited in its application to more collaborative and horizontal forms of leadership. Further theoretical developments in the study of leadership have moved away from the individual highlighting the importance of relationships and networks (for example see ‘network leadership’ and ‘collaborative leadership’).

Transactional leadership

Transactional leadership understands leadership in terms of an exchange or transaction between leader and follower, for example the exchange of reward for work. Transactional is often contrasted with transformational (see p.23). The main criticism of transactional approaches is that the rewards provide only basic motivation, may increase work rather than quality and may produce poorer results relative to transformational leadership.

Servant leadership

Servant leadership was formulated by Greenleaf (1977) who argues that leaders are required to curb their egos, convert their followers into leaders, and become the first among equals. The needs of others are the leaders’ highest priority, they are expected to build relationships that help their followers grow, while power has to be shared by empowering followers. According to Bass and Bass (2008) servant leadership shares much in common with transformational leadership such as vision, influence, credibility and trust. It is also linked with other models of leadership including self-sacrificial leaders.

Authentic leadership

Authentic leadership is a nascent but popular concept in the leadership literature that emphasises self-awareness, openness, fair-mindedness and the ethical foundations of leadership. The concept is related to ‘charismatic’ and ‘transformational leadership (see p.22 and p.23 respectively); the suggestion that there are pseudo (i.e inspirational but self serving) versus authentic transformational leaders led to research into authentic leadership (Avolio et al 2009:423). The moral or ethical component of authentic leadership has been questioned. Some have speculated on whether people can remain true or authentic to a value system or organisation that is itself damaging, harmful or corrupt. Similarly one might be able to inspire or build trust in people through superficial means without being trustworthy or honest in your interaction with them. These considerations highlight a distinction and potential tension between the norms or ideals of good leadership and broader considerations of the good. The philosophical foundations and methods of empirical study have also been challenged in the literature.

Adaptive leadership

Heifetz et al (2009) argue that adaptive leadership is a practice not a position. They define it as the practice of mobilising people to tackle tough challenges and thrive. It is an example of a ‘distributed leadership’ model (see p. 31), meaning leadership can be displayed by people across an organisation regardless of managerial role or seniority of position. Adaptive challenges have no ready answers and cannot be met by existing procedures or expertise. Adaptive change is uncomfortable, challenging our assumptions, beliefs and habits. Adaptive leadership requires non-traditional leadership behaviour, whereby leaders do not provide answers and accept a degree of conflict and discomfort to sustain adaptive change.

Three activities said to be core to adaptive leadership are

• Observing events and patterns without forming judgements about the data’s meaning.
• Tentatively interpreting observations by developing multiple hypotheses about what is going on.
• Designing interventions based on observations and interpretations in the service of making progress on the adaptive challenge.

Adaptive leadership has been criticised for failing to conform to traditional views of the leader, stretching the concept of leader to the point where it might be better described as a theory of facilitation. McCrimmon (n.d) develops an argument against the concept that suggests not all leadership occurs in the context of a problem, and not all change entails a response to an adaptive challenge. It is not clear that adaptive leadership makes such assumptions, though it may be better understood as a recommended response to a specific type of challenge rather than a general theory of leadership.

Complexity Leadership Theory

According to Uhl-Bien et al (2007), complexity leadership theory is a leadership paradigm that focuses on enabling learning, creative and adaptive capacity of complex adaptive systems within the context of knowledge-producing organisations. The conceptual framework includes three entangled leadership roles (adaptive leadership, administrative leadership, and enabling leadership) that reflect a dynamic relationship between the bureaucratic, administrative functions of the organisation and the emergent, informal dynamics of complex adaptive systems.

Morrison (2010) provides a critique of complexity theory. While acknowledging its rise in popularity and the valuable insights it offers, Morrison presents a range of concerns with the approach. These include the claim that it can be regarded as disguised ideology conflating description and prescription and that it risks exonerating leaders from expectations of accountability and responsibility.

Related theories: Complex Adaptive Systems: General [75]

Collaborative leadership

Collaborative leadership entails working across boundaries and in multisector and multi actor relationships (O’Leary et al 2010). In discussion of collaborative governance, Getha-Taylor and Morse (2013), observe that the traditional model of leadership development focused on leading within bounded hierarchy and via command and control mechanisms. This approach, they argue, fails to accurately reflect the nature and challenges of leadership encountered in contemporary joint public service delivery, which involves multiple government and for profit and nonprofit agencies. Such an approach must therefore be moderated with a focus on collaborative problem solving, working in flattened structures and incentivising behaviour in new ways. Collaborative governance, collaborative leadership and collaborative management are prominently discussed in leadership literature to highlight these considerations.

Related theories: Collaborative management: General [1][17] Collaborative governance: General:[24][27][29][51] [67][71][87] [107] Adaptive: [34]

Network leadership

According to Ospina (2017), network leadership theory views leader or follower attributions as properties of the system, in which influence relationships define relational structures, whether they be within a single organisation or across inter-organisational and cross sector networks. Silvia (2011) describes understandings of governance moving from hierarchical or command and control mechanisms to public services jointly produced by networks including government and private and third sector organisations. Network leadership can be understood as the study of leadership and management within these collaborations. For example, Silvia and McGuire (2010 in Silvia 2011) find differences in leadership between these two contexts, with an increased emphasis on people oriented behaviours such as motivating personnel, creating trust, maintaining a close-knit group and treating others as equals. The concept is also discussed in terms of collaborative leadership (see p.27). While the discussion of collaborative leadership is often framed as a response to a change in the nature of public administration, requiring consideration of factors including networks, discussion of network leadership appears to centre discussion on those networks and understand further features of the system through this lens.

Leader Member Exchange

Leader member exchange (LMX) refers to the exchange relationship between a leader and member (follower). LMX theory claims that the quality of the relationship between leader and member determines the effectiveness of leadership. High quality LMX relationships yield high levels of mutual trust, support and obligation, while low quality relationships are more instrumental and less effective (Ospina 2017). Associated with Graen (1976 in Bass and Bass 2008), LMX theory assumes that the leader behaves differently toward each follower and that these differences must be analysed separately. This theory is contrasted with most earlier theories that assume leaders behave in much the same way to all group members. Graen (1976) categorises followers as belonging to an in-group and an out-group with different behaviour expected of leaders in relation to these groups. Although it is less leader-centred it remains person-centred, and therefore has received some criticism from those seeking to broaden the object of study to factors external to the individual (such as ‘collective leadership’ on p.31 for example).

Related theories: See also Relational leadership [13]

Distributive leadership

Distributive models of leadership decouple leadership roles from formal positions of authority and propose that leadership may emerge in different locations, drawing on the collective intelligence of an organisational system in which interdependence and connectedness are critical. According to Ospina (2017), shared/distributed theories focus more directly on the relational nature of leadership and its collective dimensions by attending to new demands associated with horizontal relationships of accountability in contemporary organisations. The terms ‘distributive’, ‘distributed’ and occasionally ‘distributary’ leadership appear to be used interchangeably in the literature to capture the same issue.

Collective leadership

Collective leadership theories locate the source of leadership one level up from the individual or the relationship at the system of relationships — the collective (Ospina 2017). The primary source of leadership is not exclusively the leader (see transformational), the dyadic relationship (see leader member exchange), or the shifting roles (see shared/distributed), leadership can also emerge from other system properties such as the networks of interdependent relationships influencing what its members can and ought to do or other processes associated with the new demands of organising to achieve joint results (Ospina 2017:281).

Discussion of collaborative leadership focuses on shifts in the nature of public administration and the changing requirements of leaders, there is more flexibility in how leadership is discussed relative to these changes. In contrast, discussion of collective leadership reflects a more deliberate effort to reimagine the nature of leadership. Relative to some of the more traditional approaches to leadership, collective leadership can be understood as seeking to incorporate these approaches yet also broaden the scope of the object of study. It shares similar theoretical strands with network leadership and complexity leadership theory (p. 28 and p.27 respectively). Ospina et al (2017) argues that collective leadership lenses are particularly helpful in the study of leadership in networked governing arrangements.

The risks presented by expansive projects such as collective leadership is that they are vulnerable to concept stretching, distorting talk of leadership to the point that it loses explanatory value. When the focus moves beyond individual catalysts and persons, it is reasonable to question whether we are meaningfully talking about leadership at all.

Public Service Motivation

Public Service Motivation (PSM) is not a theory of leadership in itself but it is a widely referenced concept in discussions of public leadership. It is defined as an attribute of government and NGO employment that explains why individuals have a desire to serve the public and link their personal actions with the overall public interest. This concept features prominently in literature on leadership, notably in relation to transformational leadership (p.23) and discussions of roles, identity and motivation relating to both leaders and followers.

Leadership of place

Leadership of place is described as an inclusive model of leadership based on systems thinking in a spatial context. It is discussed within the context of New Civic Leadership (NCL), an approach which is understood as an alternative to New Public Management, and a response to the challenges of the complex multi-level, multi-disciplinary environment of a knowledge based economy (Gibney et al 2009). NCL, and by extension leadership of place, draws attention to the power of place in policy making. It is argued that the strong feelings of commitment people have to their locality have been neglected by other approaches to public management theory and practice. NCL highlights the role of place based leadership in spurring the co-creation of enhancing life in a locality. It has been associated with a number of aims, including drawing on the commitment of leaders to their locality in delivering long term benefits for the local community, using and building on local knowledge and building relationships and capacity within a community and local context. It has been observed that the concept of leadership of place is in its infancy and is used by different organisations to mean subtly different things.

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Collaboration: a Literature Review Research Report

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The impact of technology on collaborative learning, students’ participation and collaboration skills through radec learning model and the influencing factors, using collaborative formative assessments in enhancing students' understanding of concepts in grade 9 electron configuration, collaborative feedback in a blended learning environment: a case study of an efl writing class, effect of service and collaborative learning strategies on learners’ environmental attitude, quantitative approach to collaborative learning: performance prediction, individual assessment, and group composition, university academics’ experiences of learning through mentoring, getting radical: using design thinking to tackle collaboration issues, why 6 cs the urgency of learning at elementary school, collaboration in east africa: a contextualised approach to defining the construct, 42 references, the evolution of research on collaborative learning.

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The relationship between organisational agility and informal learning

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• Sebo Boerma 1 , 2 ,
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In dealing with rapid and profound technological, occupational and societal changes organisations benefit from paying attention to their organisational agility. Learning as part of organisational agility however is an under researched area of attention. In this integrated literature review we answer the question if organisational agility and learning are related, focussing on informal learning as an important way to learn in the workplace. We analyse ways in which papers on organisational agility integrate concepts as learning in their definition/approach. We conclude that the business literature includes to some extend perspectives on learning within the approach to agility. But the way learning is conceptualised is mostly moderately and instrumental. This means that learning is mostly seen as a way to become agile as an organisation. The integrative review identifies three areas in which understanding of organisational agility and specifically the framework of Wendler can be enriched and deepened with results from research on informal learning. The integration of both concepts results in three overlapping areas: leadership, social networks and knowledge development. These three areas contain mechanisms that influence both informal learning and organisational agility and therefore describe the relationship between these two concepts. Examples of these mechanisms include working closely together, valuing contributions from different professionals in knowledge development, and stimulating entrepreneurship and risk-taking by employees. More research into the nature of these three areas contributes to a more precise integration of learning theory into the development of the concept of organisational agility. It also provides organisations with approaches for dealing with the changes in their environment in effective and developmental ways.

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1 Introduction

Working in an ever-changing environment means that professionals must adjust their practices daily to be able to provide high quality services and products (Billett 2021 ). This means that learning, knowledge work and organisational change should be inextricably linked to the daily work practice. Researchers refer to organisational agility (OA) when discussing the way organisations can deal effectively with their constantly changing environment. Agile organisations are open, transparent and fluid structures with features that resemble the contingencies of their environment (Dove 1999 ; Sherehiy et al. 2007 ; Tolf et al. 2015 ). Some researchers consider learning at the workplace as one of the main characteristics of an agile organisation (Menon and Suresh 2021 ; Teece et al. 2016 ; Tsou and Cheng 2018 ; Vaszkun and Sziráki 2023 ). However, the exact relationship between OA, learning and knowledge development is still understudied (Tsou and Cheng 2018 ). A few case studies have been conducted on the relationship between organisational learning and agility (Gunsberg et al. 2018 ; Wang et al. 2018 ), but because of the small samples used in this existing research (Tsou and Cheng 2018 ), more in-depth and broader research is recommended.

This integrative review aims to investigate how research on learning, specifically informal learning (IL), can contribute to our understanding and improvement of the concept of OA. Based on Jeong et al.’s ( 2018 ) understanding of IL, this article explores the relationship between learning and organisational agility via the research question: What is the relationship between OA and IL and what mutual mechanisms influence both concepts?

2 Background

2.1 organisational agility.

In organisational theory, the term agility is used in the context of the supply chain, the workforce, software engineering or the organisation as a whole. Agility refers to the capability to respond to changes in the environment in a pro-active, reactive or embracive manner. Scholars argue that a rapidly changing and competitive environment necessitates organisational agility (Dove 1999 ; Gunsberg et al. 2018 ; Phuong et al. 2012 ; Tolf et al. 2015 ).

Although there is no common definition of OA (Walter 2020 ), a review by Förster and Wendler ( 2012 ) concluded that there are several similarities among the various definitions found in the literature. Common elements include speedy response and adaptation, keeping close relationships with both professionals and clients, and skilful handling of knowledge. Further, OA requires the ability to be sensitive to indicators for change in the environment and to create possibilities for acting efficiently and effectively.

Skilful handling of knowledge is one of the common elements identified by Förster and Wendler ( 2012 ), but little is said about this in relation to learning and development. Because Charbonnier-Voirin ( 2011 ) explicitly mentions learning and emphasises the continuous nature of agility; we therefore prefer to take her comprehensive definition of OA:

… a response capability which is intentionally sought out and developed by the organization in order to enable it to act efficiently in a changing environment characterized in particular by complexity, turbulence, and uncertainty. Agility corresponds to the organization’s capacity for permanent adaptability, which it attains not only by reacting rapidly to change but also through its potential of action in anticipating and seizing the opportunities offered by change, in particular through anticipation, innovation, and learning. (Charbonnier-Voirin 2011 , p. 123)

Charbonnier-Voirin argues that learning is one of the mechanisms that allows for agility. The way in which this mechanism manifests is object of this review study. To provide guidance in our review we use the work of Wendler and colleagues (Förster and Wendler 2012 ; Wendler 2014 ; Wendler and Stahlke 2014 ). These scholars developed a framework that breaks the concept of OA down into three clear, observable components: structure , people and prerequisites . In 2018, Gunsberg et al. extended this framework to incorporate the need to treat agility as an ability of the entire eco-system, including its customers, suppliers, partners, stakeholders as well as internal processes and procedures. OA is not merely a phase, but a state of being which enables organisations to deal with the need to change, innovate and learn.

The structural component of OA refers to the organisation having structures in place that allow for fast and flexible action in response to changes, and which enable effective internal and external collaboration (Wendler 2014 ). An example of structural OA is having a flat hierarchical structure as opposed to a controlled hierarchical structure. It is necessary to strategically use these structural components, deliberately focus on engagement with the environment, and use this to plan pro-active change. For example, a management may focus on its relationship with other organisations and customers in order to gather information on innovations in the field or a changing request be the clients (Gunsberg et al. 2018 ).

The second component, people agility, refers to the capabilities needed for the workforce and management to translate OA into action and deal with change. Gunsberg et al. ( 2018 ) emphasised the role of learning in this component. People agility pays attention to risk taking and being involved in research and innovation, and using this as a way to reflect and obtain feedback on actions taken in order to learn and improve.

The third component, agility prerequisites , refers to the values and infrastructure that support and encourage organisations to be agile. Examples include: treating change as an opportunity to anticipate, learn and innovate; or the way the infrastructure supports efficient communication such as increased possibilities for collaborating online (Wendler 2014 ). Prerequisites for agility also encompass the way in which values and principles are part of people’s behaviour. For example, whether or not employees are accountable for their actions and results, and whether the organisation is built on a foundation of trust (Gunsberg et al. 2018 ).

