Leadership 4.0: Navigating the Challenges of the Digital Transformation in Healthcare and Beyond

Abstract

The Fourth Industrial Revolution (4IR), characterized by the integration of advanced digital technologies, is transforming industries globally and significantly impacting leadership practices, particularly in the healthcare sector. As organizations adapt to this digital evolution, the demand for effective leadership becomes increasingly critical. This paper explores Leadership 4.0, a framework that identifies the skills and competencies required for successful leadership in the digital age. The study employs a mixed-methods approach, combining a Systematic Literature Review (SLR) with qualitative insights gathered through case studies and the Delphi method, involving healthcare leaders, to investigate leadership practices in organizations undergoing digital transformation. Through case studies and literature reviews, the research seeks to provide a comprehensive understanding of the changing leadership landscape, addressing the unique challenges and opportunities presented by digital transformation in healthcare. The findings indicate that effective Leadership 4.0 requires a combination of digital literacy, strategic foresight, and emotional intelligence. Leaders must exhibit adaptability, drive innovation, and foster a culture of continuous learning to navigate the complexities of digital transformation successfully. The study also emphasizes the importance of internal branding as a critical strategy for aligning employees with the organization’s mission and digital vision, thereby fostering collective commitment to transformation objectives. Key challenges include resistance to change and the ongoing need for upskilling, while opportunities lie in leveraging digital innovations to enhance organizational performance.

1. Introduction

The Fourth Industrial Revolution is ushering in transformative changes across various industries, with healthcare experiencing significant impacts. This revolution is marked by the integration of advanced technologies such as artificial intelligence (AI), big data analytics, cloud computing, and the Internet of Things (IoT), collectively reshaping operational processes and elevating the complexity of leadership roles within the sector. In response to these shifts, the concept of Leadership 4.0 has emerged, emphasizing the necessity for leaders to be digitally literate, agile, and adaptable to effectively guide organizations through digital transformation and foster innovation.

A growing body of literature explores Leadership 4.0, focusing on the competencies required to drive digital transformation. Studies have examined various leadership styles pertinent to the 4IR, including digital leadership, transformational leadership, and ethical leadership, highlighting the significance of agility, technological literacy, and innovation-driven thinking. However, despite the increasing scholarly attention, there remains a critical gap in understanding how Leadership 4.0 principles can be effectively applied in healthcare settings. Existing research often emphasizes internal branding, employee engagement, and change management strategies in digital transformation, yet empirical evidence on how healthcare leaders integrate these principles into their digital strategies is limited (Brown & Treviño, 2006). Healthcare organizations face unique challenges, such as stringent regulatory requirements, complex stakeholder relationships, and the integration of emerging technologies like AI-powered diagnostics, big data analytics, and telemedicine. Traditional leadership models, such as transformational and transactional leadership, which prioritize stability and hierarchical structures, are insufficient for addressing the rapid technological advancements characterizing the digital era. These approaches fall short in enabling healthcare leaders to respond proactively to the swift pace of change and the growing demands for more personalized and efficient patient care (Schwab, 2017; Kergroach, 2020; Ulrich et al., 2017).

To address this gap, the present study systematically examines the competencies required for Leadership 4.0 in healthcare through a Systematic Literature Review (SLR). The research utilizes key search terms derived from seminal works in the field, including “Leadership 4.0”, “Digital Leadership”, “Transformational Leadership”, “Healthcare Digital Transformation”, and “Industry 4.0”, applied across major academic databases such as Scopus, Web of Science, and IEEE Xplore (Schwab, 2017; Kergroach, 2020; Ulrich et al., 2017). These terms were selected for their established relevance in leadership and digital transformation research, ensuring a comprehensive exploration of the topic.

To supplement the literature review, the study incorporates expert insights through the Delphi method, aiming to bridge the gap between theoretical insights and practical leadership applications in digital transformation. The research provides actionable recommendations for healthcare leaders, outlining strategies to develop digitally competent teams, foster a culture of innovation, and overcome resistance to change. Ultimately, this study contributes to the broader discourse on Leadership 4.0 by advocating for a leadership approach that integrates technological advancements with human-centric values, ensuring healthcare organizations remain adaptive and resilient in the digital era (Bag et al., 2024).

The importance of Leadership 4.0 in healthcare cannot be overstated. As healthcare organizations strive to remain competitive and effective amidst rapid technological change, leaders must not only understand how to implement digital tools but also how to cultivate a forward-thinking culture that embraces innovation and adaptability. Successful digital leadership in healthcare involves leveraging technologies like AI and big data analytics to improve decision making and enhance patient outcomes while simultaneously addressing the human factors of change management and workforce development. Leadership 4.0 advocates for a more decentralized, networked leadership approach, integrating digital fluency, data-driven decision making, and agile methodologies into leadership practices. This shift enables healthcare leaders to foster interdisciplinary collaboration and respond to emerging challenges with greater flexibility and speed.

2. Conceptual Background

The 4IR marks a transformative period in human history, driven by the convergence of advanced technologies such as artificial intelligence (AI), the Internet of Things (IoT), big data, and robotics. This technological shift is reshaping industries, economies, and societies, fundamentally altering how leaders operate within organizations. The complexity introduced by 4IR challenges traditional leadership models and creates new demands for ethical behavior, relationship building, competency development, and the management of digital transformation. This section examines the impacts, challenges, and future prospects of leadership within the context of the 4IR, along with preliminary insights into these areas (Sekiyama, 2020; Bachtiar et al., 2023).

2.1. Introduction to the Fourth Industrial Revolution and Leadership Transformation

The 4IR is characterized by the rapid integration of advanced digital technologies—such as artificial intelligence, automation, and data analytics—into all aspects of organizational life. These innovations are not only transforming operational processes but also prompting a fundamental shift in how organizations are structured and led. In this evolving context, Leadership 4.0 has emerged as a comprehensive framework designed to navigate the complexities of the digital age.

Leadership 4.0 synthesizes elements of transformational, digital, and ethical leadership, equipping leaders to manage technological disruptions while fostering adaptability, innovation, and ethical responsibility within their teams (Sekiyama, 2020; Bachtiar et al., 2023). This framework responds to the multifaceted challenges of 4IR by promoting leadership that is both visionary and grounded in core human values.