Learning is essential for the development of adaptable, creative, and autonomous employees (Charbonnier-Voirin 2011 ), yet it remains largely undefined in OA research (Tsou and Cheng 2018 ). In the context of knowledge-intensive organisations, one can assume that learning is deeply connected to every aspect of the organisation, not only for the maintenance of that knowledge, but also to promote greater agility in work practices and to enhance the capability to deal with change. It is therefore important to gain a more in-depth insight in the relationship between agility and learning in organisations. In the next section we discuss IL in organisations as this form of learning deals specifically with spontaneous and emergent workplace learning in response to change (Marsick 2009 ; Skule 2004 ).

2.2 Informal learning

Literature on learning in organisations makes a distinction between formal, non-formal and informal learning (Colardyn and Bjornavold 2004 ). In general, formal learning refers to pre-planned and well controlled certified learning and training programs. Non-formal is seen as intended self-organised learning, and IL is the more or less hidden curriculum, driven by spontaneous and responsive learning activities undertaken by the workforce to deal with emerging issues and challenges of daily work (Colardyn and Bjornavold 2004 ; Marsick and Watkins 2001 ). IL is increasingly recognised as the primary form of workplace learning (Ellinger 2005 ; Kim and McLean 2014 ; Rogers 2014 ; Skule 2004 ), accounting for 60–80% of all learning (Jeong et al. 2018 ; Manuti et al. 2015 ). Form a theoretical viewpoint, the responsive nature of IL is well-aligned with the emergent continuous learning that is expected to occur in conditions of organisational agility.

The integrative review by Jeong et al. ( 2018 ) provides a conceptual framework for IL and a clear overview of empirical factors supporting IL in organisations. IL in the workplace is often triggered by change in the working context or emerging problems or challenges. Change can therefore be seen as an opportunity or trigger for learning, overlapping with Charbonnier-Voirin’s ( 2011 ) definition of agility and the role of learning therein. According to Jeong et al. ( 2018 ), IL is:

an individual learning process that is highly embedded and integrated with daily work activities, primarily delivers tacit, implicit knowledge, and can be deliberate, conscious, planned, and intended, or spontaneous, unconscious, unplanned, and unintended, resulting in the enhancement of knowledge and skills. (Jeong et al. 2018 , p. 132)

Jeong’s definition integrates aspects of studies on IL in the workplace, such as planned versus unplanned learning (Lohman 2006 ), tacit versus explicit knowledge (Marsick and Volpe 1999 ), and the specific learning conditions at work that support IL (Rogers 2014 ; Skule 2004 ). Although Jeong et al. ( 2018 ) emphasise the individual character of IL, they place it on a continuum from self-directed learning to learning from and with others. The importance of the social aspect of IL (Marsick and Volpe 1999 ) is supported by other researchers (Aring and Brand 1998 ; De Laat 2006 ; Lohman 2006 ). In the description of antecedents, Jeong et al. ( 2018 ) make a distinction between the individual, collective and organisational level of IL. Alongside personal characteristics they found that feedback, networking, interpersonal relationships and different organisational interventions are factors that impact IL activity. Learning in this context is interactive and happens between people and artefacts by making new connections and developing knowledge in a specific context (Greenhow and Lewin 2019 ). But this still is seen as learning from the individual point of view, in which the network or collective is seen as a condition for learning, not a characteristic of learning. Knowledge creation embedded in experience and its context can be personal (individual) but also collective (Garavan et al. 2015 ; Marsick and Watkins 2003 ). Collective learning goes beyond the sum of individual learning processes and encompasses the joint creation and sharing of knowledge within organisations. In order respond to changes in an effective way it is necessary to learn on a collective level, which is not the same as the sum of the individuals (Marsick and Watkins 2003 ). This collective perspective of learning is close to what has been defined as networked learning:

Networked learning involves processes of collaborative, co-operative and collective inquiry, knowledge-creation and knowledgeable action, underpinned by trusting relationships, motivated by a sense of shared challenge and enabled by convivial technologies. Networked learning promotes connections: between people, between sites of learning and action, between ideas, resources and solutions, across time, space and media. (NLEC 2021 , p. 319)

Lack of proximity of colleagues, overly rigid boundaries, and lack of responsibilities, autonomy and risk taking are seen as important impediments to IL activities (Ellinger 2005 ; Jeong et al. 2018 ; Lohman 2006 ; Marsick and Watkins 2003 ). In the social and collaborative environment, trust and interdependence are essential for stimulating a culture of reflection, feedback and problem-solving (Jeong et al. 2018 ; Kim and McLean 2014 ; Marsick 2009 ). From the collective perspective these are all characteristics of learning. As Jeong et al. ( 2018 ) conclude, it is necessary when performing research on the topic of IL to use a multilevel perspective of the interaction between individuals, groups, organisations and their contexts. For this research we therefore will use both definitions (i.e. Jeong et al. 2018 and NLEC 2021 ) to follow up this suggestion.

The review is focused on the relationship between OA and IL and what mechanisms influence this relationship. We want to understand to what extent insights into IL can enrich the understanding of OA.

3 Research method

One of the goals of an integrative literature study is to make critical remarks and create a conceptual framework by synthesising literature on chosen concepts (Torraco 2005 , 2016 ). This methodology is often applied when dealing with new concepts that are not yet well identified and where a conceptual framework is needed to get a grasp of the emerging topic. In this study we predominantly use the work of Jeong et al. ( 2018 ) to scrutinise the relationship between OA and IL.

Our methodology follows the guidelines of Torraco ( 2016 ) for carrying out an integrative review:

Establish a clear focus of the review: define the scope by using a guiding theory to start framing the research and focusing on a specific area. The focus of both concepts (OA and IL) is described in the Background.

Be clear about boundaries of the review , like types of organisations or professions to be included in the review topic or topics. The context is workplace learning, specifically IL as conceptualised by Jeong et al. ( 2018 ) is used to study OA.

Organise and structure the review according to a timeline , research method , or the concepts or themes reviewed. The model of Wendler ( 2014 ) provides the structure. We searched literature prior to 31 March 2021. In order to capture recent reviews on OA, we went back to 2011. For “OA and learning” no limit was used.

Use a transparent search and selection process , like choice of databases and excluding criteria. We chose to perform our search via EBSCO because of the widespread number of databases it covers. We included Google Scholar as an additional check for missing articles. We used the PRISMA approach to increase the transparency of our selection process.

Perform a critical analysis of the themes found during the review. For the critical analysis of the relationship of OA with learning we used the conceptualisation of IL provided by Jeong et al. ( 2018 ).

Create a new formulation of the topic by synthesising the themes , insights and own ideas. In this research the perspective of IL was used to study the concept of OA to gain deeper insights in the relationship between OA and learning.

The new model should be explained by transparent and logical reasoning. This article offers and clearly explains a new model for IL and OA.

3.1 Search and selection process

We first searched using the combination of the terms “Organisational Agility” AND “Informal Learning” in the databases covered by EBSCO. Focusing on peer reviewed articles in scholarly journals, this resulted in only one hit. Therefore, we expanded the search by using the term “Learn*” instead of “Informal Learning”.

Using the same search terms, Google Scholar suggested more possible articles. We selected published peer reviewed articles that referred to OA and learning in their title or description.

Alongside the search for research in which a relationship was made between OA and learning, we also wanted to gain an overview of the concept of OA to be able to integrate it with literature on IL. Jeong et al.’s ( 2018 ) integrative review on IL provided us with the basis for IL, but is supplemented with literature on collective learning. For OA we conducted a second search on “Organisational Agility” and “Review” to find review articles in EBSCO. With Google Scholar we only selected published review articles focusing on OA and including a clear definition of OA.

Initial selection of appropriate literature was based on the title and abstract.

3.2 Appraisal of the literature

The first literature search on “OA AND Learn*” returned 92 results, 49 peer reviewed via EBSCO, 43 via Google Scholar. Of these articles six where duplicates, four where non-English, four had no text, leaving 78 articles. No definitions of OA were found in 31 articles. While Google Scholar does not distinguish between peer reviewed and non-peer reviewed articles, each article was checked for peer reviewed status. After checking another six articles were excluded. For two non-peer reviewed articles we made an exception because they paid special attention to OA and IL, are often referred to in other research. Of the remaining 41 articles, 16 were excluded after reading the texts. Among these articles were those that mentioned learning only once or twice without paying attention to the definition; learning used as a word for which the definition was taken for granted, not as a concept that must be clarified. In some other articles, OA was only mentioned as part of the trends in the context of the organisation. Therefore, a total of 25 articles were included because of search 1.

The second literature search focused on “OA AND Review” resulted in 51 articles (31 via EBSCO, 20 via Google Scholar). We excluded 16 articles which also appeared in the first search. One article was excluded because it was not written in English or Dutch. 24 articles weren’t review articles and were excluded. Two articles were excluded after reading because they dealt with information technology agility. The remaining eight articles were included (See Fig.  1 ).

PRISMA overview of selection of literature: OA and Learning

Via snowballing. seven articles and one book were added to the final sample. Finally, 41 articles were studied for this integrated literature review. They are listed in Appendix 1.

What is the relationship between OA and IL and what mechanisms influence this relationship?

We present the results of the integrative review, focusing on the way aspects of IL are addressed within the description of OA in the articles featuring in this study. To structure our findings, we use the OA components identified by the framework of Wendler ( 2014 ); structures enhancing agility , people agility and agility prerequisites.

4.1 Structures enhancing agility

Structures enhancing agility refers to the ability of the organisation to cooperate and collaborate and make changes in their structure in order to respond to changing needs in their context, like changing questions from customers (Wendler 2014 ). This ability is described by the strategy of the organisation towards agility (engagement/awareness) and the way the operational outlook is structured to be collaborative.

Based on the 41 studies included in this review, we found that 35% reported outcomes on the strategy that could be related with IL and similarly 49% reported on the structure and IL.

4.1.1 Strategy and IL

According to Holbeche ( 2018 ) in her book titled The Agile Organization: How to build an Engaged , Innovative and Resilient Business , organisations should be self-ware, and able to decide in what way to deal with changes. They should develop the knowledge and capability to deal with these changes, and navigate between between resilience and response. In short, Holbeche outlines in her book the strategy that organisations need in order to be agile. Researchers agree that developing the capability to become and stay agile is a conscious organisational strategic choice (Appelbaum et al. 2017a ; Crocitto and Youssef 2003 ; Margherita et al. 2020 ; Tallon et al. 2019 ; Walter 2020 ). Jeong et al. ( 2018 ) found that IL depends explicitly on factors in the context in which it takes place. IL cannot be seen separately from the extent to which the organisation is perceived to have an eye for the long term, the degree of organisational? change, and appreciation of and room for learning. Based on the strategic decision to become agile Margherita et al. ( 2020 ) found, in their literature review of a framework for the development of OA, that organisations should investigate and learn about the important drivers for change and construct a proper strategic reaction. This should include an assessment of the needed capabilities, either present or missing, and, if required, an approach to develop these capabilities. Jeong et al. ( 2018 ) found that the capabilities for dealing with change, such as networking and reflecting on the work, are similar to the capabilities needed for IL Based on her literature review of the functions and roles of agility drivers, enablers and capabilities, Walter ( 2020 ) argues that OA is not a stable state, but instead fluctuates. OA therefore includes the ability of an organisation to regain skills and knowledge needed to restore agility. In regaining these capabilities, IL can be supportive. On the one hand, IL supports the learning process of the individual and the organisation itself. On the other hand, improving IL requires competencies that correspond to the competencies needed to be agile, like managerial responsibility and motivation (Jeong et al. 2018 ). When developing these capabilities in the workplace it is important to realise that innovations and changes in the social networks or social contracts are important drivers or catalysts for change, which will influence the way the profession is developing. IL particularly benefits from social connections such as professional networks and communities of practice. Jeong et al. ( 2018 ) mention that mixed internal and external social networks are important antecedents to learning in the workplace. Collective learning is already characterised by the diverse network (Garavan et al. 2015 ). This collective perspective of learning aligns with the strategic perspective of OA, and emphasises the organisational value of learning.

According to Appelbaum et al. ( 2017a ), in their literature review on how to achieve a greater level of OA, the strategic focus of an organisation should not be on what the organisation delivers, but on how the organisation is achieving its results. Organisations should focus their strategy on becoming a learning organisation. A deeper understanding of human motivation and behaviour is of utmost importance to help develop the organisation (Appelbaum et al. 2017a ). The capability of OA can only be developed when network partners are involved in a collaborative way (Wang et al. 2018 ). According to a review by Sherehiy et al. ( 2007 ), an intimate relationship with customers and suppliers makes organisations more aware of signs of change. Jeong et al. ( 2018 ) also emphasises the importance for IL of having open and trustful relationships in a diverse network. When combining these findings and the perspective of networked learning this means that focusing on the wider learning network instead of the learning organisation itself will be beneficial for OA.

Gunsberg et al. ( 2018 ) performed a case study of an Australian university to identify factors for establishing the maturity of OA in an organisation. For employees, industrial awareness is found to be a strategic factor, enabling them to value the information they receive and make decisions on what to explore and what to disregard. This awareness supports the absorptive capacity of the organisation, that is, the acquisition, assimilation, transformation and exploitation of knowledge in an organisation (Demuner Flores 2023 ; Walter 2020 ). Organisations should work strategically on this absorptive capacity. In their study of innovative industries, Felipe et al. ( 2016 ) identified,, how absorptive capacity and information systems capabilities influence OA. They conclude that: “managers should foster and deploy the firm’s knowledge absorption mechanisms to effectively maximise the impact of IS [information systems] efforts and investments on achieving agility” (Felipe et al. 2016 , p. 4630). Results of a study of innovative activities among 102 manufacturing companies support the finding that absorptive capacity is needed for an effective response to changes in the environment (Demuner Flores 2023 ). One of the dimensions of IL that comes close to absorptive capacity is learning competence. This refers to the cycle of experiencing and reflecting (Jeong et al. 2018 ). The cycle that is defined by absorptive capacity is more elaborated. IL enhances knowledge and skills of individual employees, who are “more likely to gain new, practical knowledge” (Jeong et al. 2018 , p. 129).

In order to enhance OA, it is necessary to involve knowledge workers in strategy development. This contributes not only to a collaborative culture, but also brings in expertise where it is needed (Appelbaum et al. 2017b ). For IL, valuing the application of knowledge means improving its development (Jeong et al. 2018 ). Bringing knowledge workers together to share knowledge and negotiate meaning can promote collective learning (Garavan et al. 2015 ).

4.1.2 Structure and IL

Margherita et al. ( 2020 ) mention collaborative action as a necessity for achieving agility. This means having a collaborative mindset, and a clear and shared (aligned) approach to daily operations. Govuzela and Mafini ( 2019 ), in their quantitative study of business owners, found that collaborative innovation and OA had a positive relationship. In this light, cross-functional teams with a high level of autonomy promote OA (Akter et al. 2023 ; Menon and Suresh 2021 ; Vaszkun and Sziráki 2023 ). To promote collaboration, the structure of an organisation should be fluid in terms of roles, boundaries and functions. The organisation should develop in a more organic structure (Sherehiy et al. 2007 ). Coordination in agile organisations is informal and there is a minimum of formal hierarchy (Nijssen and Pauwe 2012 ). Internal collaboration and open communication between different departments and functions is essential when relying on informal structure (Sharma et al. 2014 ; Wendler and Stahlke 2014 ). For IL from the individual perspective, a collaborative mindset is needed to meet and learn from each other. Interpersonal communication in which open sharing is possible will make IL more effective (Jeong et al. 2018 ). From the collective perspective, collaboration and open sharing are part of the definition of learning (NLEC 2021 ). Focusing on networked learning means promoting connections not only between people, but also between people and artefacts. Networked learning sees learning as a process happening in an ecosystem and of value for that ecosystem. It fosters generous thinking and helps strengthen connections between organisations (NLEC 2021 ). In the section below on People agility we further elaborate on this.

In their integrative literature review on OA, Tolf et al. ( 2015 ) found that organisations need to know how to maintain network relationships in such a way that the network can respond to change by reforming itself. The crucial actors in this network are working and developing interdependently, based on information they exchange. No one has the complete picture. Everyone needs each other in their job (Tolf et al. 2015 ). The fluidness of the organisational structure is not limited to the internal organisation (Crocitto and Youssef 2003 ; Tolf et al. 2015 ; Wang et al. 2018 ). According to Tolf et al. ( 2015 ), a transparent and transient network of relationships at all levels of an organisation and its environment is one of the most frequently mentioned characteristics of an agile organisation. This way, employees get access to new knowledge as well as creativity and innovation (Appelbaum et al. 2017b ; Wang et al. 2018 ). Wang et al. ( 2018 ) found that working in a diverse network which reflects the complexity of the business process itself is supportive to OA. But also, these networks themselves should be flexible (Wang et al. 2018 . Sambamurthy et al. ( 2003 ) call this ‘partnering agility’:, the ability to leverage the qualities represented in the network itself. Garavan et al. ( 2015 ) see this leveraging as part of collective learning. Learning is interdependent and socially determined. Learner and context are inseparable.

4.2 People agility

People agility refers to the capability of the employees and management to deal with changes and be able to act in a way that suits the values of agility (Wendler 2014 ). Gunsberg et al. ( 2018 ) mentions two sub-themes, the first one leadership and management , the second one learning and changing . Of the 41 articles we reviewed, 17% reported outcomes on leadership and management that could be related with IL and 38% on learning and changing.

4.2.1 Leadership and management and IL

Sharma et al. ( 2014 ) studied the way customers are involved in innovation in the health care sector in Australia. They found that innovation driven by customer participation is needed for health care organisations to act on change. Because of this customer participation, innovations and therefore changes in knowledge and behaviour occur at all levels of the organisation. This implies that employees at all levels should be accountable and responsible for implementing these changes and therefore be able to make decisions. Decentralised leadership responsibility and accountability at all levels of the organisation support customer participation and are essential in order to act on the results of this participation (Sharma et al. 2014 ; Sherehiy et al. 2007 ; Tolf et al. 2015 ). Researchers disagree on the decision-making process, with some finding that hierarchical decision making improves OA because it speeds up the process (Felipe et al. 2016 ), and others finding that decentralised decision making is much more effective for OA (Appelbaum et al. 2017a ; Safari et al. 2018 ; Sherehiy et al. 2007 ; Vaszkun and Sziráki 2023 ; Wendler and Stahlke 2014 ). According to proponents of decentralised decision making, the responsibility for making decisions should relate to task and expertise, rather than a function or person. According to Felipe et al. ( 2016 ) this difference in findings could relate to customers’ changing demands for greater efficiency at lower cost. Alignment of strategy, processes, behaviours and systems have a significant positive influence on agility (Govuzela and Mafini 2019 ; Walter 2020 ). So, it is possible that such alignment is the bridge between hierarchical and decentralised decision making. A strong hierarchy combined with high competition between teams is unsupportive of IL. On the other hand, task autonomy, and within that controllable complexity, are supportive of IL (Jeong et al. 2018 ). For IL it is also important that employees notice that their expertise and knowledge is useful for their job. When this is the case, they are more willing to use their knowledge and expand it (Jeong et al. 2018 ). In the case of the collective perspective of IL, leadership needs to create opportunities for dialogue and to demonstrate exemplary behaviour by, for instance, listening and respecting (Garavan et al. 2015 ).

Management should provide an atmosphere where risk-taking is supported (Appelbaum et al. 2017b ). The learning perspective on work can be useful in this because it values risk-taking for its possibilities for development. Teece et al. ( 2016 ) developed a framework of the ‘dynamic capabilities’ needed by agile organisations to deal with uncertainties. These capabilities are clustered into three elements: sensing, seizing and transforming. In these capabilities they see a central role for managers. The manager can determine the level of agility needed for the observed or desired changes. They can support employees to be entrepreneurial and override routines when necessary. This supportive role is also needed for the continuous learning processes, which is key for effective knowledge sharing and management in achieving OA, according to Paterek ( 2017 ) in his multiple case study. Paterek ( 2017 ) mentions the importance of communities of practice in facilitating effective knowledge management. Encouraging risk taking and encouraging employees to develop and share knowledge are antecedents for IL (Jeong et al. 2018 ). Garavan et al. ( 2015 ) also see risk-taking in cross-functional networks as an important cultural antecedent for collective learning, especially focusing on networked development.

Walter ( 2020 ) found that it is the role of the management team to explore what drivers for agility are at stake and, based on that, choose the required strategy, and the required agility capabilities such as responsiveness, speed and flexibility, to react in an agile way. The management team must establish whether the capability is at the required level or if it needs to be developed. The role of management in literature on OA is often described as determining. This seems to contrast with the call for autonomy and personal responsibility for professionals, both for OA as for IL. Although not always clear, the researchers are probably referring to strategic-level decision-making. But here, too, other researchers point to the involvement of professionals in strategic choices in order to be challenged for adjustments in their work either for their own benefit or for the benefit of the organisation (Appelbaum et al. 2017b ; Jeong et al. 2018 ).

4.2.2 Learning and changing and IL

Learning is scarcely defined in research on OA. The few exceptions interpreted learning in a variety of ways. Menon and Suresh ( 2021 ), in their study to identify factors that influence agility in higher education, define learning as one of the crucial factors for agility, by acquiring knowledge and distributing information in the organisation in order to put this information into practice. Teece et al. ( 2016 ) define learning as sensing changes, building hypotheses about these changes, and testing these hypotheses in one’s own practice. They suggest doing this in an abductive way. This means looking at complex phenomena and intuitively coming up with solutions, after which data is to be found to make these solutions plausible. Tsou and Cheng ( 2018 ) surveyed 170 business to IT companies about the mediating role of OA between learning and service innovation performance. They define learning as translating the results of experience into accessible knowledge. Experience is core to IL. One of the challenges for organisations is to make the knowledge tangible (Jeong et al. 2018 ). Promoting learning can cultivate OA (Tsou and Cheng 2018 ). Bahrami et al. ( 2016 ), in their study of the mediating role of learning in the relationship between organisational intelligence and OA, describe learning abilities according to Senge’s definition of a learning organisation (shared vision, mental models, system thinking, teamwork and interpersonal skills). This alignment of mental models is mentioned as a condition for the strategic success of the organisation and partly describes the ability for collective learning (Marsick and Watkins 2003 ). In a large survey among public sector organisations during COVID, Ludviga and Kalvina ( 2023 ) found learning to be an important driver for OA. They follow the definition of Marsick and Watkins ( 2003 ) and define learning as the capability of an organisation to develop and innovate, and the capacity to share knowledge among coworkers. Theirs is the only research for we know that explicitly emphasises the collective perspective of learning. Govuzela and Mafini ( 2019 ) see learning as an investigation that leads to shared values and knowledge. Like Tsou and Cheng ( 2018 ) several researchers find learning supportive to OA in developing knowledge and capabilities (Bahrami et al. 2016 ; Ludviga and Kalvina 2023 ; Menon and Suresh 2021 ; Teece et al. 2016 ). In most cases, learning relates to developing capabilities to become agile, not as a state of being that supports agility. The only exception to that, as far as we could establish, is the study of Ludviga and Kalvina ( 2023 ). They see collective learning as an important mechanism for being agile as an organisation, but not for becoming agile. Because IL is integrated with daily work (Jeong et al. 2018 ) it has the potential of being more than a way to learn the knowledge and skills that are required to become agile.

Developing knowledge, sharing it, and putting this knowledge into practice is seen as key to being agile and can be organised through communities of practice, networks as well as promotors of change. Facilitating management of knowledge is seen as one of the major obstacles for OA (Paterek 2017 ). In dealing with change the importance of a solid knowledge infrastructure is supported (Appelbaum et al. 2017a ; Crocitto and Youssef 2003 ; Phuong et al. 2012 ). Cegarra-Navarro et al. ( 2016 ), in their survey of 360 users of a knowledge platform, found that the relationship between applying knowledge and organisational performance was moderated by OA. Emphasis on knowledge creation and application therefore is not enough. Becoming agile to use the knowledge in an effective way is also necessary, so it will be a self-reinforcing process (Cegarra-Navarro et al. 2016 ). In their meta-analysis of 176 primary studies, Cerasoli et al. ( 2018 ) found that IL behaviour, like self-experimentation or learning by doing, supports the creation of new knowledge and skills, both individually and collectively. Furthermore, Kavosi et al.’s ( 2021 ) study of organisational intelligence, forgetting, learning and agility, which involved a questionnaire distributed among 316 co-workers in Shiraz public teaching hospitals, found that forgetting knowledge, both on purpose or by accident, supports OA. They conclude that getting rid of old knowledge makes room for new knowledge (Kavosi et al. 2021 ).

Developing specific workforce capabilities for customer activation, organisational activation, interaction capabilities, and learning agility enhances OA (Sharma et al. 2014 ). These four concepts describe the four types of capabilities an organisation must have to innovate through co-creation. Customer activation deals with the capacity to identify and act on customer needs. Organisational activation refers to the willingness to collaborate among disciplines and teams and is found to be crucial (Menon and Suresh 2021 ; Sharma et al. 2014 ). Interaction capabilities are capabilities for understanding, developing and empowering customers, and involving them in the process by relating to them and intervening appropriately in the process of innovation (Sharma et al. 2014 ). Learning agility is defined as the capability to improve the processes of an organisation. This means responding to customer needs with improvements, flexibility and systematic reflection on the way the organisation can meet the needs of the customer, while also abandoning processes that hinder the adoption of customer-needed innovations (Sharma et al. 2014 ). Cerasoli et al. ( 2018 ) found that, by facilitating IL behaviour, organisations can enhance employee knowledge, skills, performance and expertise - enabling their workforce to continuously identify opportunities and implement improvements to organisational processes. The latter is part of OA establishes the relation with IL.

4.3 Agility prerequisites

Wendler ( 2014 ) refers to the prerequisites supporting the agility of an organisation in both culture and innovation, the first focusing on agile values, and the latter being defined as the systematic approach of the organisation towards innovation, incorporating flexibility and proactivity. Based on the 41 studies included in this review, we found that 20% reported outcomes on culture that could be related with IL and 41% on innovation.

4.3.1 Culture and IL

According to Vaszkun and Sziráki ( 2023 ), agile organisations value customer satisfaction and response to change over following a fixed plan. Paterek ( 2017 ) found that, in supporting these values, a learning organisational culture plays a significant role. Such a culture supports the transformation towards OA. A learning organisational culture recognises that learning is a social process and a shared responsibility, which align with the characteristics of IL (Marsick and Volpe 1999 ).

Organisations may endorse the values associated with customer satisfaction and response to change, but struggle to put them into practice (Wendler and Stahlke 2014 ). This might be caused by the ambidexterity of sustainable innovation, exploring on one hand while exploiting on the other. Co-workers being open about this duality and having a clear idea of their own role in innovation contributes to OA (Appelbaum et al. 2017b ). Crocitto and Youssef ( 2003 ), by proposing an integrative model for OA based on the literature they reviewed, plead for employees to be called organisational associates. This changes the relationship of the employee with the organisation towards more responsibility. The importance of accountability is also indicated by the needed willingness to continuously monitor for improvement and to experiment and improvise (Sherehiy et al. 2007 ). This asks for the development of an agile mindset, not only agile capabilities. And for an agile mindset a collaborative mindset is essential (Margherita et al. 2020 ). In collective IL, this collaborative mindset is inevitable. In this sense, participation as an antecedent of collective learning is beneficial. A collaborative mindset asks for active engagement, expressing insights and interaction (Garavan et al. 2015 ).

OA is based on trust (Tolf et al. 2015 ). This includes employee trust when discussing findings on working together in networks and establishing customer intimacy, and management trusting employees with a great deal of responsibility and accountability. Trust requires an open atmosphere among team members (Vaszkun and Sziráki 2023 ). A safe, open and trustful working environment helps co-workers to be frank about their questions and mistakes, which supports learning (Jeong et al. 2018 ; Tolf et al. 2015 ). Such an environment also supports proactive behaviour, shifting responsibilities when helpful in the process and spontaneous collaboration (Sherehiy et al. 2007 ). It fosters IL (individual and collective) by creating an environment where people feel safe to experiment and share knowledge (Garavan et al. 2015 ; Jeong et al. 2018 ). In larger organisations trust is more wanted by employees then in smaller organisations (citation for this? ). On the other hand, the presence of trust is always a vulnerability for organisations due to the complexity of collaboration and communication (Wendler and Stahlke 2014 ). Trust takes a short time to break, but a long time to build.

4.3.2 Innovation and IL

Tsou et al. (2018) found that the impact of learning on innovation is mediated by OA. Learning is supportive of becoming more agile. Hamad and Yozgat ( 2017 ) performed quantitative research on 158 top and middle managers at commercial banks in Jordan. They found that OA positively impacted learning. Agility improves aspects of learning such as experimentation, risk taking, interaction and cooperation. This relationship fosters innovation by the way knowledge is effectively applied (Crocitto and Youssef 2003 ; Hamad and Yozgat 2017 ; Menon and Suresh 2021 ). The assimilation of external knowledge, which involves analysing, interpreting and internalising new knowledge, is particularly important for innovation (Demuner Flores 2023 ; Teece et al. 2016 ). Ravichandran ( 2018 ), in a survey among 710 large firms in the United States, found that innovative capacity is only supportive to OA when it not only contains access to new ideas, but that these new ideas can also be connected to existing processes and knowledge. This coupling is in fact learning, because it involves changing perspectives and ways of doing things. Innovative capacity is supported by an adjustable infrastructure and scalable workforce (Nijssen and Paauwe 2012 ), both connected with structure enhancing agility and people agility . Responding to changes with speed, making decisions quickly and applying the solutions quickly is required, according to Phuong et al. ( 2012 ) in their literature review on the way information systems in general and enterprise systems in particular contribute to OA. Govuzela and Mafini ( 2019 ) emphasise the significance of collaborative innovation for OA, with various stakeholders involved in improving existing or creating new processes and knowledge. Sharma et al. ( 2014 ) emphasise the importance of customer involvement in innovation, for it brings in the feedback and needs of customers. Making the customer part of the creation of knowledge ensures the speed in which needs are translated into innovation. Innovative behaviour is found to be an IL activity that enhances knowledge and expertise in the workplace (Bednall and Sanders 2014 ).

Organisations with proactive behaviours acknowledge change as part of the routine and see change as beneficial to their performance (Tolf et al. 2015 ). Proactivity means that organisations like to experiment, take informed risks, and are supportive to testing new innovative ideas (Appelbaum et al. 2017b ; Gunsberg et al. 2018 ). Monitoring these experiments by continuous data gathering and analytics can be seen as one perspective on knowledge creation (Margherita et al. 2020 ; Walter 2020 ). Doornbos et al.’s ( 2008 ) study of Dutch police officers found a positive correlation between the possibilities for collegial feedback and the frequency of informal work-related learning activities. Jeong et al. ( 2018 ) also found other research supportive of the fact that feedback and reflective dialogue improve the learning activities and therefore IL. Innovation benefits from IL because it in turn is fostered by experimentation and creative problem solving (Jeong et al. 2018 ).

An organisation’s IT (Information Technology) capability is an enhancer of OA in facilitating innovation. It helps avoid redundant processes and miscommunication if information about customers is up to date, applicable, and keeps all necessary staff in the knowledge loop (Phuong et al. 2012 ; Tsou and Cheng 2018 ). For IL (individual and collective) IT provides a platform for collaboration and knowledge exchange (NLEC 2021 ; Jeong et al. 2018 ).

5 Integrating the findings

The main purpose of this study is to gain insight in the relationship between OA and IL and to investigate what mechanisms influence this relationship. In this section we integrate the main findings.

A general observation is that most of the literature reviewed sees (informal) learning as a mechanism to become agile as an organisation. Learning relates to the development of the dynamic capabilities or absorptive capacity needed to be able to act on changes in an effective way. Learning is only once reported as an approach in itself that enables agile organisations to act on change (Ludviga and Kalvina 2023 ).

In the results presented here, we show that there is enough potential to integrate the OA and IL as qualities of an organisation to be utilised for dealing with an ever-changing environment. The relationship between the two concepts not only has similarities with the Learning and Changing component of the framework presented by Wendler ( 2014 ) and Gunsberg et al. ( 2018 ). IL also exhibits many similarities with the other components of their framework. Integrating the two concepts offers suggestions for a framework of mechanisms that support both OA and IL. For a visualisation of the integration see Fig.  2 .