The conceptual foundation of this study is built upon this evolving leadership paradigm, emphasizing the need for adaptive and integrated leadership approaches in digitally transforming environments. Supporting this, the theoretical framework anchors Leadership 4.0 in established leadership theories—transformational, digital, and ethical—providing a solid basis for the study’s research methodology and analysis (Obidile et al., 2023; Sheehan et al., 2020; Souza & Pietrafesa, 2023; Mihardjo et al., 2019; Hai & Văn, 2021). Together, these frameworks offer a robust lens through which to understand leadership transformation in the era of the Fourth Industrial Revolution.

2.2. Theoretical Perspectives on Leadership 4.0

Leadership 4.0 is grounded in established leadership theories that provide a robust theoretical foundation for understanding how leaders navigate digital transformation.

Transformational Leadership: This theory emphasizes the role of visionary leadership in inspiring innovation, adaptability, and motivation within teams. Transformational leaders encourage a culture of continuous learning and creativity, which is essential for organizations undergoing rapid technological change in the 4IR (Obidile et al., 2023; Souza & Pietrafesa, 2023). Their ability to foster engagement and shared purpose ensures that digital transformation efforts are successfully implemented and sustained.

Digital Leadership: This theory extends leadership into the digital domain, focusing on competencies required to leverage technology for organizational success. Digital leaders excel in managing remote teams, utilizing big data, and integrating emerging technologies to drive strategic goals. This leadership model is critical in the 4IR, where digital fluency and agility are necessary for maintaining a competitive edge (Drescher et al., 2014; Holbeche, 2018; Petrillo et al., 2018).

Ethical Leadership in a Technologically Advanced World: One of the most profound impacts of 4IR is the heightened importance of ethical leadership. As organizations adopt advanced technologies or teleworking, leaders must ensure that these technologies are used responsibly (Imran et al., 2020; Mayer, 2024). According to Hai and Văn (2021), while the principles of ethical leadership—integrity, transparency, and accountability—remain the same, the digital era amplifies their significance. The potential misuse of AI or big data can erode stakeholder trust, making it essential for leaders to prioritize ethical considerations in their decision-making processes.

Distributed Leadership and Employee Autonomy: The rise of distributed leadership, where authority is shared across different organizational levels, is becoming a central theme in leadership in the 4IR. As the complexities of digitization increase, leaders can no longer possess all the expertise needed to oversee every aspect of an organization. According to Drescher et al. (2014), distributed leadership fosters trust and improves team performance, especially in virtual settings. For instance, companies like W. L. Gore & Associates and Buurtzorg operate without permanent executives, instead relying on task-based leadership structures that empower employees (Holbeche, 2018).

Technological Enablement and Decision Making: The integration of AI and big data enables leaders to make more informed decisions and optimize processes. Petrillo et al. (2018) suggest that organizations that embrace these technologies can enhance operational efficiency and gain a competitive edge. Leaders must, therefore, cultivate a mindset of innovation and agility, enabling them to capitalize on technological opportunities while ensuring ethical application.

By integrating these established leadership theories and emerging leadership approaches, Leadership 4.0 provides a comprehensive model for guiding organizations through the complexities of digital transformation, ensuring both technological progress and ethical governance.

2.3. Conceptualization of Leadership 4.0

Leadership 4.0 integrates transformational, digital, ethical, and distributed leadership theories to create a holistic and adaptive framework for navigating digital transformation. Each theory contributes a unique strength:

• Transformational leadership provides vision and motivation.
• Digital leadership ensures technological competence and innovation.
• Ethical leadership safeguards integrity and public trust.
• Distributed leadership empowers teams and fosters resilience.

This integrated model forms the conceptual and theoretical basis for the present study. It positions leadership not only as a driver of technological change but also as a guardian of organizational ethics and human-centered progress. As the digital revolution continues to unfold, Leadership 4.0 offers a roadmap for sustainable, inclusive, and future-ready leadership.

2.4. Leadership 4.0 in the Healthcare Sector

The healthcare sector represents a uniquely complex and high-stakes environment, making it a critical context for examining the role of Leadership 4.0. This study specifically focuses on healthcare due to its unparalleled reliance on digital transformation and the sector-specific challenges that accompany it. As the industry undergoes rapid technological evolution—including AI-driven diagnostics, electronic health records (EHRs), telemedicine, and advanced data analytics—leadership must play a central role in ensuring these innovations are effectively integrated into clinical and operational practice.

What sets healthcare apart is not just the pace of innovation, but the sensitivity and ethical gravity of its services. Digital ethics, patient data privacy, and the human impact of automated decision making present significant challenges that require leaders to balance technological advancement with moral responsibility. Furthermore, healthcare operates within rigid regulatory frameworks that demand rigorous compliance, ethical governance, and accountability—all of which can be navigated more effectively through the principles of Leadership 4.0.

Leadership 4.0 offers a strategic lens to lead through digital disruption, emphasizing adaptability, emotional intelligence, and collaborative innovation. It becomes especially vital when addressing resistance to change among healthcare professionals, and in managing workforce adaptation to new technologies and workflows.

The COVID-19 pandemic has only amplified the urgency for digital transformation across the sector, revealing vulnerabilities but also catalyzing innovation. In this context, Leadership 4.0 is not only about embracing technology but fostering resilience, driving sustainable change, and ensuring that digital solutions serve both operational efficiency and patient-centered care (Holbeche, 2018; Petrillo et al., 2018; Mayer, 2024).

2.5. The Challenges and Opportunities of Leadership in the 4IR

Among the challenges faced are the following:

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Job Displacement and Skill Development

One of the most significant challenges posed by 4IR is the displacement of jobs due to automation. Zervoudi (2020) highlights the risks of widespread unemployment as robots and AI replace human labor in certain industries. Leaders must advocate for policies that support continuous workforce development, retraining, and upskilling. Proactive strategies are necessary to address the socio-economic impacts of technological disruption, especially in vulnerable regions (Ojo-Fafore et al., 2021).

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Increased Competency Requirements for Managers

With the proliferation of remote work and globalized teams, managers now need a more diverse set of competencies. These include the ability to manage virtual teams across different time zones, navigate intercultural communication challenges, and foster trust in remote settings (Schwarzmüller et al., 2017). Leaders must also be proficient in using digital tools to monitor performance and facilitate team collaboration.