Venn diagram showing relationship between OA and IL

OA is an action or reaction towards a changing environment. Research on OA states that agility is a state of mind of an organisation: an awareness of changes in the environment that are approaching or about to happen and that, when noticed early, can be acted upon effectively and efficiently. Changes in the environment or organisation themselves are not continuous, but come and go (Walter 2020 ). Changes differ in time, tempo, intensity and meaning. And changes are contextual. Changes can be initiated or acted upon. Characteristic of change is that it is never the same. Therefore, every change brings a new situation, and the organisation needs a new way to cope with this situation. This is the core of learning processes, therefore research on IL provides us with insights on ways to improve these learning processes offered in the daily working practice. This is an important benefit of integrating IL and OA.

Both concepts emphasise change as being part of the daily routine of an organisation. For IL, the emphasis is on valuing the individual and collective learning that happens in daily work triggered by change (Cerasoli et al. 2018 ; Jeong et al. 2018 ; Marsick and Volpe 1999 ). For OA, the emphasis is on the capability of the organisation to deal with change as part of daily work (Charbonnier-Voirin 2011 ; Demuner Flores 2023 ; Förster and Wendler 2012 ; Gunsberg et al. 2018 ; Walter 2020 ). OA leads to a supportive atmosphere where (informal) learning and working are valued more equally. OA also provides the organisation with reasons to connect the strategic development goals of the organisation with individual and collective learning. IL, on the other hand, provides the organisation with a way to collectively create knowledge and practices that lead to the innovations needed in response to change. The main similarities between OA and IL as presented in the results are summarised in Table  1 .

Taking into account the aspects of structure enhancing agility, people agility and agility prerequisites and integrating it with the aspects that let IL flourish, three key attributes of an organisation clearly overlap: (1) seeing the boundaries of an organisation as fluid and having close and meaningful relationships, (2) being accountable for work and working, and (3) having processes for creating or acquiring, processing and applying knowledge. These attributes will be referred to as social networks, leadership, and knowledge development. In the second part of Section 5 the relationship between IL and OA is described in terms of these three key attributes.

5.1 Social networks

Learning happens in a social context, in which it is important to have peers both inside and outside the organisation. These close relationships and multiple connections play a key role for both IL and OA. For IL, the social element is a main ingredient for a rich learning environment (Jeong et al. 2018 ). For OA, involving the appropriate parties, maintaining this network and involving different departments facilitates an effective and speedy response to change. In both concepts, involvement means working closely together, knowing each other’s language, context and profession, and including each other’s values and interests. This is why autonomous cross-functional teams with a large amount of autonomy are mentioned by some researchers as beneficial for OA (Akter et al. 2023 ; Menon and Suresh 2021 ; Vaszkun and Sziráki 2023 ). But these teams need to be fluid in composition and roles (Ludviga and Kalvina 2023 ; Sherehiy et al. 2007 ; Tolf et al. 2015 ). By having a more developmental organisational approach towards networks and processes, participants would be more aware of the learning process itself and how to improve that process. By paying attention to the composition of the network, people become aware of their interpersonal relationships and the influence of these relationships on innovation and improvement and therefore learning. This awareness makes the learning processes more conscious and therefore the results of IL can be made more visible. The ability to leverage qualities evident in the network (Sambamurthy et al. 2003 ) also sets a focus for IL. Another aspect worth mentioning here is the supportive role of IT for staying connected with others. Jeong et al. ( 2018 ) also found a supportive role of IT for IL.

While it is often considered from the individual perspective, IL provides insight into the way relationships can be maintained, by developing interpersonal communication, being able to openly share ideas, and by influencing in what way these capabilities support the learning process (Jeong et al. 2018 ). Research on how close relationships and diversity in social networks support learning and innovation is beneficial here (Baer et al. 2015 ; De Laat 2006 ; Haythornthwaite and De Laat 2010 ).

The diverse network also enables employees to identify developments as soon as possible, to weigh up options, make informed decisions, and act swiftly, all in a collaborative way. This organisational focus for improvement in cooperation provides a breeding ground for IL in that it combines the learning of individuals and connects it to learning collectively, and ultimately to the interest of the organisation (Jeong et al. 2018 ).

5.2 Leadership

The way leadership operates influences employees’ accountability for work and learning. From an OA perspective, commitment of employees to the organisational goals are important and, with it, entrepreneurial behaviour (Teece et al. 2016 ). Involving employees actively in decision making and problem solving, challenging them by giving them a high level of responsibilities and autonomy affects the way employees are involved in IL (Cerasoli et al. 2018 ; Jeong et al. 2018 ; Manuti et al. 2015 ). This autonomy makes work challenging and valued, according to Kim and McLean ( 2014 ). Task autonomy gives freedom and a variety of opportunities which stimulates the employees to learn (Jeong et al. 2018 ).

From the OA perspective, leadership is about providing the conditions for collaboration between different departments (Vaszkun and Sziráki 2023 ). Bringing people together and identifying possible experts to involve can bring diversity and commitment into the network. Facilitating meetings and encouraging open communication with other organisations stimulates information exchange (Sharma et al. 2014 ). These are all aspects of leadership that support IL (Ellinger 2005 ). Paying attention to shared meaning-making and better communication is part of collective IL (Garavan et al. 2015 ). Leadership that facilitates these processes is not a condition, but a characteristic of collective IL.

OA benefits from an alignment of systems, processes, departments, roles,. and so forth, which makes the process of informing and understanding one another easier. The process of alignment is itself of great support to IL, as are knowledge exchange, being clear about mental models and paying explicit attention to the goals of the organisation is organised. Leaders in organisations should create possibilities for working on this alignment and collaboration (Vaszkun and Sziráki 2023 ). Results of research on delegated responsibilities do not lead to clear insights for OA. Some researcher claim that swift decision making requires a clear and strong hierarchy (Felipe et al. 2016 ), while other researchers claim that OA is supported by collaborative decision making, which fosters adaptability (Nijssen and Paauwe 2012 ; Wendler and Stahlke 2014 ). The main tendency, though, is to support the distribution of responsibilities with those who have the professional expertise in order to become faster and more flexible (Menon and Suresh 2021 ; Safari et al. 2018 ; Vaszkun and Sziráki 2023 ). OA appears to be a matter of dealing with complex situations, involving the balancing of competing values, such as speed, engagement, support, thorough analysis, short-term versus long-term considerations, and so forth. OA involves the ability to adapt and learn iteratively throughout a process of improvement and innovation (Teece et al. 2016 ).

5.3 Knowledge development

Being able to respond in a rapid way means there is a need for accurate and up-to-date knowledge involving the ‘right’ people at the ‘right’ time (Charbonnier-Voirin 2011 ; Demuner Flores 2023 ). IT-systems (Phuong et al. 2012 ), communities of practice (Paterek 2017 ), interpersonal skills (Bahrami et al. 2016 ) and absorptive capabilities (Demuner Flores 2023 ) support the processes needed for collaborative and collective knowledge development and exchange. Placing greater value on and consciously utilising IL within the organisation can strengthen this process of collective knowledge development. It provides the organisation not only with forms of learning, but also makes the organisation aware of the learning processes that are happening in daily work. Seeing knowledge as an important value for the organisation and linking it to the strategy of the organisation (Dove 1999 ) also helps valuing IL as a strategic instrument (Jeong et al. 2018 ).

In order to give meaning and direction to innovation, knowledge development should be supported by hypothesising and analysing the available information. By making clear in a collaborative way the possible consequences of changes via ‘for instance’ scenarios, people not only become aware of the possibilities and hypotheses entailed, but also the data that underpins these possible solutions (Teece et al. 2016 ). This can support critical reflection (Jeong et al. 2018 ), especially when management sees it as its task to make tacit knowledge available for the organisation. It also provides ways to make IL more conscious so that employees are motivated to use a research-related approach that can also give direction for experimentation (Teece et al. 2016 ). After improvements are implemented, one should monitor the results and the process, through iterative cycles of action and reflection (Marsick and Watkins 2001 ). Monitoring results and processes provides the organisation with data that can be learned from, because it gives the organisation the opportunity to check whether hypotheses and analyses were accurate (Jeong et al. 2018 ). Performing this in a dialogic way between co-workers in a network of different organisations working together puts IL in a collective context (Garavan et al. 2015 ).

Developing skills to support OA, such as interaction capabilities, improving processes and reflecting systematically, sets a focus for learning, but these capabilities also support a learning climate. Becoming more sensitive to their environment makes people more aware of the signals for change in this environment, which trigger learning and initiate a research-related approach (Jeong et al. 2018 ). Seizing the information means organising information and therefore the action needed for IL, as mentioned by Marsick ( 2009 ). Transforming capabilities deal with keeping the structure, strategy and culture aligned when changes are implemented. Transforming capabilities foster a culture in which experimentation and innovation are valued, which creates a rich climate for IL (Gunsberg et al. 2018 ; Jeong et al. 2018 ). Seen form the collective perspective, this in fact is how networked learning is defined (NLEC 2021 ). These elements form the basis for the trustful climate necessary for open communication and accessibility of knowledge (Jeong et al. 2018 ). An important condition for individual IL is also the supportive role of leaders in which risk taking for experimentation and knowledge exchange is seen as just as important as being productive (Jeong et al. 2018 ; Skule 2004 ). Continuous training and workshops support improvements in OA. Furthermore, combining IL with formal learning makes IL more effective (Jeong et al. 2018 ). IL is closely related to daily work and therefore the results are expected to be directly applicable to the daily workplace context (Marsick and Volpe 1999 ). In fact, being less conscious about this as a learner is showing both the strength and the weakness of IL in supporting OA. Making tacit knowledge tangible is a key aspect of IL in order for it to become valuable for others in the organisation or the network (Kim and McLean 2014 ; Nonaka and Takeuchi 1996 ). The way knowledge is strategically valued contributes also to the learning.

Mechanisms that influence both IL and OA

culture of an organisation (Dove 1999 ; Ellinger 2005 ; Kim and McLean 2014 ).

We summarise the integration of the findings in detail in Fig.  3 .

6 Discussion and conclusion

The main purpose of this study was to examine the relationship between OA and IL and to investigate what mechanisms would be beneficial for both concepts. IL finds it origin in the theory of Dewey (Kim and McLean 2014 ), for whom learning was the effect of acquiring experience. Learning, in this scientific tradition, is contextual and social. This fits the way OA must be conceived according to the literature studied. However, the primary approach to learning in research on OA is, at best, instrumental; learning is considered a way to become agile as an organisation by improving the adaptive capacity and dynamic capabilities. But learning, as we have shown, is much more than an instrument. It can be seen as a quality of an organisation and another way to deal with change in the environment. And as IL is part of every organisation, whether beneficially used or working unconsciously, it provides organisations with an opportunity to be more agile. Learning is poorly defined in most literature on OA, and the benefit of informal learning seems under-valued. Based on an in-depth insight into the relationship between IL and OA in this article, the mechanisms that either support or characterise IL can be an answer to the rapid changes in the environment, just as OA is. The knowledge that is gained by studying the way IL is beneficial for organisations can enrich the field of study of OA, and this warrants further research. For example, OA is supported by a variety of professionals working together and bringing in their perspectives in order to be innovative. One could use the knowledge from the studies on IL about strengthening these networks on the one hand and keeping it fluid on the other hand. Both strong and weak social connections are important for learning and innovating. These insights might be helpful in reflecting on the way that organisations’ networks are developing. Paying attention to the development of networks not only improves OA, but also IL. The way learning networks can be beneficial for OA should be studied in more detail, especially in the context of hierarchy and task autonomy.

The collective perspective of IL is hardly considered in research on OA; most learning is seen as individual. Collective learning is interesting, and OA itself also deals with dynamic capabilities and absorptive capacities of groups and networks of organisations. To date, most of the research on OA taken from our database is based on queries that gather individual perspectives. It would be interesting to focus more on research methods that look at the system as a whole, not only as a sum of its parts. The model of Garavan et al. ( 2015 ) for looking at individual and collective learning, either organised or emerging, could be beneficial in looking at OA from a collective and learning perspective.

The model presented here as the result of integrating OA and IL is also an agenda for further research. We recommend further research into the effects of leadership mechanisms on the way (networks of) organisations (continue to) learn to deal with change. Similarly, it is important to further scrutinise the impact of informal learning mechanisms that influence social networks and knowledge development effects within agile organisations.

Both OA and IL are concepts that are strongly interwoven with their environment. This interconnectedness means that they themselves are also constantly subject to change and learning. As such, they form complex and multi-level processes which are challenging to investigate in an appropriate manner. In this context, it is fitting to be able to dwell in the space of not knowing, just as with OA and IL themselves, whilst the researcher searches for answers.

6.1 Practical implications

Organisations dealing with a rapidly changing environment can benefit from the findings of this study. By paying attention to the mechanisms mentioned in Fig.  3 , they can strengthen their learning capacity on the one hand. Focusing on the composition, quality, and development of relationships in social networks helps organisations to utilise these networks for innovation and improvement of their processes, products, and services. Attention to how leadership is shared within these networks and relocated where necessary, depending on knowledge and expertise, creates space for ownership of results and thus for reflection and improvement. Recognising the value of knowledge and expertise contributes to the sharing of this knowledge and thereby to collective learning.

The same mechanisms contribute to the organisation’s agility. The networks can provide rapid information dissemination and early detection of changes. Shared leadership can accelerate the implementation of changes. And the appreciation of knowledge and expertise can lead to increased attention to its development and the processes that facilitate it.

The identified mechanisms are not isolated from one another. They are interrelated and require an integrated approach at both individual and collective levels.

7 Limitations in the research

As both IL and OA derive from different disciplinary domains, bringing the two concepts together is a challenging exercise. This is especially so when similar concepts like learning and knowledge are used in both contexts but may not have a shared meaning across these domains. The use of barely defined concepts such as learning and knowledge in studies on OA did not help in this regard. The often instrumental view of learning also makes this study a cautious exploration of the relationship. Therefore, more research into bringing together both concepts is desirable.

Furthermore, the meaning and definition of OA is still very much developing, resulting in different weights or emphases applied to learning and knowledge in the articles included in this review. In this study, we attempted to be as clear as possible about the interpretations we made and the definitions we have used. Nevertheless, this is an integrative literature review and a first attempt to bridge a dialogue about how to foster dealing with change from the perspective of IL and OA. This review might inspire inter-disciplinary research and develop ways in which IL can help promote and facilitate OA and, similarly, where OA can include a richer understanding of learning and knowledge processes in its definition. Further empirical research, in which learning and change processes relate to orientations towards OA will help to further unpack this relationship and reveal how IL can play a key role in achieving a sustained approach to agility. The identified key conditions for improving IL and OA – based on social network, knowledge development and leadership – is a first take on this.

Data availability

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Leadership Development in Medicine: A Review

Lulu alwazzan.

1 Medical Education, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU

The complex and unique challenges of healthcare require physicians who are competent leaders. Leadership is shaped by complex dynamic processes and various factors. Such factors include intrapersonal (leadership identity, cognitive abilities, and self-leadership) and interpersonal factors (vision and mission development and team building). The purpose of this paper is to review current thinking and advancements in leader and leader development by drawing on the administrative literature and discussing how it may apply to medicine, focusing on the contemporary approaches, challenges, and opportunities in this field. More specifically, this review analyses the intrapersonal and interpersonal development of medical leadership, beginning with a consideration of the current state of medical education and practice. It also covers the current challenges affecting medical leadership, as well as the implications for practice, policy, and research. In this paper, it was found that leader and leadership development are both essential for leader growth and to enhance leaders' competencies and effectiveness. The latter leads to improved organizational performance. The paper also highlights the importance of integrating various methods of teaching and learning to optimize leadership development programs.

Introduction and background

Leader and leadership development in healthcare are essential and active areas of study [ 1 ]. This scholarly interest is a response to the dire need for competent leaders and effective leadership to deal with the ever-evolving medical sector. Population growth, the emergence of new diseases and disease complications, and technological advances are among the factors that have led to the emergence of complex organizational challenges [ 2 ]. To face such challenges, leaders require innovative approaches, dynamic problem-solving skills, and a tolerance for organizational complexity. Drawing on the administration literature, the purpose of this paper is to present current thinking and advancements in leader and leadership development, focusing on the challenges, and opportunities in this field and as it relates to medicine. While the conceptual advancements offered in this literature review are not novel, they are not easily implemented. The findings of this review should inspire medical leaders to think globally, creatively address challenges, and innovate.

There is wide recognition that leadership competencies can be cultivated and developed amongst individuals and teams through intentional education and development [ 3 , 4 ]. Consequently, academic and medical institutions have dedicated enormous efforts and resources to provide leadership development opportunities and initiatives to cultivate the current and next generation of leaders in the healthcare sector. A distinction between the development of the leader and leadership development must be made. The former is concerned with arming individuals with the necessary competencies to lead, while the latter is a process of development that involves multiple people [ 5 ].

A "leader" is an individual who guides activities and obligations in healthcare settings such as managing, leading, and making decisions. Medical leaders often hold positions of authority, such as administrators or department heads, and are responsible for organizing and leading medical teams and systems [ 6 ]. Leadership development in medical education and practice refers to the deliberate pursuit of enhancing an individual's knowledge, talents, and competencies to effectively lead and manage in the healthcare business. It consists of mentorship, experience learning, and formal and informal training courses aimed to prepare healthcare professionals for positions of leadership [ 7 , 8 ]. For leader development formal leadership training programs typically include a combination of formal and informal training opportunities. Formal opportunities include didactic teaching, short courses, and experiential learning [ 9 ]. While informal opportunities include mentorship, coaching, and reflective practice [ 10 ]. By providing individuals with deliberate and structured opportunities to enhance their leadership knowledge, skills, and attitudes, institutions aim to arm a cadre of elite individuals that, as a result of their newly found knowledge and skills, can positively influence human resource development, workplace culture, and healthcare outcomes [ 11 ].

More recent approaches, however, target leadership development, that is, targeting the process of leadership that involves several people in the workplace context [ 12 - 14 ]. This calls for leaving behind the constant need to link leadership development to individualistic leadership theory, arguing that leadership development is a complex set of processes that occur in the context of ongoing adult learning [ 15 ]. Leadership development is multilevel and longitudinal in nature, meaning there needs to be a focus on the intra-personal and inter-personal aspects of development simultaneously and over time [ 16 , 17 ]. Intra-personal factors include self-leadership and formalized training programs, while interpersonal aspects include relationship-building and influencing others. 

It is critical to realize that the path to medical leadership development is challenging. The healthcare industry's often complex and dynamic structure, combined with a plethora of competing demands and limited resources, presents substantial barriers to the development of leaders and leadership in the healthcare sector [ 18 , 19 ]. Complexity is defined by Cohen et al. (2013) [ 20 ]: “a dynamic and constantly emerging set of processes and objects that not only interact with each other but come to be defined by those interactions”. Such processes are characterized by multiplicity (the number of elements), interdependence (the degree of connection between the elements), and heterogeneity. While often starting with the same elements, these properties often lead to unpredictable outcomes [ 21 , 22 ]. This makes the role of the leader more essential in leading in and through unpredictability. It is important to note that not everything in medical practice is considered complex, as some processes are complicated and outcomes can be predicted and managed.

Recent data from the literature underscore the increasing demands placed on medical leadership and the increasing importance of talented leaders in navigating the shifting healthcare landscape [ 1 ]. Additionally, the traditional hierarchical structure of medical education and practice may present barriers to implementing and sustaining leadership development initiatives [ 23 ]. Addressing these challenges requires a comprehensive understanding of the unique context and dynamics of medical practice, as well as innovative and evidence-based approaches to leadership development. By offering an understanding of leadership development in medicine, the medical sector may offer better leadership that leads to the optimization of organizational performance and enhances healthcare outcomes.

The review has not identified and discussed all the articles on leadership development, rather, it aims to present a prevalent discourse within administrative literature and to present and discuss high-level concepts within the context of current published works. The ultimate purpose of this review is to assist in the development of competent and diverse medical leaders who are capable of successfully navigating the complex and ever-changing healthcare environment in order to improve patient outcomes and the system as a whole. In what follows, this review paper elaborates on the context of medicine and presents the intra-personal and inter-personal development of leadership. Moreover, it discusses the challenges to leader and leadership development and the implications for policy, practice, and research.

Leadership in medical education and practice

The leadership training of physicians has often been categorized according to stages: undergraduate, postgraduate, and continuous education. The literature argues for integrating leadership training in undergraduate [ 17 ] and postgraduate medical curricula [ 4 ]. The most commonly cited reason for adding leadership training in medical curricula is that it will better prepare medical practitioners to manage and lead in a complex and changing healthcare environment, increasing organizational performance and patient care. Such works report formal leadership training programs. Often such educational interventions lack grounding in conceptual leadership frameworks, neglect to evaluate outcomes properly, and most focus primarily on cognitive leadership domains. In terms of training targeting more practicing doctors [ 1 ], Steinert et al. (2012) reviewed faculty development initiatives that target leadership competencies amongst medical faculty members, and they identified key features of successful programs, including the use of multiple instructional methods, experiential learning, and peer support and mentorship. Research has also taken a deeper look, advocating for the development of leadership amongst course coordinators and recommending a complex adaptive style of leadership based on whole systems theory to enhance undergraduate programs [ 22 ].

Beyond embedding leadership development in learning outcomes and educational frameworks within the work context, there is also an increasing recognition of clinical leadership, that is, leadership development rooted in work-based activities [ 17 , 23 - 25 ]. This trend shows a shift towards integrating leadership competencies directly into clinical practice, acknowledging the intrinsic role leadership plays in the clinical context. This shows that leadership is perhaps honed and developed in real-world scenarios and practical applications and that medical or clinical leadership is a distinct style of leadership. Moreover, medical leadership often involves cross-disciplinary collaboration. As a result, a common challenge is facilitating effective communication and collaboration among professionals with diverse professions and experiences [ 26 , 27 ]. Furthermore, navigating the complex healthcare system poses a challenge to leaders as well. Navigating complex, often conflicting, regulations and operational intricacies requires that medical leaders make strategic decisions while ensuring high quality patient care.

Individual-level leadership

According to Day et al. (2014) [ 5 ], three aspects of leader development are broadly addressed in the literature: identity development, cognitive abilities, and self-leadership. First, leader identity development in healthcare is a complex dynamic process that is shaped by various factors. Such factors include personal experiences, interpersonal relationships, formal leadership roles, and organizational culture [ 11 ]. The leadership literature describes several models for leadership identity development, one of the most well-known being the Komives et al. (2006) Leadership Identity Development Model [ 28 ]. The model categorized six stages of leadership identity development: 1) Awareness (individuals begin to recognize their potential leadership), 2) Effortful Identification (individuals begin to explore their leadership interests and abilities, 3) Involvement (take on leadership roles and responsibilities), 4) Leadership for Self-Growth (focus on developing their leadership skills and knowledge), 5) Leadership for Impact (focus on using their leadership to make a difference in their context), 6) Authentic Leadership (develop a clear sense of their own leadership identity and are able to lead).

The leadership identity development process is not linear, rather, it is complex. Within this model, individuals move back and forth between stages as they learn and grow. The model offers a conceptualization of the different stages of leadership identity development. By understanding the different stages of leadership identity development and the factors that can influence this process, individuals can better prepare themselves for leadership roles. These different stages can be achieved by explicit training and development efforts and involvement in leadership roles. In identity development, it is important to draw focus to influence others. Influence is one’s ability to motivate and mobilize followers to participate in change (steps 5 and 6 of Komive’s development model). While influence is a relational process it may be considered as an individual competency to be developed [ 29 ]. This can be appreciated through a shared social identity, once a group of people have a shared organizational identity, they are more likely to follow those who share this identity. For the leader, it is important to recognize this social identity and have the ability to influence the actions of others through it.

Another important aspect addressed in the literature is the cognitive domains vital to leader development. Such critical skills include problem-solving, planning and implementation, solution construction and evaluation, social intelligence, and self-awareness [ 30 ]. These abilities have been the locus of many leadership development programs, the premise being the more skilled the individual the more likely they are able to lead [ 8 ]. As vital as these skills are, the more senior a leader becomes in organizational positions, the acquisition of strategic and business skills becomes more important for effective performance [ 31 ].

Self-leadership is also of crucial importance at the individual developmental level; that is, being a self-directed lifelong learner [ 30 ]. Ensuring leaders are self-aware and able to diagnose themselves in terms of their learning is crucial for organizations that are continuously evolving. This is true for any organization but especially true for healthcare organizations where administrative practice is often a reflection of clinical practice and updated clinical guidelines and ways of practice rapidly evolve. Additionally, self-directed learning is an efficient and often cost-effective way to develop human capital [ 30 ], as learners self-diagnose and take charge of their own learning needs and requirements based on their current leadership assignment. 

Group-level leadership

According to Day et al's (2014) categorization, leadership development is an interpersonal process that involves a team of people to occur [ 5 ]. As a dynamic process that involves several individuals, the examination of leadership development requires a multi-level approach [ 29 ]. A simultaneous examination of the individual (their emergence and enactment of leadership, as explained in the above section), their interaction with others, and their interaction with the broader culture [ 31 ]. Here the exchange between individuals in an organization becomes central [ 32 , 33 ]. This exchange may be between leaders or leaders and followers. Such interactions shape social capital and human resource development. As a result, positive values have been the focus of previous studies [ 12 ]. Moreover, certain psychological processes such as knowledge, interpersonal skills, and communication competence coupled with organizational culture and environment leverage the development of strong, fruitful professional relationships, that one can draw on to accomplish organizational objectives [ 34 , 35 ].

Here it is important to draw a distinction between social capital and human capital. Social capital is concerned with interaction in the social context. However, human capital is concerned with the individual leader attributes [ 34 ]. Social capital is characterized by contact (e.g., mentoring), assimilation (e.g., job assignment), and identification (e.g. leadership training). These educational practices vary in their potential for social capital development; thus design of educational interventions should be done accordingly [ 34 ].

When considering leadership as a process, the literature presents the importance of social networks and the time it takes to develop such relationships. According to Cullen-Lester et al. (2016), groups of leaders must understand the leverage and the influence of their positions within an organization [ 30 ]. Such leverage can enhance a group's ability to accomplish organizational goals and enhance alignment with the overall aims of the organization.

Challenges facing leadership development

Leader and leadership development in medicine face certain challenges. First is the intra-personal development, that is the development of self-identity prior to the development of leadership competencies. It is often difficult to recognize talent, making talent acquisition for leadership challenging [ 19 ]. Moreover, the dearth of tailored leadership development programs for leaders in the medical context pushes aspiring leaders to utilize current leadership development initiatives that lack a clear focus on addressing the specific challenges faced by healthcare leaders or that help in addressing contextual issues such as navigating interdisciplinary collaborations and fostering an understanding of local legal systems that often influence practice [ 36 ].

Furthermore, when considering interpersonal development, the hierarchical nature of healthcare may hinder leadership development. Traditional healthcare structures prioritize individual achievements and performance, this may discourage potential relational leaders from pursuing leadership roles [ 37 , 38 ]. Another pertinent challenge is leadership succession planning [ 3 ]. Many institutions fail to identify and foster leadership, leading to potential disruptions in the continuity of leadership within institutions. The lack of diversity and inclusion of underrepresented groups, such as women in leadership positions is a significant issue. This limitation hinders addressing emerging health disparities effectively [ 36 , 37 ].

Healthcare faces several challenges. Such challenges include limited access to quality healthcare services, especially in remote areas, resulting in disparities in healthcare services. Moreover, there is a need to re-skill and up-skill the healthcare workforce to meet emerging healthcare demands [ 31 , 39 ]. In addition, there is a great emphasis on emerging technologies and how they are to be utilized to enhance healthcare services. Such technologies include artificial intelligence, telemedicine, electronic health records, and robotics and automation. Finally, healthcare financing and insurance systems are currently taking shape in many parts of the globe and are fast becoming essential skills for leaders within healthcare.

To address healthcare challenges successfully, a complete understanding of the intricate and ever-changing components of medical leadership development is required. Effective leadership at various levels of an organization requires certain attributes such as self-awareness, problem-solving talents, and social intelligence. This is especially significant given the complexity of the healthcare system [ 21 ]. Healthcare necessitates the continued development of business- and strategy-focused competencies in order to advance to higher-level roles. Furthermore, a leader's skills will have a significant impact on how successfully they perform in the future. This stresses the significance of career advancement and specialized professional development programs for healthcare executives. These types of training are critical in equipping physicians with the skills and knowledge they need to deal with the rising healthcare concerns [ 40 , 41 ].

The prevalent patterns in academic studies on leadership development stress the importance of having a multi-level perspective. This entails rigorously scrutinizing how leaders emerge and exercise leadership, as well as how they interact with others and the greater business culture [ 37 ]. The emphasis on positive attributes such as trust and respect for one another emphasizes the importance of social capital in developing effective working relationships.

Implications for policy, practice, and research

In terms of policy, there is a need for ones that cater to the recruitment and development of leadership. Policies that target these two areas promote better working environments in addition to healthier and more effective organizations [ 32 ]. The continuity of leadership within the confines of medical institutions is in danger if such institutions fail to identify, recruit, groom, and develop potential leaders. Moreover, setting policies that are based on sound needs assessment studies and that promote diversity and inclusion can create a bigger pool to select potential leaders. While previous research has highlighted these policy recommendations, many healthcare organizations still face challenges in recruitment and development. Given the complex systems where healthcare takes place, it is important to recruit those who have the highest tolerance for ambiguity and can navigate the evolving healthcare sector. Moreover, training for such skills requires embracing leadership programs that are longitudinal in nature and workplace-oriented [ 3 ]. Here it becomes necessary to recognize that leader development is closely related to administrative positions. As a result, leader development may be a prerequisite to nomination for positions and a requisite during tenure. 

For practice, there is a need to integrate formal leadership training in medical education. It is vital that potential leaders are not discouraged from seeking out leadership roles, as is commonly promoted in traditional academic and healthcare structures [ 31 ]. Customized programs in leadership development not only incentivize potential and current leaders but are also crucial measures to elevate leadership competencies within healthcare [ 39 ]. Integrated programs relieve potential and current leaders from the burden of seeking out programs that may or may not be suitable for their current roles. Institutions clearly identifying the target programs that potential leaders enroll in help keep focus on the skills and knowledge that are needed for their context [ 36 ].

For research, further studies should aim to explore the juxtaposition of leader development with identity development. For example, how much of a leader’s identity is developed during each stage of their leadership journey. Do a group of leaders have a shared leadership identity given that they all belong to the same medical institution? This is important against the backdrop of interprofessional practice, that is, how shared leadership identity is nurtured not only amongst a group of physicians but also amongst a multi-professional healthcare team. Research in the area of leader and leadership development can identify and highlight key areas of interest within the field. Furthermore, researchers should evaluate leadership development in terms of process, starting from identifying who is fit to lead to how to further develop a seasoned leader to developing a group of leaders who are in different stages of their leadership journey. This line of thinking impacts medical education, as leader and leadership development must be integrated at an early stage, beginning in undergraduate programs and throughout postgraduate programs and across different specialties. Such training measures cannot be considered impactful unless impact is truly measured. Hence, research focusing on how to measure the impact of leader and leadership development within healthcare is quite vital in providing insight into the effectiveness of such programs.

Limitations

First, given the method's limitations, a wider search strategy, including more databases and ensuring cross-disciplinary data collection, may have yielded richer results. Second, the review was written by one person. A multidisciplinary team, including a leadership expert and other health professionals, might have provided richer insights and strengthened the arguments put forth.

Conclusions

This paper discusses the advancement of leaders and leadership development in the medical field with a special emphasis on comprehending the individual and community components. Moreover, it focuses on concerns and repercussions relating to recruitment and development of leadership policies, practices, and planned research projects. Combining these two aspects of leadership development provides a comprehensive perspective that is required for successfully navigating the complex healthcare environment. It further explores the leader and leadership challenges and implications for policy, practice, and research. As an active area of study, and given the ever-evolving nature of the healthcare sector, much interest has been shown to equip leaders with the tools necessary for effective leadership. Facing challenges, such as the emergence of diseases, disease complications, and technological advances, leaders are constantly put in situations that require new ways to approach challenges, thinking-on-your-feet problem-solving skills, and a high tolerance threshold for ambiguities within the organization.