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Relationship Building in a Digital Work Environment

Given the rise of remote work, leaders must prioritize relationship building and trust more than ever. Alade and Windapo (2021) argue that successful leadership in the 4IR involves investing in team-building initiatives and fostering collaboration across departments and national borders. Furthermore, it is essential for leaders to convey appreciation and support, especially in a digital environment where physical interactions are limited.

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Managing Employee Health and Well-being

The digital work environment, while flexible, can also blur the lines between professional and personal life. The increased expectation for constant availability, coupled with frequent interruptions and information overload, leads to employee stress. Leaders must manage these pressures by promoting a healthy work–life balance, implementing clear communication protocols, and modeling appropriate behavior themselves (Munsamy et al., 2023). For example, companies like Volkswagen have set limitations on after-hours communication to protect employees from burnout.

The following are some of the key opportunities:

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Fostering a Culture of Innovation and Agility

Leaders in the 4IR must embrace continuous learning and adaptability. As technological advancements disrupt traditional business models, leaders are required to be flexible and open to change. Munsamy et al. (2023) emphasize the importance of digital leadership competencies, such as the ability to navigate uncertainty and complexity. Leaders who foster a culture of innovation and encourage their teams to experiment with new ideas will be better positioned to capitalize on the opportunities presented by 4IR.

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Democratization of Leadership

The democratization of leadership—where employees are more involved in decision-making processes—offers a promising avenue for fostering engagement and motivation. Studies show that when employees are given autonomy, decision-making authority, or equity stakes in their companies, organizational performance improves. This trend is evident in companies like Front and Umantis, which empower employees to influence strategic decisions or even elect their managers (Schwarzmüller et al., 2017).

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Continuous Employee Education

As 4IR technologies evolve, the need for ongoing education and upskilling is critical. Leaders must create environments where employees are encouraged to develop new skills continuously. This includes both technical skills, such as IT proficiency, and soft skills, such as self-management and communication in virtual settings (Schwarzmüller et al., 2017).

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Technologization of Leadership

As leadership becomes increasingly reliant on digital tools, the technologization of leadership is inevitable. New technical tools, such as virtual collaboration platforms and data analytics systems, support managers in their roles. However, leaders must also be cautious about over-reliance on technology and ensure that human-centric leadership principles, such as empathy and trust building, remain at the forefront of their management practices (Munsamy et al., 2023).

Notable prospects should also be highlighted:

Fostering a Culture of Innovation and Agility: Leaders in the 4IR must embrace continuous learning and adaptability. As technological advancements disrupt traditional business models, leaders are required to be flexible and open to change. Munsamy et al. (2023) emphasize the importance of digital leadership competencies, such as the ability to navigate uncertainty and complexity. Leaders who foster a culture of innovation and encourage their teams to experiment with new ideas will be better positioned to capitalize on the opportunities presented by the 4IR.

Democratization of Leadership: The democratization of leadership—where employees are more involved in decision making—offers a promising avenue for fostering engagement and motivation. Studies show that when employees are given autonomy, decision-making authority, or equity stakes in their companies, organizational performance improves. This trend is evident in companies like Front and Umantis, which empower employees to influence strategic decisions or even elect their managers (Schwarzmüller et al., 2017).

Continuous Employee Education: As 4IR technologies evolve, the need for ongoing education and upskilling is critical. Leaders must create environments where employees are encouraged to develop new skills continuously. This includes both technical skills, such as IT proficiency, and soft skills, such as self-management and communication in virtual settings (Schwarzmüller et al., 2017).

Technologization of Leadership: As leadership becomes more reliant on digital tools, the technologization of leadership is inevitable. New technical tools, such as virtual collaboration platforms and data analytics systems, support leaders in their roles. However, leaders must also be cautious about over-reliance on technology and ensure that human-centric leadership principles, such as empathy and trust building, remain at the forefront of their leadership practices (Schwarzmüller et al., 2017; Alade & Windapo, 2021).

Overall, the 4IR presents a complex landscape for leadership, filled with both challenges and opportunities. Leaders must navigate the ethical implications of new technologies, manage job displacement, and foster relationship building in an increasingly digital world. At the same time, they must cultivate a mindset of innovation, embrace distributed leadership models, and invest in continuous learning to ensure organizational success. By balancing technological enablement with human-centric leadership, leaders can effectively guide their organizations through the transformative era of the 4IR and thrive in the face of rapid technological change.

2.6. Identified Research Gaps and Research Questions

A critical review of the existing literature reveals several notable shortcomings that warrant further investigation. Although extensive research has been conducted on various leadership styles—such as transformational, digital, and ethical leadership—these are often examined in isolation. This fragmented approach limits our understanding of how leadership can holistically support digital transformation initiatives, particularly in complex and regulated environments such as healthcare.

There is a conspicuous gap in studies that attempt to integrate multiple leadership styles into a cohesive model tailored for the 4IR. Specifically, limited research has been devoted to synthesizing these leadership paradigms within a unified framework that can effectively address the multifaceted demands of digital transformation. This study addresses this gap by proposing the Leadership 4.0 conceptual model, which integrates transformational, digital, and ethical leadership theories. The model offers a structured approach for navigating organizational change by combining innovation, ethical governance, and adaptability (Holbeche, 2018; Mayer, 2024).

In the healthcare sector—where digital transformation is both a pressing priority and a complex undertaking—there remains a lack of theoretical models that explicitly examine how different leadership styles interact to manage critical factors such as workforce adaptation, regulatory compliance, and technological ethics. By distinguishing between conceptual background and theoretical foundations, this study aims to provide a more structured and comprehensive understanding of the dynamic relationship among leadership, technology, and organizational culture.

Based on these research gaps, the following research questions were formulated to guide the review:

RQ1: How does digital transformation impact leadership roles and responsibilities in healthcare? This focuses specifically on how leadership roles in healthcare evolve due to digital advancements and emerging responsibilities.

RQ2: What competencies are essential for effective leadership in the digital age within the healthcare sector? This aims to identify the specific skills and attributes required for Leadership 4.0 in the context of healthcare’s rapid digital transformation.

RQ3: How can healthcare leaders successfully navigate digital transformation? This aims to investigate strategies and approaches that healthcare leaders can adopt to manage and guide their organizations through digital changes.

By addressing these questions, this study intends to contribute to the development of a comprehensive leadership framework that is theoretically grounded and practically relevant for navigating digital transformation, particularly in healthcare and other technology-intensive sectors.