Given the wide-held belief that conscious education and development can increase leadership competencies, resources have been allotted in medical and academic programs in this vein. As such, opportunities and initiatives that cater to developing leaders and leadership have been a focus in the healthcare context. Some approaches used in leadership development programs are short courses, mentoring, and shadowing opportunities. Leader development and leadership development are not one and the same. Leader development focuses on the individual and their identity and competencies to lead while leadership development is more rooted in the process of developing more than one leader and harnessing the interpersonal relationships that ultimately one draws on to accomplish organizational goals.

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:   Lulu Alwazzan

Acquisition, analysis, or interpretation of data:   Lulu Alwazzan

Drafting of the manuscript:   Lulu Alwazzan

Critical review of the manuscript for important intellectual content:   Lulu Alwazzan

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The multiple advantages of self-leadership in higher education: the role of health-promoting self-leadership amongst executive mba students.

1. Introduction

2. literature review, 2.1. self-leadership, 2.2. value- and behaviour-oriented self-leadership, 2.3. self-efficacy-oriented self-leadership, 2.4. energy-oriented self-leadership, 2.5. mental fitness and performance, 2.6. the importance of physical exercise, socialization, and laughter for mental fitness, 3. the cases and research questions.

The purpose of the assignment is to apply the literature and meta-cognition about how you should think and carry out a self-development process to “become” a better fellow human being and leader. Choose your arena(s) and situation (organization/company, business area, position, and/or your private life) and begin by writing your own “case” that describes your everyday life and experienced challenges. Follow this with a section on theoretical reflections, linking them to your challenges by highlighting their theoretical relevance. Then, define four to six self-selected development areas, connect them to relevant theoretical concepts, and evaluate yourself in these areas. The self-evaluation may include self-observation, results from questionnaires related to the theoretical concepts, and opinions from external sources such as colleagues, partners, and friends. Summarize the self-evaluation section by listing the challenges and strengths of each area/concept. Conclude by defining the challenges you will prioritize as your self-development areas, including objectives for the self-development process. In the section where you report on your self-development process, it is important to describe the methods/tools/exercises you use to achieve your objectives. It is recommended to maintain a training program and a diary with notes and reflections throughout the process. Conclude the report with a results section that includes reflections summarizing and concluding the self-development process.

4. Methodology

4.1. method, 4.2. the mba program, sample, and demographics, 4.3. research ethics, 5. findings, 5.1. areas for self-evaluation and prioritized self-development (rq1).

“Negative self-talk, or what I have called ‘my inner critical voice’, is a topic I have consciously worked with as a manager but is a challenge that has become more prominent in the past year. Feedback from friends, colleagues and manager also illuminates this in that I am perceived as self-critical, sometimes have difficulty accepting bragging, am frugal and at times make too high demands on myself. I have experienced that this is often linked to feelings of inadequacy, inferiority, and a lack of faith in myself—I especially experience this as reinforcing in a context where one feels overwhelmed.”

5.2. Types of Methods, Tools, and Exercises (RQ2)

5.3. objectives and achieved results (rq3).

“By working on this assignment, I have come to the conclusion that choosing a lifestyle that improves mental and physical surplus is in itself a self-leadership strategy, as well as an important premise for getting the surplus needed to better manage myself. At the same time, the concept of self-leadership can be seen as a project of liberation, where it is about recognizing that you have opportunities for influence in all contexts.”

“I have therefore set myself a new goal to become even better at focusing. Developing my inner dialogue and improving my physiology. I have set myself the objective of losing the 10 kilos that I have put on since 2016. I will practice 15 min of mindfulness to train my attention. I should aim to get a minimum of 7 h of sleep each night.”

“What I am left with is not something I can show on paper or through any statistics, but a feeling, a sense of ease when I go to work and know that I am contributing to the positive.”

6. Discussion and Implications

6.1. discussion, 6.2. theoretical implications, 6.3. practical implications, 7. conclusions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Bjerke, R. The Multiple Advantages of Self-Leadership in Higher Education: The Role of Health-Promoting Self-Leadership amongst Executive MBA Students. Adm. Sci. 2024 , 14 , 211. https://doi.org/10.3390/admsci14090211

Bjerke R. The Multiple Advantages of Self-Leadership in Higher Education: The Role of Health-Promoting Self-Leadership amongst Executive MBA Students. Administrative Sciences . 2024; 14(9):211. https://doi.org/10.3390/admsci14090211

Bjerke, Rune. 2024. "The Multiple Advantages of Self-Leadership in Higher Education: The Role of Health-Promoting Self-Leadership amongst Executive MBA Students" Administrative Sciences 14, no. 9: 211. https://doi.org/10.3390/admsci14090211

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Peer-reviewed

Research Article

Perpetrators of gender-based workplace violence amongst nurses and physicians–A scoping review of the literature

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Roles Data curation, Formal analysis, Investigation, Validation, Writing – review & editing

Affiliation Princess Margaret Cancer Centre, Toronto, Canada

Roles Conceptualization, Investigation, Methodology, Validation, Writing – review & editing

Roles Formal analysis, Investigation, Writing – original draft

Roles Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – review & editing

• Basnama Ayaz, 
• Graham Dozois, 
• Andrea L. Baumann, 
• Adam Fuseini, 
• Sioban Nelson

• Published: September 6, 2024
• https://doi.org/10.1371/journal.pgph.0003646
• Peer Review
• Reader Comments

In healthcare settings worldwide, workplace violence (WPV) has been extensively studied. However, significantly less is known about gender-based WPV and the characteristics of perpetrators. We conducted a comprehensive scoping review on Type II (directed by consumers) and Type III (perpetuated by healthcare workers) gender based-WPV among nurses and physicians globally. For the review, we followed the Preferred Reporting Items for Systematic and Meta Analyses extension for Scoping Review (PRISMA-ScR). The protocol for the comprehensive review was registered on the Open Science Framework on January 14, 2022, at https://osf.io/t4pfb/ . A systematic search in five health and social science databases yielded 178 relevant studies that indicated types of perpetrators, with only 34 providing descriptive data for perpetrators’ gender. Across both types of WPV, men (65.1%) were more frequently responsible for perpetuating WPV compared to women (28.2%) and both genders (6.7%). Type II WPV, demonstrated a higher incidence of violence against women; linked to the gendered roles, stereotypes, and societal expectations that allocate specific responsibilities based on gender. Type III WPV was further categorized into Type III-A (horizontal) and Type III-B (vertical). With Type III WPV, gendered power structures and stereotypes contributed to a permissive environment for violence by men and women that victimized more women. These revelations emphasize the pressing need for gender-sensitive strategies for addressing WPV within the healthcare sector. Policymakers must prioritize the security of healthcare workers, especially women, through reforms and zero-tolerance policies. Promoting gender equality and empowerment within the workforce and leadership is pivotal. Additionally, creating a culture of inclusivity, support, and respect, led by senior leadership, acknowledging WPV as a structural issue and enabling an open dialogue across all levels are essential for combating this pervasive problem.

Citation: Ayaz B, Dozois G, Baumann AL, Fuseini A, Nelson S (2024) Perpetrators of gender-based workplace violence amongst nurses and physicians–A scoping review of the literature. PLOS Glob Public Health 4(9): e0003646. https://doi.org/10.1371/journal.pgph.0003646

Editor: Tanmay Bagade, The University of Newcastle Australia: University of Newcastle, AUSTRALIA

Received: May 22, 2024; Accepted: August 2, 2024; Published: September 6, 2024

Copyright: © 2024 Ayaz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are included in the manuscript and its supporting information files.

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

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

Introduction

The International Labour Office (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO), and Public Services International (PSI) defined WPV as "incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health" [ 1 ]. The ILO [ 2 ] further defined "gender-based violence and harassment means violence and harassment directed at persons because of their sex or gender, or affecting persons of a particular sex or gender disproportionately".

Irrespective of industry, workplace violence (WPV) can cause lasting trauma and injuries and is a serious threat to human and health resources. WPV includes physical and psychological violence, including physical assault, verbal abuse, sexual harassment, and bullying. Gender-based workplace violence (GB-WPV), which is experienced across operational layers of an organization (horizontal) and organizational hierarchy (vertical), reinforces the differential risk for exposure and outcomes of violence for men and women [ 3 ]. Despite extensive research on workplace violence in healthcare, GB-WPV, its perpetrators, and its impact on healthcare professionals remains understudied. We presented the sex-segregated prevalence and risk factors for WPV somewhere else [ 4 ]. The earlier paper focused on the scope and scale of workplace violence (WPV), risk factors and its impact on men and women. As part of the same scoping review protocol, this paper reports on GB-WPV perpetrators. It specifically focuses on explaining the root causes of violent acts by individuals and the triggers and circumstances to provide gender-sensitive recommendations.

A systematic review [ 5 ] of the consequences of exposure to WPV in the healthcare setting based on 68 studies reported psychological and emotional effects such as post-traumatic stress, depression, anger, and fear. These effects impact work productivity, leading to increased sick leaves, poor job satisfaction, burnout, and higher attrition rates, particularly for women [ 5 ]. Studies have also shown that men are more likely to commit physical violence [ 6 ] and sexual harassment [ 7 , 8 ], while women are more often engaged in verbal abuse [ 9 ]. Moreover, gender stereotypes and inequalities in the distribution of roles and responsibilities can worsen power imbalances [ 3 ]. By recognizing and understanding these issues, employers and organizations can more effectively prevent and deal with gender-based workplace violence, ensuring a safer and more equitable work environment for everyone.

The classification of workplace violence has evolved, delineating distinct categories shaped by the nature of its perpetrators. The current working taxonomy categorizes WPV into four types based on the perpetrators of violence. This typology, as shown in Table 1 , emerged from a collaborative effort of a workshop on workplace violence intervention research held in Washington, DC, in 2000. The findings of this endeavour were subsequently published by the U.S. Department of Justice in 2001 [ 13 ]. Since then, this framework has been adopted by multiple organizations [ 10 , 11 , 14 ], and by researchers [ 12 , 15 ].

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https://doi.org/10.1371/journal.pgph.0003646.t001

This paper explores the dynamics of workplace violence by categorizing and summarizing both Type II WPV, from patients and significant others, and Type III WPV (horizontal and vertical), which pertain to violence perpetuated by colleagues, supervisors, and administrators within the organization. Additionally, we explore the nuances of GB-WPV, considering both the perpetrators and nurses and physicians as victims of WPV. We summarized perpetrators based on their gender and synthesized the factors attributed to Type II and III, which are prevalent forms of violence reported in the literature. Type I and Type IV violence are beyond the scope of this paper as they focus on a security-based rather than workplace culture interventions. Understanding the factors contributing to these types of WPV is crucial to developing effective preventive interventions and strategies. Currently, there is a dearth of information identifying the characteristics of individuals who are more likely to commit GB-WPV and the characteristics of those targeted by such offences. This review addresses this gap by synthesizing data from studies that reported on the gender/sex data for various forms (please see S1 Text : Definitions of the Forms of Violence) of WPV and perpetrators of WPV among nurses and physicians.

While WPV affects individuals across the gender spectrum and in different professional groups, women are disproportionately affected. Some studies attributed it to their preponderance in the health workforce, their overrepresentation in lower positions in organizational and professional hierarchies, and societal gender norms in most cultures that subjugate women [ 9 , 16 ]. Recognizing that workplace violence is fundamentally intertwined with broader societal structures rooted in socioeconomic, cultural, and institutional factors, we underscore the necessity of a systematic approach to address this issue—one that is integrated, participatory, culturally and gender-sensitive, and non-discriminatory [ 1 ]. While current interventions aimed at addressing WPV primarily focus on assessing the effectiveness of training interventions to prevent and manage WPV in healthcare settings [ 17 – 19 ], they often lack gender-segregated findings for their effectiveness. Clarifying the existing situation on the gender of victims and perpetrators for specific Type/s of violence would help develop gender-sensitive interventions and policies to more effectively address WPV. This scoping review focuses on understanding GB-WPV and its perpetrators in the global health workforce, including nurses and physicians. Our preliminary search for a scoping review revealed that GB-WPV affects men, women, and non-binary persons. However, most studies included in this review reported gender as binary (men and women); only a few studies included non-binary personnel (for sample-see Table 2 , in results section). Therefore, we defined gender as a binary for this review and deliberated on it in the discussion section.

https://doi.org/10.1371/journal.pgph.0003646.t002

Our specific objectives set out for this paper were:

• Describe the proportions of WPV and related perpetrator/s contributing to Type II (from patients/clients/families) and Type III (worker-to-worker) violence among nurses and physicians in different contexts.
• Summarize the gendered perpetration of Type II and Type III WPV against men and women in the health workforce.
• Identify gaps in the state of knowledge to recommend direction for future empirical research studies.

Protocol registration and study design

Following the Joanna Briggs Institute (JBI) revised guidelines, we conducted a scoping review. The protocol for this review was registered on the Open Science Framework on January 14, 2022, and is accessible at https://osf.io/t4pfb/ and S2 Text : Registered Protocol. The scoping literature review design addressed the research questions and accommodated the heterogeneous and complex nature of the literature. This method is appropriate for exploring the extent of the literature, mapping and summarizing the evidence, and identifying and analyzing knowledge gaps to inform future research. The framework used for this review consists of eight steps; they are built upon the seminal framework of Arksey and O’Malley’s scoping review, which was further developed by Levac and colleagues. The revised guidelines of JBI align these eight steps with the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), ensuring rigour, transparency, and trustworthiness in Reporting the conduct of the scoping review. The first step of the scoping review framework is to align with research objectives, the title, and the inclusion criteria, as well as the exclusion criteria (see Box 1 ). Please see S1 Checklist : PRISMA-ScR Checklist.

Box 1. Study selection criteria.

Inclusion Criteria for Studies

1. The study participants included nurses and/ or physicians who experienced WPV during their careers.

2. Provided sex-segregated data for any form of violence and any type of perpetrators among nurses and physicians, including students, globally.

3. Published in English and after 2010.

Exclusion criteria

4. Studies that did not provide sex-segregated data and information for perpetrators.

5. Exclude systematic/ scoping reviews, concept or theoretical papers, and theses.

Search strategy

The research team collaborated with a health sciences librarian to develop a comprehensive search strategy. The systematic search focused on published literature in various databases, including Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations, which were translated in CINAHL Plus, APA PsycINFO, Web of Sciences, and Gender Studies Databases, Applied Social Sciences Index & Abstracts (ASSIA), and Sociological Abstracts ( S3 Text : Ovid MEDLINE search strategy, which was translated in all other databases). The search terms related to the population (midwifery, nursing, and physicians), concepts (violence and gender-based violence), and context (healthcare) were combined appropriately based on the scoping review objectives. These terms were identified through a preliminary literature search on various aspects of workplace violence in Google Scholar. The final search results were exported to EndNote, a citation manager, to de-duplicate sources from multiple databases. After de-duplication, the sources were imported into the Covidence online software program that streamlined the screening process by two independent reviewers. The final search of the literature review for this study was conducted on 11 th February 2024.

Evidence screening and selection

The identified sources were screened based on the inclusion criteria ( S4 Text : Excluded Sources). Two independent reviewers screened the titles and abstracts to shortlist the sources. Discrepancies were resolved through discussion and consensus, with a complete source review conducted, if necessary, followed by a full-text review against the inclusion criteria by two reviewers. The selection process is presented in the PRISMA diagram ( Fig 1 ). Given the overall objective of the review to map the most frequent forms and prevalence of GB-WPV for midwives, nurses, and physicians in different contexts and clinical settings, a quality assessment of the identified sources was not conducted.

https://doi.org/10.1371/journal.pgph.0003646.g001

Data analysis and synthesis of results

This paper is a component of a multi-part scoping review; it reports on the perpetrators of WPV from gender-segregated prevalence data reported from a global context among the health workforce, including nurses and physicians. The prevalence and risk factors have been reported elsewhere [ 4 ]. This paper reports on Type II and Type III (vertical and horizontal) WPV perpetrators. Data from all sources ( S1 Data ) that reported sex/gender segregated findings and provided information for the types of perpetrators were included in mapping the prevalence of GB-WPV (See Table 2 ) for several types/forms of WPV and the clinical setting across countries/special regions. We could not calculate a mean score for various forms of violence based on gender for all the studies that provided information on perpetrators because of the wide variability in the operational definitions of the terms and the concepts in these studies. These studies also did not consistently provide quantifiable data for the Types of perpetrators. Only 34 studies (19%) provided the gender of perpetrators. We summarized the proportion of male and female perpetrators in those studies for Type II, Type III-A (horizontal) and Type III-B (Vertical) violence (see Table 3 ).

https://doi.org/10.1371/journal.pgph.0003646.t003

After de-duplication, 8435 possible references were imported for screening in the Covidence. These studies were screened against the title by one person, 1551 were shortlisted to be screened (for title and abstract) by two independent reviewers, and 402 were assessed for full-text eligibility. After applying the inclusion and exclusion criteria, 178 [ 6 – 9 , 15 , 20 – 125 ] studies were retained (PRISMA diagram, Fig 1 ) and analyzed to report on perpetrators that provided gender-segregated findings for WPV and information on various types of perpetrators ( Table 2 ). We included studies published between 2010–2024. The most common study design was quantitative, cross-sectional (n = 168), mixed methods (n = 4), and qualitative methods (n = 6).

Perpetrators for the three types of violence

A total of 178 studies provided information on the perpetrators of either Type II (consumers/patients, including patients’ companions), Type III-A (from colleagues), and Type III-B (from administrators and superior authorities within and between professions) violence. Studies included in this review did not consistently provide data for all types of violence and perpetrators; instead, they provided data for any Type/s. Of 178 studies, 141 (79%) reported perpetrators for Type II violence, followed by 93 (52.2%) for Type III-B (vertical) and 92 (51.6%) for Type III-A (horizontal) violence. Only 40 (22.5%) studies [ 9 , 21 – 53 , 164 , 168 , 172 , 177 , 178 , 191 ] reported information about all three types of violence.

While the search terms yielded many studies, there was significantly less information on the gender of perpetrators of WPV. Of the 178 studies reported on perpetrators, only 34 studies provided data for perpetrators’ gender (detailed in Table 3 ). Across the three types of violence, more men (65%) were responsible for perpetrating WPV compared to women (28%). Both men and women perpetuated violence in the remaining 7% of cases. Of the 34 studies, 25 studies reported on Type II violence, predominantly perpetrated by men, encompassing general violence [ 37 , 40 , 53 – 60 ], physical violence [ 6 , 35 , 44 , 61 – 63 , 178 ], verbal violence [ 6 , 35 , 44 , 53 , 63 , 172 , 178 ], and sexual harassment [ 8 , 41 , 44 , 63 , 64 ]. In most of these studies, women experienced a higher prevalence of violence than men. Gender-based workplace violence against nurses emerged as a pressing issue for Type II (56.2%) violence in ten studies [ 6 , 8 , 35 , 40 , 53 – 56 , 168 , 178 ]; men perpetrated 80% of the violence while women were responsible for only 19% violence, and almost all studies reported a higher prevalence of WPV against female nurses. A recent study [ 168 ] from 79 countries, though reported gender was not significant for WPV, being a nurse had higher odds of experiencing WPV (OR = 1.95; 95% CI 1.46 to 2.59, p<0.001) than a physician (OR = 1.70; 95% CI 1.33 to 2.18, p<0.001). In this study, most perpetrators were consumers (56%), followed by supervisors (16%) and colleagues (9%), or a combination of all (19%).

Violence perpetrated by colleagues (Type III-A) was reported by 15 studies, including seven for physicians [ 41 , 43 , 65 – 68 , 172 ], three studies for nurses [ 40 , 53 , 178 ], and five that included both professionals [ 29 , 37 , 44 , 60 , 63 ]. Approximately 24% of violence was perpetrated by colleagues (Type III-A) among nurses and physicians. More perpetrators were men (63.5%) than women (23%), and some violence by colleagues was reported as perpetrated by both men and women (13.5%). Only one study [ 29 ] reported higher rates of bullying by women (37.9%) than men (10.5%) and by both genders (51.6%). Two other studies reported higher mobbing behaviours (20% Vs. 69%) (192) and (8%vs.93%) (72) by women. In these studies, most perpetrators (40.7%) were supervisors and senior colleagues (Type III-B). Victims were both physicians (53.1%) and nurses (53.6%) with similar intensity, but a higher number of women (n = 195, 56.4%) were exposed to bullying than men (n = 18, 36%). Additionally, those who experienced bullying had lower levels of psychological health status. Bullying from colleagues (26.4%) and patients/consumers (7.7%) was perceived as less harmful than bullying from supervisors (Type III-B), which was also less reported because of the fear of consequences.

Of the 34 studies reporting on the gendered perpetuation of WPV ( Table 3 ), 24 reported on Type III-B (vertical) violence, which was more prevalent among physicians (51.5%) than nurses (16%). When it did occur among nurses, more men (77%) perpetuated Type III-B violence than women (18%) and both men and women (5%). Several studies highlighted physicians as perpetrators of WPV against nurses regardless of gender [ 8 , 51 , 53 ]. Similarly, more men (67.5%) than women (24.2%) and both genders (8.2%) perpetuated Type III-B violence among physicians. In seven of ten studies (70%) for Type III-B violence among physicians, male supervisors and administrators perpetuated sexual harassment [ 41 , 64 – 69 ]. Four studies reported bullying [ 43 , 70 , 172 ] and emotional abuse [ 71 ], which was also perpetrated by men.

Medical residents appear to be particularly vulnerable to Type III-B violence, with more than 60% of studies [ 41 , 43 , 64 , 66 , 67 , 71 , 172 , 175 ] reporting this type of violence in medical residency programs. Furthermore, several studies highlighted that the perpetrator of sexual harassment was most often of the opposite sex [ 63 , 64 , 66 ]. For instance, Freedman-Weiss et al. [ 66 ] reported that male residents experienced 65.9% of harassment from men compared to 81.8% from women. On the other hand, female residents reported experiencing more harassment from men (97.7%) compared to women (42.4%). In the same study, the main perpetrators for female resident victims were attending physicians (72.9%), followed by nurses (68.5%), senior colleagues (44.7%) and same-level residents (23.5%). Among male residents, nurses were the most common perpetrator of WPV (69%), followed by attending physicians (62%), senior colleagues (41.9%) and same-level residents (25.6%).

Healthcare professionals in lower hierarchical positions, such as nurses and residents, often contend with stressful conditions and managerial or administrative abuse and harassment, posing challenges to patient care, institutional integrity, and the healthcare system. These experiences also detrimentally impact the victims’ health and career progression. For instance, Tekin and Bulut [ 51 ] found that Turkish nurses who experienced Type III-B violence reported feelings of anger, humiliation, confusion and sadness. Moreover, these experiences also led to strained relationships with others, decreased performance, and caused them to consider leaving the profession. Although this study did not specify the gender of the offender, women experienced significantly higher verbal abuse. The highest perpetuation for all forms of abuse, including verbal (85.7%), physical (46.4%) and sexual (94.4%), was from physicians. In these cases, gender and status within the organizational hierarchy played a critical role in perpetuating Type III-A and III-B WPV, which requires serious attention from employers and health organizations to address GB-WPV through a gender-sensitive approach.

Our examination explores the complexities of gender dynamics concerning both the perpetrator and the victims of workplace violence within the global healthcare community, mainly focusing on nurses and physicians. While 178 studies provided information about perpetrators and sex-segregated findings for workplace violence, only 34 studies (19%) reported the gender of the perpetrator for Type II and Type III violence. These findings provided insights into how gender and an individual’s position within the organization create unique vulnerabilities to WPV. The consequences of such violence against health workers not only affect patient care but also have broader implications for healthcare organizations and workforce landscapes. In our review, men were found to be the primary instigators, accounting for 65% of incidences of WPV, while women were responsible for 28% of instances. Both men and women perpetrated the remaining 7% of incidents. Additionally, our analysis identified distinctive behaviour patterns among male and female offenders. Recognizing that each type of violence requires a different approach for its management and prevention, we will discuss the divergent behavioural patterns of men and women perpetrators of Type II and Type III violence. We examine the underlying factors contributing to these differences and discuss the implications of adopting gender-sensitive approaches to prevent and manage GB-WPV.

Type II WPV- Client/patient

Of the 34 studies that provided the gender of perpetrators for any type/s of violence, the majority (74%, n = 25) reported on Type II WPV perpetrated by patients, their families, or visitors. In this context, male perpetrators were more prevalent, targeting both nurses (77.9%) and physicians (70%). The majority of studies that reported on Type II violence indicated a higher prevalence of various forms of violence against female nurses and physicians. The higher perpetration of WPV by men can be linked to societal norms associating aggression and dominance with masculinity [ 193 ]. At the same time, violence against a feminized nursing workforce is normalized as part of the job [ 24 , 75 , 98 , 193 ]. This link between societal norms and assigned roles was evident in several studies [ 76 , 125 ], which is deliberated in the following section.

Type II violence typically targets healthcare providers in the performance of their professional duties and is characterized by acts of physical violence [ 6 , 35 , 44 , 61 – 63 , 166 ]; verbal violence [ 6 , 35 , 44 , 53 , 63 ], and sexual harassment/ violence [ 8 , 41 , 44 , 63 , 64 , 167 ]. Most of these studies reported a higher prevalence of WPV for women for all forms of violence [ 8 , 9 , 44 , 53 , 62 , 64 , 169 , 174 , 176 ]. The social norms, which stem from social relations dictate gender roles and responsibilities, and healthcare institutions are no exception to these forces. For example, a study conducted in Italy that included all areas of practice and the entire health workforce, investigating determinants of aggression against the health workforce reported women were 1.37 times more likely to experience aggression from consumers and colleagues. In this study, nurses experienced the highest number of episodes of violence (64%). Most of these aggressive acts occurred during assistance and supportive care to patients (38%) [ 125 ]. On the other hand, men were not immune to WPV, particularly physical [ 44 , 61 , 166 , 185 ] and both physical and verbal violence in the emergency department in Saudi Arabia, Turkey and China [ 37 , 59 , 189 ]. In Turkey, male physicians experienced higher violence (62.4%) in contrast to their female counterparts (37.6%) [ 59 ]. A similar pattern emerged in Saudi Arabia, with male physicians and nurses reporting a higher prevalence (57.8%), than their female counterparts (42.8%) [ 37 ]. These three studies identified several factors for the high occurrence of WPV from patients and their relatives, including dissatisfaction with the treatment, long wait times and lack of staff [ 37 , 59 ], overcrowding and lack of security [ 37 ]. Though these highlighted factors are important to explain the occurrence of workplace violence for both men and women in the workforce, in the Saudi context, culture seems to have a protective factor for women, where public abuse from men is socially unacceptable [ 88 ]. Similarly, three other studies in Jordan attributed the higher prevalence among male physicians to culture and the existence of laws that intensify legal penalties against women abusers [ 87 ], the cultural norm of altruism and tolerance towards females, particularly physical violence [ 42 ], and a lack of encouragement for reporting WPV by females as part of the male-dominant culture [ 150 ]. Additionally, the higher occurrence of physical violence for men can also be explained by the cultural expectation of masculinity.

In contrast, women’s experience of severe sexual harassment was associated with pregnancy, family responsibilities, and occupational segregation [ 63 ]. Newman et al. [ 63 ] explained that occupational segregation also creates a vertical hierarchy where women are assigned to lower-level tasks (typically front-line care providers). The WHO report analyzed gender and equity in the health and social workforce ‘delivered by women, led by men’ (2019) and acknowledged occupational segregation as universal, which is reinforced by the broader societal norms and creates discriminatory practices with regard to gender and occupational roles [ 194 ]. In these lower positions, women experience sexual harassment from male colleagues, male patients and community members [ 16 , 194 ]. Considering the prevalence of Type II violence for both men and women linked to sex-segregated responsibilities and societal structures. Jafree [ 195 ] calls on policymakers to ensure security and protection for the health workforce, particularly women; legislative reforms for healthcare governance and zero-tolerance policies for violence were also recommended. Several other sources, too, advocate for zero-tolerance policies and emphasize the need for a managerial approach that takes all complaints seriously, reports investigation outcomes, and enforces sanctions to eliminate impunity [ 9 , 92 , 131 ]. Collaborative community efforts are required to acknowledge and alter the patriarchal culture and reduce violence against women by creating awareness about the public role through various forums, including the media [ 28 , 79 , 94 , 195 ].

Several contributing factors have been identified in the context of Type II WPV, such as noise levels, inadequate communication skills [ 74 ], perceived/actual staff incompetence or unsympathetic attitudes, dissatisfaction with service provision, prolonged wait times, and poor communication [ 53 , 196 ]. These circumstances can escalate emotions and increase the likelihood of violent encounters. Furthermore, specific treatment specialties, such as emergency departments [ 35 , 75 , 191 ], psychiatric units [ 76 , 77 ], and geriatric care [ 26 , 76 ], have demonstrated a higher risk of Type II workplace violence. Factors specific to these settings include a lack of privacy and personal space, unrealistic expectations of clients, insufficient staffing and resources, poor staff skills mix, healthcare systems and processes not understood by clients, perceived favouritism, overcrowding in emergency departments, delays in providing analgesia, and inflexible visiting hours [ 196 ]. These challenges, compounded by a shortage of skilled professionals, unclear expectations and communication, scheduling issues, and environmental stressors can generate increased stress and, thus, uncertainty. Addressing these factors constitutes the initial step in decreasing or eliminating the risk of violence for both men and women [ 197 ].

Both primary research and systematic reviews have acknowledged the difficulty associated with addressing multifactorial violence, given the diversity in population and setting and the types/classifications of violence [ 94 , 95 , 102 , 198 ]. However, these sources did not provide information about perpetuators, particularly gendered nature. For instance, a recent umbrella review examined 32 systematic reviews for WPV prevalence and characteristics. This comprehensive assessment reported that the overall prevalence from the meta-analysis of 11 reviews was 57.9%, ranging from 34.1% to 78.9% among healthcare providers and most affected were nurses working in psychiatric wards [ 198 ]. This prevalence aligns with the findings of this review. Of note, the umbrella review too did not provide information on perpetrators and prevalence based on gender and stated that the included reviews had reported variable results for men and women; however, it did underscore how gender imbalances in emergency departments could increase the risk of violence among women. Several studies in our review recommended ensuring gender equality in the health workforce and leadership positions to reduce the prevalence of WPV among women [ 9 , 30 , 63 , 80 ].

Type III WPV-Worker-on-Worker

Type III-A (Horizontal or lateral) workplace violence perpetrated by one healthcare worker against another may stem from interpersonal conflicts, workplace stress [ 12 ], or other factors contributing to a hostile work environment. Among studies that provided data on Type III-A violence, most perpetrators were men (63.5%) compared to women (23%). Horizontal WPV was reported more frequently by physicians [ 41 , 43 , 65 – 69 ] than among nurses [ 40 , 53 ]. The studies that sampled both nurses and physicians [ 29 , 37 , 44 , 60 , 63 ] also reported that men perpetuated all forms of violence in most cases for both male and female victims [ 37 , 44 , 63 ]. In some instances, women experienced violence from both men and women [ 63 ].

Type III violence is also rooted in cultural norms and societal expectations that allocate roles and responsibilities based on gender [ 63 ]; in most cultures, women are responsible for childbearing and rearing and men hold decision-making positions. This phenomenon transcends the household and is also seen in the workplace and healthcare institutions [ 9 , 68 , 78 ]. These gendered roles and responsibilities often position men in leadership positions while women are assigned to caring roles with less authority and responsibility, perpetuating discriminatory practices that negatively impact women [ 9 , 63 , 70 ]. This dynamic prevails in both wealthy and lower- and middle-income countries in varied behaviors. For instance, in Australia and New Zealand, women experienced significantly higher discrimination (31% vs. 8%) and sexual harassment (23% vs. 0.5%) than men, primarily due to family responsibilities, lack of mentorship and rigid promotion criteria [ 70 ]. In Rwanda, women’s experiences of childbearing and care, including managing pregnancy, motherhood and work, and the widespread negative stereotyping of women at work led to discrimination that co-occurred with sexual harassment within health workplaces [ 63 ]. Jacobson et al. [ 12 ] report on Type III-A violence in medical residency programs, and women experienced a significantly higher frequency of work-related incidents from colleagues and support staff, explaining the higher workload for women due to the coexistence of family responsibilities. Additionally, relational and managerial issues, including organizational affairs within large, complex health organizations, shifting duties and cohabitation of various teams on the same unit, were identified as factors contributing to Type III-A violence in Italy [ 53 ].