3. Materials and Methods

This study explores Leadership 4.0, with a particular emphasis on the critical competencies required for leaders to effectively manage digital transformation. A mixed-methods approach is employed, integrating a SLR and the Delphi method to address the research questions. The combination of these methods allows for a thorough analysis of the existing literature while providing qualitative insights from experienced healthcare leaders, ensuring a comprehensive understanding of leadership dynamics in the digital age, particularly within healthcare environments.

3.1. Overview of the Research Approach

This study adopts a mixed-methods research design that strategically integrates a Systematic Literature Review (SLR) with the Delphi method to comprehensively investigate leadership competencies and challenges in the context of digital transformation within the healthcare sector. The rationale for employing this combined approach lies in its ability to harness the strengths of both theoretical synthesis and empirical validation, thereby addressing the study’s central aim: to bridge the gap between academic knowledge and practical leadership needs in a rapidly evolving, technology-driven environment (Fathullah et al., 2023).

The SLR forms the foundational component of the research, offering a rigorous and systematic analysis of the existing literature to identify key leadership competencies, trends, and gaps related to digital transformation. This process ensured a broad yet detailed understanding of the theoretical landscape, drawing on diverse frameworks and findings from across disciplines. However, given the complex and dynamic nature of leadership in healthcare—especially under the pressures of digital change—the literature alone is insufficient to fully capture the practical nuances and contextual variables at play.

To address this limitation, the Delphi method was employed as a complementary strategy, engaging a panel of 15 experienced healthcare leaders in a structured, multi-round consultation process. The Delphi study allowed for the critical validation and refinement of the SLR-derived findings by collecting expert opinions, prioritizing themes, and surfacing real-world contradictions and insights that the literature alone might overlook. Through iterative feedback rounds, consensus was achieved on several leadership priorities, while divergent views offered valuable depth on issues such as resistance to change, the role of institutional culture, ethical concerns, and skills gaps.

The integration of SLR and Delphi thus reflects a dual commitment: first, to the academic rigor of evidence synthesis, and second, to the practical applicability ensured by expert-driven validation. This methodological synergy not only reinforced the relevance of existing theoretical models but also extended them through context-specific insights from digital transformation in healthcare. Ultimately, this approach produced findings that are both generalizable and grounded in practice—enabling the development of informed, actionable strategies for strengthening leadership in digitally evolving healthcare organizations.

3.2. Systematic Literature Review (SLR)

The SLR forms the foundation of this study, providing a structured and comprehensive examination of the current literature on Leadership 4.0 and digital transformation. The aim of the SLR is to identify, evaluate, and synthesize the existing research on the competencies, challenges, and opportunities related to leadership in the digital era, particularly in healthcare settings. The review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to ensure rigor, transparency, and reproducibility (Alanazi, 2022; Darmawan & Laksono, 2021; Bag et al., 2024; Lim et al., 2021).

3.2.1. Objectives and Scope of the SLR

The primary objective of the SLR is to investigate the intersection of Leadership 4.0, digital transformation and organizational culture within healthcare. Specifically, the review aims to

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Identify the key leadership competencies required in digitally transforming healthcare environments.

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Examine common challenges such as resistance to change, skills gaps, and leadership preparedness.

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Explore opportunities and strategies for sustainable leadership development in response to ongoing digital advancements.

The scope of the review is aligned with the broader research aim of bridging theoretical knowledge and practical insights to inform leadership practices in digital healthcare transformation.

3.2.2. Search Strategy and Databases

This study adheres to structured protocols and selection criteria to examine the relationships among sustainable leadership, job satisfaction, organizational culture, and digital transformation in modern healthcare settings. To ensure methodological rigor, the SLR follows the PRISMA framework, a widely accepted guideline for conducting systematic reviews, ensuring transparency, reliability, and reproducibility (Bag et al., 2024; Lim et al., 2021; Belle & Zhao, 2023; Shamseer et al., 2015).

A comprehensive literature search was conducted across Scopus, Web of Science, and IEEE Xplore to ensure the inclusion of high-quality sources.

3.2.3. Inclusion and Exclusion Criteria

To ensure a focused and high-quality literature review, strict inclusion and exclusion criteria were applied. The review included peer-reviewed journal articles published between 2017 and 2024 that addressed Leadership 4.0, digital transformation, and organizational culture in healthcare. Studies providing empirical data or theoretical frameworks aligned with the research objectives were also considered.

Non-peer-reviewed sources, such as white papers, conference proceedings, and blogs, were excluded. Additionally, articles that focused solely on leadership without discussing digital transformation, as well as publications in languages other than English, were not included.

The study identified challenges and prospects in Leadership 4.0 through a combination of a SLR, qualitative case studies, and the Delphi method. This structured approach ensured that the identified challenges and prospects were derived from both theoretical and practical perspectives, making them relevant to the evolving digital transformation in healthcare.

Regarding additional potential challenges, the research scope was defined by the most pressing and recurrent issues found in the existing literature and expert insights. While other challenges may exist, those discussed were prioritized based on their frequency, impact, and relevance to Leadership 4.0 in healthcare. Any omitted challenges were excluded due to limited evidence in the literature or lower relevance to the core themes of digital transformation and leadership effectiveness.

Data Extraction and Synthesis: A standardized data extraction template was used to systematically capture study objectives, methodologies, key findings, and their relevance to Leadership 4.0. The extracted data were synthesized narratively, identifying recurring themes and research gaps related to sustainable leadership, organizational culture, and digital transformation.

Addressing Bias and Limitations: To enhance robustness and minimize bias, a dual-reviewer screening process was applied to validate article selection. Conflicting inclusion decisions were resolved through consensus. Grey literature was excluded to maintain a focus on high-quality, peer-reviewed sources. This rigorous and structured approach, aligned with the PRISMA framework, enhances the reliability of findings and provides valuable insights into sustainable leadership and digital transformation in healthcare (Bag et al., 2024; Lim et al., 2021; Shamseer et al., 2015).

3.2.4. Screening and Selection Process (PRISMA)

The PRISMA framework (illustrated in

Table 1. PRISMA flow diagram. This table was created by the authors of the article.

Phase	Description	Records (n)
Identification	Records identified through database searching (Scopus, Web of Science, IEEE Xplore)	420
	Duplicate records removed	75
	Records after duplicates removed	345
Screening	Records screened (title and abstract)	345
	Records excluded (not meeting eligibility criteria)	180
	Full-text articles assessed for eligibility	120
Eligibility	Full-text articles excluded: Non-peer-reviewed sources	15
	Full-text articles excluded: Solely focused on leadership without digital transformation	12
	Full-text articles excluded: Not in English	14
Included	Studies included in qualitative synthesis	79

) ensures transparency and reproducibility in the study selection process, reinforcing methodological rigor in the systematic literature review (Belle & Zhao, 2023; Shamseer et al., 2015).

Search Terms and Boolean Operators: A structured search query was applied to capture studies related to Leadership 4.0, digital transformation, and their impacts on healthcare and organizational outcomes. The following is an example of the Boolean search string used in this study: (“Leadership 4.0” OR “Digital Leadership” OR “Transformational Leadership”) AND (“Healthcare” OR “Hospital Management”) AND (“Digital Transformation” OR “Industry 4.0”).

Diagram Representation (Narrative Explanation):

• Identification Stage: A total of 420 studies were retrieved from three academic databases (Scopus, Web of Science, IEEE Xplore). After removing duplicates, 345 unique records remained.
• Screening Stage: Titles and abstracts of these 345 records were screened, resulting in the exclusion of 180 studies that did not meet the predefined eligibility criteria.
• Eligibility Stage: The full texts of the remaining 120 articles were assessed for eligibility, leading to the exclusion of 41 studies due to factors such as non-peer-reviewed sources, lack of relevance, or language constraints.
• Final Inclusion: Ultimately, 79 studies were included in the systematic review, forming the basis of the synthesis (Van Dinter et al., 2021; Afzal et al., 2023; Jünger et al., 2017).

3.2.5. Data Extraction and Thematic Analysis

A standardized data extraction template was employed to collect information on study objectives, methods, key findings, and relevance to Leadership 4.0. Each article was analyzed using thematic analysis techniques to identify recurring patterns, insights, and research gaps. The analysis focused on the interrelationships among sustainable leadership, organizational culture, job satisfaction, and digital transformation.

To minimize bias, a dual-reviewer process was used throughout article selection and coding. Discrepancies were resolved through consensus, and grey literature was excluded to maintain the review’s academic rigor and focus (Lim et al., 2021; Belle & Zhao, 2023; Shamseer et al., 2015).

3.2.6. Key Themes Identified from the SLR

The thematic analysis of the selected literature revealed several dominant themes:

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Core Leadership Competencies:

• Traits such as digital literacy, adaptability, strategic foresight, and change management skills were frequently cited as essential for leaders navigating digital transformation in healthcare.

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Barriers to Transformation:

• Common challenges included resistance to change, limited digital skills, and misalignment between organizational culture and digital strategies.

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Strategies for Overcoming Challenges:

• Recommendations included leadership development programs, organizational culture shifts, and the creation of interdisciplinary teams to support innovation and transformation.

These themes provide a conceptual framework for the subsequent application of the Delphi method, aimed at validating and contextualizing the findings in practical settings.

3.3. Delphi Method

This study employed a qualitative Delphi method to identify and validate the leadership competencies required for healthcare administrators managing teleworking teams in public hospitals during the COVID-19 lockdowns. The Delphi method was selected for its structured, iterative approach, which fosters consensus building among expert leaders and systematically refines insights through multiple feedback rounds. This method was particularly suited to the rapidly evolving healthcare environment and the increasing demand for digital adaptability, offering a robust framework for assessing leadership challenges and competencies critical to digital transformation in healthcare during a global crisis (Van Dinter et al., 2021; Afzal et al., 2023; Jünger et al., 2017; Vasileiou et al., 2024; Kakouris et al., 2022).

3.3.1. Purpose and Rationale

The primary objective of the Delphi method in this study was to explore and validate the essential leadership competencies needed during digital transformation in public healthcare systems, particularly under the constraints imposed by pandemic-related remote work. Given the complexity and novelty of leading digital transitions in public hospitals, the Delphi approach was ideal for leveraging the expertise of seasoned healthcare administrators and promoting reflective, consensus-driven analysis. It enabled the identification of competencies that are not only theoretically relevant but also grounded in the lived experiences of healthcare leaders (Van Dinter et al., 2021; Afzal et al., 2023; Spranger et al., 2022; Keeney et al., 2011).

3.3.2. Delphi Design and Process (Three Rounds)

The Delphi process consisted of three iterative rounds, each designed to synthesize expert opinion and progressively deepen the understanding of leadership challenges and competencies.

Round 1 involved presenting participants with a questionnaire based on key themes derived from a systematic literature review (SLR), such as organizational culture, resistance to change, technological infrastructure, and leadership adaptability. Participants provided feedback via Likert-scale ratings and open-ended responses, offering both quantitative evaluations and qualitative insights.

Likert-scale sample questions:

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“How critical is fostering an adaptable organizational culture for driving digital transformation?”

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“To what extent does resistance to change act as a barrier in your organization?”

Open-ended sample questions:

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“What leadership competencies are most essential in managing digital change?”

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“How do you address skills gaps within your team during digital transformation?”

Round 2 focused on areas of divergent feedback from Round 1. Participants reviewed aggregated group responses and revised their evaluations to promote convergence toward consensus, particularly on issues such as reskilling feasibility and infrastructure constraints.

Round 3 addressed areas where consensus had not yet been reached, such as ethical concerns and persistent resistance to change. Final refinements were made to identify stable themes and competencies.

This iterative process ensured that new insights were incorporated while progressively narrowing the scope to high-priority leadership challenges and solutions (Simeli et al., 2023; Jacob et al., 2022).

3.3.3. Participant Selection and Demographics

The expert panel for the Delphi study comprised 15 healthcare leaders who were purposively selected for their senior roles in public hospitals and their experience in managing teleworking teams in the course of the coronavirus lockdowns. Participants were chosen based on their firsthand experience with the challenges associated with remote work and digital transformation in healthcare. They were recruited through expert referrals to relevant settings. To ensure a broad and representative range of perspectives, the sample included administrators from hospitals of varying sizes and geographic locations across Greece. This purposive sampling strategy aimed to capture rich, context-specific data that directly aligned with the study’s objectives (Simeli et al., 2023; Jacob et al., 2022).