This type of interpersonal violence, including violence against women, is prevalent in science, technology, engineering and math (STEM), which are considered male-dominant disciplines [ 199 , 200 ], unlike healthcare, where 70% of the workforce globally are women and higher rates of violence are associated with their roles and responsibilities and the gendered workplace hierarchy [ 194 ]. In STEM, violence against women can be explained by the backlash effect, in which gender equality is associated with higher prevalence [ 200 ].

Given the social reality of women’s lives and career development in healthcare, flexible human resource development and management policies could empower women to balance their work and family responsibilities. Zampieroni et al. [ 53 ] recommend adopting realistic workloads and skill-mixed staffing, promoting gender equality in staff allocation, and participatory leadership to overcome relational conflict and managerial actions that enhance working conditions. Nurse managers must play the role of cultural gatekeepers, hold individuals accountable and foster staff empowerment; utilizing research-informed methods such as ‘cognitive rehearsal and crucial conversations’ [ 20 ] and conducting team-building workshops will assist in mitigating the impact of horizontal violence [ 21 ].

Type III-B (vertical) violence is primarily perpetrated by senior colleagues, supervisors, and administrative personnel occupying higher positions in the organizational hierarchy than the victim. Among the 34 studies, 66% reported perpetrators’ gender for Type III-B violence; men perpetuated 77% among nurses and 67.5% among physicians. The causative factors for vertical violence included organizational structure, leadership and administrative authorities, and power struggles in the health workplaces. These factors not only perpetuated WPV but also prohibited reporting of the instances due to fear of reprisal [ 29 , 63 , 66 ]. Two prevalent forms of violence linked to hierarchical/ organizational structure were sexual harassment and bullying/mobbing. The majority of studies reporting Type III-B violence reported sexual violence from male supervisors and administrators [ 8 , 41 , 44 , 63 – 69 ], particularly in medical residency programs—placing these trainee residents in a vulnerable position [ 41 , 66 , 67 ]. Additionally, vertical violence was the only type reported to be perpetuated by women at higher levels in the organizational hierarchy, particularly bullying (women: 37.9% vs. men: 10.5%) among nurses and physicians [ 29 ]. Additionally, two studies reported higher rates of mobbing behaviours by women than men among healthcare professionals, including nurses and physicians [ 72 , 192 ].

Type III-B violence is emblematic of the hierarchical and inflexible organizational culture historically dominated by male medical professionals. This stemmed from beliefs and negative stereotypes, such as women being weak, unwilling to speak up, indecisive and incompetent [ 63 ]. Additionally, perceived competence was expressed as a predictor for bullying among women [ 42 , 153 ]. Such perceptions reinforce the structural power held by men, particularly with male managers and physicians. The patriarchal institutional structures provide power domination among women as well, who could use their power to oppress individuals under their control. A qualitative study [ 201 ] from Estonia exposed this dynamic of domination and sexual harassment among nurses; it highlighted the association between power and the use of sexualized language. A female nurse stated, “I am more disturbed by their patronizing behaviour"; the nurse characterizes physicians’ attitude as: “I am a man, I am a physician, I can do and say whatever comes to my mind” (Nurse 18, p.30). Lamesoo [ 201 ] further explained that nurses placed themselves in the hospital hierarchy between physicians and patients and acknowledged that they could not challenge a physician’s incivility. However, these nurses can easily ask patients to refrain from such behaviour without hesitation because patients have less power than nurses, and patients are expected to follow hospital rules [ 201 ] dictated by nurses. These instances explain organizational power as a protective factor for offenders. However, women’s underrepresentation in positions of power places them in a vulnerable position.

Another qualitative study in Uganda by Newman et al. [ 9 ] reported from key informant interviews in the Uganda health system that "we have women over-represented in the bottom of any organization and for the men, it is an upward or inverted pyramid whereby as you go up the power ladder…. There is a tendency to abuse that power and they don’t even think that they are abusing it because they have grown up thinking they may be flattering the women…". The authors further stated that "Sexual coercion started during recruitment of health workers and continued after hiring, perpetrated by men in hierarchically superior decision-making positions supervisors, senior managers (including human resources) or medical superintendents” [ 9 ]. These severe human rights violations necessitate a transformation in the mindset of individuals in the workforce and a cultural shift at organizational levels to rectify the dominant, hierarchical and permissive environment [ 65 ]. Ensuring gender equality at the upper echelons of healthcare organizations and in decision-making positions is crucial to establishing a secure and equitable environment for all, regardless of gender. A scoping review of three evidence-based guidelines and 33 systematic reviews on strategies to prevent and manage WPV in healthcare settings reported a correlation between strong leadership to cultivate and enforce a culture of inclusivity, support and respect as a prerequisite for successful prevention of WPV [ 202 ]. Therefore, healthcare organizations’ leadership must proactively seek organizational solutions to end gender-based WPV and prioritize gender equality and protecting employees’ rights as part of their human resources for health (HRH) policy [ 9 ].

Sexual harassment in academia was found to be an issue across various contexts, particularly among women in medical residency programs. A study [ 78 ] in a U.S. medical college reported that one-third of respondents experienced sexual harassment, including medical students (51.7%), residents/fellows (31%) and faculty members (25%), which was inversely proportional to their position in the program. Similarly, sexual harassment was more prevalent among women in vascular surgery in the U.S. [ 67 ], ophthalmology in Australia and New Zealand [ 79 ] and cardiothoracic surgery, reported by a global survey [ 28 ], and rates of sexual harassment in almost all contexts were higher among female trainees. In one instance, in the U.S., male (70%) and female (69%) residents [ 41 ] in obstetrics and gynecology residents experienced sexual harassment at similar levels [ 41 ]. Additionally, one study in the U.S. with a large, representative sample (n = 6000) from a national survey reported that higher women’s representation within a specialty was associated with lower sexual harassment for both men and women from coworkers and patients [ 80 ]. This observation held true in the Canadian context where reporting of sexual harassment incidents was low (2.9%) in a study with female participants constituting 53% of the sample [ 33 ]. These women did report slightly higher rates of intimidation, harassment, and discrimination (IHD) based on gender (males 40.4%; females 48.0%). Hence, findings underscore the recurring recommendation of gender equality in the health workforce and leadership positions and the role of leadership in preventing Type II and Type III violence, including harassment.

Acknowledging sexual harassment as a prevalent problem is the crucial initial step in formulating a successful strategy to prevent its occurrence [ 65 , 203 ]; a comprehensive strategy should encompass a zero-tolerance statement across the specialty with a transparent and fair mechanism for reporting sexual harassment [ 65 , 78 ]. Moreover, it is essential to provide trainees with both direct face-to-face and electronic routes for anonymous and confidential reporting to alleviate concerns related to personal reattribution and academic detriment [ 64 , 78 ]. Standardized, transparent reporting mechanisms with well-delineated consequences for the offender must be established. Additionally, the institutions should ensure the availability of links to all the required resources is the first hit on online searches, displaying posters/presentations/ads [ 78 ].

Recognizing harassment as an institutional structural issue, senior leadership can have a protective role by serving as role models. A qualitative study conducted in Germany [ 197 ] representing women nurses (50%) and physicians (50%) explored preventive options for sexual harassment in academia. The findings revealed that leadership commitment and clear statements can significantly influence multiple levels by demonstrating openness to address taboo topics, raise awareness, and place the issue at the decision table. A participant stated, "A culture of political correctness is communicated from the top down, with the management committee and senior management acting as role models” (p.12). Another participant stated, "It is the senior staff that creates a team culture that should be supportive and transparent, with clear boundaries… .. I have an open door and open eyes policy and try to initiate rituals that allow us to work together in the correct way” (p.12). While commitment and stated actions are essential, meaningful cultural change necessitates the consistent, active, structured, and continued engagement of all health workforce members, including students and trainees, staff and especially from senior leadership. Senior leadership must be actively engaged in this process, particularly male leaders. Therefore, engaging individuals at various levels in open, nonjudgmental conversations is paramount to breaking the silence [ 30 ] and ingraining these principles into the organizational culture.

Limitations

First, in our comprehensive review of workplace violence (WPV), not all studies reported on perpetrators of WPV. Therefore, we included all studies that indicated perpetrators/ sources of violence. We categorized these sources into distinctive categories of Type II and Type III WPV. Limitations to this approach include the heterogeneity of the forms of violence reported by the included studies according to gender. While studies reported victims’ exposure to Types II, and/or III, the gender of perpetrators in each case was not specified. As a result, we presented the prevalence of the various forms and categorized the perpetrators’ type for all the studies (178) in Table 2 . The final set of studies (19%) that reported on the gender of the perpetrators was analyzed. Since fewer studies provided information about the gender of perpetrators across the types/forms of violence, future research must focus on conducting and reporting gender-segregated findings for perpetrators that will strengthen recognition of the gender-based WPV and could lead to gender-sensitive strategies at the local and international levels. Another limitation of our review was that most of the included studies operationalized gender as a binary. A few studies included either non-binary (less than 4%) [ 80 , 98 ] individuals or mentioned as others (less than 4%) [ 28 , 30 ] or unknown (less than 9%) [ 85 , 128 ], in the analysis of the total population, reported in Table 2 . Even these studies did not report findings for those minority populations or address it as a limitation. Therefore, we reported findings based on gender binary. All these studies, which represented non-binary individuals, were conducted in the USA [ 30 , 80 , 98 , 128 ] and Canada [ 85 ]; in these contexts, gender diversity and inclusion are acknowledged as compared to most Low-and -middle-income countries where sex is equated with gender. These studies did not recognize it as a limitation; only one study, which reported on survey data from the Association of American Medical Colleges (AAMC) National Sample Survey of Physicians (NSSP), expressed excluding the non-binary data because of the lower sample [ 80 ]. Considering this limitation, we recommend that future research include gender-diverse populations.

The review revealed a higher prevalence of Type II and Type III WPV among women compared to men. In parallel, it was observed that men predominantly perpetrated all forms of violence against both men and women healthcare providers. Only Type III-B violence, including bullying/ mobbing, was occasionally perpetuated by women. Both Types II and Type III violence have roots in societal structures, and women were more frequently victimized. This increased victimization of women can be attributed to their lower status in society and in the healthcare settings that assign roles and responsibilities based on this status. Additionally, women’s reproductive realities, including managing pregnancy, motherhood and work, and widespread negative stereotyping contributed to their vulnerability to gender-based WPV.

Conversely, men’s domination in leadership, decision-making and supervisory positions in most contexts creates a hierarchical and permissive environment that perpetuates violence against women. Therefore, understanding gender implications concerning both the victim and perpetrator among the critical health workforce of nurses and physicians across the globe is essential. Healthcare organizations and professional stakeholders must seriously consider zero-tolerance policies, transparent mechanisms for handling violent incidents, and the provision of appropriate support to victims. These measures will empower individual professionals, enhance patient care, and positively impact healthcare institutions and society as a whole.

Supporting information

S1 checklist. prisma-scr checklist..

https://doi.org/10.1371/journal.pgph.0003646.s001

S1 Text. Definitions of forms of workplace violence.

https://doi.org/10.1371/journal.pgph.0003646.s002

S2 Text. Registered protocol.

https://doi.org/10.1371/journal.pgph.0003646.s003

S3 Text. Ovid MEDLINE search strategy.

https://doi.org/10.1371/journal.pgph.0003646.s004

S4 Text. Sources excluded.

https://doi.org/10.1371/journal.pgph.0003646.s005

S1 Data. Data for full text review.

https://doi.org/10.1371/journal.pgph.0003646.s006

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Scaling up suicide prevention in Nepal: a collaborative effort

The COVID-19 pandemic had a profound impact on mental health worldwide, with evidence pointing to an increase in anxiety and depression. In response to concerns around increased risk of suicide, Nepal has intensified its suicide prevention efforts. The Parliamentary Committee on Women and Social Affairs met to accelerate suicide prevention efforts, and a national mandate has since paved the way for the development of  a national suicide prevention strategy and the establishment of a dedicated  mental health and suicide prevention office.

“We are in a critical moment for mental health and suicide prevention, there is momentum, there is will and commitment from the grass roots level to national authorities” said Dr Rajesh Sambhajirao Pandav, WHO Representative to Nepal.

National leadership and strategic action

The government of Nepal, with support from the World Health Organization (WHO), the United Nations Development Programme (UNDP)and local NGOs, has taken critical steps to address suicide. A national suicide prevention action plan is being developed, led by the National Planning Commission in Nepal. This plan aims to ensure coordinated efforts among key stakeholders, accountability and sustained political commitment to suicide prevention.

Nepal is working to move beyond the often fragmented and one-size-fits-all approaches to suicide prevention.  Guided by WHO’s LIVE LIFE initiative , Nepal has adopted a multifaceted strategic approach to suicide prevention that acknowledges the complex nature of suicide and engages relevant stakeholders. The Ministry of Health and Population (MoHP) Nepal, in collaboration with WHO,  convened a series of policy dialogues to engage municipal representatives, including mayors,  local administration officers, and health section chiefs, in the implementation of comprehensive and community-based approaches to mental health and suicide prevention.

Limiting access to highly hazardous pesticides

Phasing out highly hazardous pesticides is a critical intervention in suicide prevention. Through collaborations with the health and research sectors, data on self-poisoning incidents were used by authorities within the agricultural sector to advocate for stricter regulation. Since 2019, Nepal has banned  26 highly hazardous pesticides. These bans, supported by research showing no negative impact on agriculture, are expected to significantly reduce suicides by pesticide poisoning, as has been the case in other countries in the region enacting bans.

Media personnel participate in training on responsible reporting of suicide in Nepal. @ WHO Nepal

Supporting responsible media reporting on suicide  

Responsible media reporting can increase awareness about mental health and suicide, challenge stigma and misconceptions, as well as  promote help-seeking behaviours. Sensationalized reporting can, however, inadvertently increase the risk of imitative suicidal behaviours. Recognizing the critical role of the media in suicide prevention, WHO Nepal, in collaboration with the National Health Education Information and Communication Centre (NHEICC), has trained 293 journalists on responsible media reporting practices, using WHO’s resource for media professionals which has been endorsed by the Department of Health Services.

Prioritizing early interventions and follow-up support

The Government of Nepal is prioritizing early identification of suicidal behaviors and follow-up support through capacity building for primary care workers and gatekeepers (people likely to come into contact with at-risk individuals). Local adaptation of WHO’s Mental Health Gap Action Programme (mhGAP)  has led to the development of a National Mental Health Care Program 2022. A capacity building program, endorsed by the Government, has also been developed for school nurses, counselors and teachers in collaboration with WHO and UNICEF. Moreover, MoHP and WHO, using mhGAP resources, are working towards a national protocol for assessment and management of people with suicidal behaviour  to provide focused guidance to assess suicide risk at health facilities as well as  tailored  support.

A 24/7 suicide prevention helpline, supported by WHO and a local NGO, has been established by the MoHP. Extensive and coordinated awareness raising campaigns promote the helpline and suicide prevention included walkathons, cycle rallies, and drama performances. The helpline has already provided ongoing counseling to over 700 individuals.

Cycle rally to raise awareness for suicide prevention and the crisis helpline. @ WHO Nepal

Strengthening surveillance for targeted intervention

To effectively address suicide, Nepal has also prioritized the development of a suicide and self-harm case registry. This tool, which is currently being piloted in two districts, will help monitor trends in suicidal behaviour, identify at-risk groups, and guide future interventions and service provision, ensuring that efforts are both targeted and effective.

Dr Pandav  reflects on the significant progress made in Nepal, stating "Nepal's comprehensive approach to suicide prevention is laying a solid foundation for lasting change. Continued monitoring and collaboration will be crucial to sustaining this momentum.” With coordinated actions like pesticide bans, media training, and community support, Nepal is making bold strides to reduce suicide and create a healthier future for all.