The selection process adhered to strict inclusion criteria to ensure that the panel’s expertise corresponded with the study’s focus on leadership competencies. Participants were identified through expert referrals, leveraging professional networks to recruit individuals with substantial experience in healthcare administration during the pandemic. Recruitment materials clearly outlined the study’s objectives and emphasized the significance of their contributions to the discourse on digital transformation in healthcare (Simeli et al., 2023; Jacob et al., 2022).

Efforts were made to ensure diversity within the panel to enhance the sector-specific relevance of the findings. Participants provided informed consent, and their anonymity was preserved throughout the study. Sociodemographic data, including years of experience, geographic location, and hospital size, were collected to contextualize the findings. Including administrators from diverse organizational contexts strengthened the generalizability of the results while also highlighting the unique challenges faced by administrators in different settings.

This carefully designed sampling approach ensured the credibility and relevance of the data collected, offering valuable insights into leadership strategies, challenges, and solutions within the evolving healthcare landscape. By engaging a panel of experts with direct experience in managing telework during a period of significant disruption, the study achieved a high level of methodological rigor and contextual validity.

3.3.4. Data Collection and Instruments

Data were collected using structured surveys administered across three Delphi rounds. Each round was designed to explore, validate, and refine leadership competencies related to digital transformation. Instruments included the following:

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Likert-scale items: Used to rate the importance of key themes.

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Open-ended questions: Allowed participants to elaborate on their organizational experiences and offer in-depth insights.

The first-round survey addressed 10 themes from the SLR, such as organizational culture, change management, and ethics. Quantitative results guided the focus of subsequent rounds.

In Rounds 2 and 3, participants reviewed synthesized feedback from previous rounds to refine their inputs. This recursive design enabled convergence toward consensus and allowed minority views to influence the group dialogue constructively.

Throughout the process,

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Responses were anonymized.

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Visual summaries and statistical analyses were shared after each round to enhance transparency and inform participants’ reflections.

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Qualitative and quantitative data were treated as equally important in shaping the evolving framework.

3.3.5. Analysis and Consensus Criteria

Analysis incorporated both quantitative and qualitative techniques.

Consensus thresholds:

• Agreement was defined as a median score of 4 or higher on Likert items (5-point scale) and an interquartile range (IQR) of 1 or less.
• This ensured statistical consensus while maintaining sensitivity to differing viewpoints.

Qualitative feedback was analyzed using thematic analysis, which identified recurring patterns and unique insights across rounds. Minority perspectives were integrated into the evolving set of themes to ensure comprehensive representation.

Feedback was anonymized, and results were communicated after each round to promote reflection and informed revision.

Moreover, throughout the data collection process, participants’ qualitative feedback complemented the quantitative ratings, capturing the complexities of healthcare leadership in digital transformation. This approach enabled a holistic understanding of core themes, offering valuable insights into the nuanced demands of leadership in a rapidly evolving healthcare landscape (Kallio et al., 2016; Shaw, 1985; Dean, 2019).

Data Visualization:

• Position Distribution (see Appendix A, Bar Figure A1): The distribution of the 15 healthcare leaders across various administrative roles in public hospitals, highlighting roles with higher representation.
• Gender Distribution by Role (see Appendix A, Stacked Bar Figure A2): The gender breakdown within each position, showing the number of women and men in each role.
• Overall Gender Distribution (see Appendix A, Pie Figure A3): A visual representation of the overall gender split among participants, with women comprising 53% and men 47% of the sample.
• Average Experience in Years by Position (see Appendix A, Bar Figure A4): The average years of experience within each role, offering insights into the expertise these leaders bring to their positions.

3.4. Data Analysis Procedures

A mixed-methods analysis strategy was employed to comprehensively examine the leadership competencies and challenges associated with managing telework in the healthcare sector during the COVID-19 pandemic. This approach integrated quantitative data from Likert-scale items and qualitative insights from open-ended responses, allowing for both breadth and depth in the analysis (Kennedy, 2004; Keeley et al., 2016).

Quantitative Analysis: Quantitative data were analyzed using descriptive statistics to assess the level of agreement among participants across each Delphi round. A consensus threshold was set prior to the study: items with a median score of 4 or higher (on a 5-point Likert scale) and an interquartile range (IQR) of 1 or less were considered to reflect consensus. These metrics helped identify priority issues and stable themes across the expert panel. The progression of consensus over the three rounds was tracked to pinpoint themes of enduring relevance and those that evolved in response to group feedback.

Qualitative Analysis: Qualitative responses were analyzed using thematic analysis to capture participants’ nuanced perspectives and experiences (Biggane et al., 2019). A coding guide was developed to organize responses into core themes, such as

▪

Leadership adaptability to technological change;

▪

Resistance to organizational change;

▪

Ethical and data protection considerations;

▪

Strategies for developing digital skills within teams.

This systematic coding process enabled the identification of recurring patterns, while also highlighting divergent or minority views that enriched the interpretation of findings.

Integration of Quantitative and Qualitative Findings: The integration of quantitative and qualitative data was achieved through a side-by-side comparison and triangulation process. For each theme, Likert-scale ratings were reviewed alongside related qualitative comments to provide contextual depth to statistical findings. For example, a high consensus score on the importance of leadership adaptability was supplemented by qualitative accounts of how administrators addressed digital skill gaps or led technological transitions during lockdowns.

Triangulation with SLR Findings: Themes that emerged during the Delphi rounds were also triangulated with findings from the initial SLR. This ensured that expert feedback not only reflected real-world experiences but also aligned with or extended existing academic knowledge. The comparison allowed researchers to

▪

Validate SLR-derived themes (e.g., digital infrastructure, resistance to change) through real-world consensus;

▪

Refine or reframe themes based on new insights from Delphi participants;

▪

Identify gaps in the literature that the Delphi study helped to address.

This triangulation strengthened the credibility and rigor of the study’s findings by grounding them in both empirical evidence and expert consensus (Kakouris et al., 2022; Terry et al., 2017; Braun & Clarke, 2006; Roberts et al., 2019).

3.5. Confirmation of SLR Results Using the Delphi Method

To further validate and enrich the findings from the SLR, a Delphi study was conducted with a panel of 15 healthcare leaders. The Delphi method, widely recognized for its ability to build expert consensus through structured rounds of feedback, was chosen to assess the applicability of identified leadership competencies and challenges in healthcare organizations undergoing digital transformation.

The Delphi process involved three survey rounds, each designed to refine insights gathered from the experts progressively. In the first round, the panel was presented with 10 key themes identified from the SLR, including organizational culture and digital transformation, leadership and change management, skills gaps, technological infrastructure, resistance to change, and ethical considerations. Participants rated the importance of these factors on a Likert scale and provided qualitative feedback regarding their relevance to their organizational contexts.

3.5.1. Round 1: Initial Responses and Emerging Themes

In the initial round, a strong consensus emerged regarding the importance of organizational culture in facilitating digital transformation. Most healthcare leaders agreed that fostering an adaptable, innovation-driven culture was critical for overcoming resistance to change. One leader commented, “Without a culture that encourages experimentation and flexibility, any attempt at digital transformation will likely fail”. However, some participants from larger institutions noted that institutional inertia—the tendency of well-established organizations to resist change—posed a significant challenge despite efforts to promote a culture of innovation.

Regarding leadership and change management, most experts confirmed that effective leadership is essential for guiding digital transformation. They emphasized that leaders must possess not only technical understanding but also the ability to inspire teams and drive cultural shifts. Interestingly, one leader highlighted a contradiction, noting that while top-down leadership is often emphasized in driving transformation, “bottom-up innovation from team members can sometimes be the key to unlocking successful digital initiatives”. This underscored the need for both strong leadership and grassroots innovation within organizations.

3.5.2. Round 2: Clarifications and Diverging Opinions

In the second round, participants reviewed the aggregated feedback from the first round and reflected on areas where consensus had not yet been reached. One key area of divergence was technological infrastructure and integration. While most leaders acknowledged the importance of a robust technological infrastructure for digital transformation, some argued that their organizations had achieved significant digital advancements despite legacy systems. One participant noted, “We were able to adopt AI-powered tools even though our core infrastructure was outdated. It’s more about leadership’s vision and willingness to push through technical barriers”. This perspective challenged the prevailing view that weak infrastructure severely hinders digital initiatives, suggesting that organizational commitment and strategic focus can sometimes outweigh technological limitations.

Skills gaps and training needs also emerged as contentious issues. Some leaders advocated for upskilling existing staff through targeted training programs, while others questioned the feasibility of reskilling in healthcare settings. One expert remarked, “The pace of digital transformation is too fast for many employees to catch up, especially in sectors like ours where technical proficiency isn’t a core competency”. This raised concerns about the potential mismatch between workforce skills and the demands of rapid digitalization.

3.5.3. Round 3: Final Consensus and Remaining Contradictions

The final round focused on synthesizing insights from the previous two rounds and achieving greater consensus where possible. While several areas of agreement solidified—such as the importance of leadership adaptability and organizational culture in driving digital change—some issues remained unresolved.

Resistance to change continued to generate mixed responses. Many leaders agreed that resistance to new technologies was a major barrier, particularly at the operational level, where employees are often reluctant to alter long-established practices. However, some participants argued that resistance stemmed more from leadership’s lack of clear communication than from employees’ reluctance to change. One participant noted, “We found that when leadership communicated a clear vision and tied digital transformation to specific, relatable outcomes for employees, resistance diminished significantly”. This highlighted the complexity of change management, where leadership plays a crucial role in articulating the benefits and processes of transformation.

Ethical considerations and data privacy also remained areas of debate. While nearly all participants recognized the growing importance of data privacy in healthcare, some believed ethical concerns were being overstated, particularly in the early stages of digital transformation. One leader stated, “Our focus right now is on adopting the tools; the ethics around them are still a secondary concern”. This perspective contrasted with others who insisted that ethical frameworks and data protection measures must be integrated into digital strategies from the outset to mitigate reputational and legal risks later.

All in all, the integration of the SLR with the Delphi method provided a robust framework for translating theoretical knowledge into practical leadership insights. By engaging 15 experienced healthcare leaders across three iterative rounds, the Delphi process validated and expanded upon the SLR findings, grounding them in real-world organizational contexts. This expert input confirmed the critical role of leadership adaptability, organizational culture, and change management in enabling digital transformation, while also revealing new perspectives—such as the potential of grassroots innovation and the strategic importance of communication in overcoming resistance to change. Furthermore, the Delphi study challenged some assumptions from the literature, particularly regarding the impact of legacy infrastructure and the urgency of ethical considerations. Overall, this synthesis of scholarly evidence and practitioner experience enriched the study’s relevance and ensured its findings were both theoretically sound and practically actionable.

3.6. Methodological Limitations

This study employed a mixed-methods approach—SLR followed by a Delphi panel—to address its research objectives. While the SLR enabled a comprehensive analysis of the existing literature and helped identify key leadership competencies relevant to digital transformation, it was limited by the predominance of Western-centric studies, which constrains the contextual generalizability of the findings. The Delphi method complemented the SLR by integrating expert perspectives, thus grounding the study in practical insights. However, the Delphi panel’s relatively small size (15 participants) and limited demographic scope may not fully capture the diversity of leadership experiences across healthcare settings and regions.

Furthermore, although the combined approach effectively bridges theoretical and practical dimensions, it does not account for all contextual variables—such as organizational culture or regional policy differences—that could impact leadership effectiveness in digital transformation.

4. Findings and Integration of Results

4.1. Key Findings from the Systematic Literature Review (SLR)

Drawing from socio-technical systems theory and the dynamic capabilities framework, this systematic literature review (SLR) synthesizes insights from 38 key peer-reviewed studies. It identifies 10 critical challenges facing digital transformation initiatives, particularly within healthcare, where financial constraints, the imperative for patient-centered care, and resistance to technological change are especially pronounced (Sfakianaki & Kakouris, 2019; Polit & Beck, 2010; Oleksa-Marewska & Tokar, 2022).

The 10 challenges, ranked by frequency and importance, are as follows:

1. Organizational Culture and Digital Transformation: Organizational culture is integral to the success of digital transformation, shaping how organizations embrace change and adopt new technologies. Resistance to change, often stemming from entrenched routines or skepticism about the benefits of digital initiatives, remains a pervasive barrier. This challenge has been extensively analyzed in the organizational behavior literature, such as in Hussain et al. (2018) Change Management Model, which emphasizes the importance of “unfreezing” existing mindsets before implementing change. Similarly, Kotter’s (in Alhaderi, 2021) Eight-Step Process for Leading Change highlights the necessity of creating urgency and engaging key stakeholders to overcome resistance. These theoretical perspectives provide a deeper understanding of the underlying dynamics and offer actionable strategies for mitigating resistance during digital transformation efforts. In healthcare, this resistance is magnified by the need to ensure high-quality patient care during technological shifts (Alanazi, 2022). Addressing this requires cultivating a culture of innovation, continuous learning, and experimentation. Organizations must actively engage employees at all levels, ensuring that the benefits of digital transformation are understood and embraced. Such cultural alignment facilitates smoother transitions and fosters resilience against the uncertainties of change (see

Table 2. Organizational culture and digital transformation. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 25 References)
Organizational Culture and Digital Transformation	Organizational culture greatly influences digital transformation success. Adaptable cultures ease resistance stemming from fear and skepticism. Fostering innovation, learning, and experimentation is critical. Engaging all organizational levels drives adoption of new practices.	(Abdul Hamid, 2022; Ajigini & Chinamasa, 2023; Al-Alawi et al., 2023; Ananyin et al., 2018; Asfahani, 2024; Bordeleau et al., 2020; Chwiłkowska-Kubala et al., 2023; Cichosz et al., 2020; Fonseca et al., 2021; Ghafoori et al., 2024; Gupta et al., 2022; Hadi & Baskaran, 2021; Hamdani et al., 2021; Kiefer et al., 2021; Kraiwanit & Terdpaopong, 2024; Meena et al., 2024; Mekonnen et al., 2022; Merten et al., 2022; Montero Guerra & Danvila-Del Valle, 2024; Nkomo & Kalisz, 2023; Omol, 2023; Serna Gómez et al., 2021; Theotokas et al., 2024; Thomas et al., 2023; Yoo et al., 2024)

).

2. Leadership and Change Management: Effective leadership is consistently emphasized as a cornerstone of successful digital transformation. Leaders must not only understand the strategic importance of digital tools but also motivate their teams to adopt new technologies and navigate the complexities of change management. This includes breaking down silos, promoting collaboration, and aligning digital strategies with organizational goals. Healthcare leaders face additional challenges, such as managing hybrid teams and maintaining effective remote leadership—an issue amplified by the COVID-19 pandemic (Sfakianaki & Kakouris, 2019; Šuc et al., 2009). Without strong, digitally savvy leadership, organizations risk misalignment and diminished effectiveness in their transformation efforts (see

Table 3. Leadership and change management. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 15 References)
Leadership and Change Management	Leadership is central to navigating complex change and aligning strategies. Digitally savvy leaders drive cultural shifts and collaboration. Strong leadership inspires technology adoption and prevents transformation failures.	(Ajigini & Chinamasa, 2023; Al-Alawi et al., 2023; Alos-Simo et al., 2017; Arabiun et al., 2024; Chwiłkowska-Kubala et al., 2023; Fonseca et al., 2021; Hadi & Baskaran, 2021; Hamdani et al., 2021; Kraiwanit & Terdpaopong, 2024; Lemak et al., 2024; Mekonnen et al., 2022; Nkomo & Kalisz, 2023; Omol, 2023; Tursunbayeva & Gal, 2024; Xanthopoulou et al., 2023)

).

3. Technological Infrastructure and Integration: A robust technological infrastructure is essential for successful digital initiatives. Challenges in upgrading or integrating legacy systems with modern technologies can result in inefficiencies, increased costs, and security vulnerabilities. Financial constraints are a significant barrier, especially in resource-intensive sectors like healthcare. Organizations may face difficulties in investing in the modernization of legacy systems, which can lead to inefficiencies and heightened security risks (Munsamy et al., 2023). To ensure successful digital transformation, organizations must make sure their infrastructure is scalable, secure, and capable of supporting advanced analytics, higher data volumes, and emerging technologies. A lack of such preparedness can severely hinder progress (see

Table 4. Technological infrastructure and integration. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 10 References)
Technological Infrastructure and Integration	Robust infrastructure is essential but challenging. Key components: hardware, software, and networks supporting data and analytics. Weak infrastructure risks inefficiencies, costs, and security threats.	(Al-Alawi et al., 2023; Alwaely et al., 2024; Asfahani, 2024; Bordeleau et al., 2020; Cichosz et al., 2020; Fonseca et al., 2021; Govindan, 2022; Nkomo & Kalisz, 2023; Serna Gómez et al., 2021; Tursunbayeva & Gal, 2024)

).

4. Skills Gaps and Training Needs: The rapid adoption of digital tools has outpaced the availability of skilled professionals, creating a significant skills gap. Employees in healthcare and other sectors often lack the technical competencies necessary for the effective use of digital technologies, especially in traditionally non-digital industries. In healthcare, this training must also address the unique needs of different generational cohorts, which influence digital readiness (Salman & Broten, 2017). Bridging this gap requires comprehensive training programs that focus not only on technical skills but also on fostering a digital mindset that aligns with organizational goals (see

Table 5. Skills gaps and training needs. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 9 References)
Skills Gaps and Training Needs	Skills shortages hinder transformation efforts. Demand is growing for digitally proficient workforces. Closing gaps requires technical, mindset, and strategic training programs.	(Abdul Hamid, 2022; Al-Alawi et al., 2023; Alwaely et al., 2024; Fonseca et al., 2021; Gatell & Avella, 2024; Kraiwanit & Terdpaopong, 2024; Merten et al., 2022; Serna Gómez et al., 2021; Theotokas et al., 2024)

).

5. Digital Transformation Strategy and Alignment: A coherent and integrated strategy is essential for aligning digital transformation efforts with broader organizational goals. Many organizations, including healthcare providers, initiate digital projects without a clear roadmap, leading to fragmented initiatives that fail to deliver meaningful value (Zhao et al., 2020). Strategic misalignment can waste resources and disrupt operations, highlighting the need for a well-defined digital strategy that supports organizational objectives and drives sustained growth (see

Table 6. Digital transformation strategy and alignment. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 4 References)
Digital Transformation Strategy and Alignment	Strategic alignment between digital and organizational goals is critical. Lack of alignment leads to fragmented, ineffective efforts. Clear, mission-linked strategies avoid wasted resources and missed opportunities.	(Ajigini & Chinamasa, 2023; Kovrigin & Vasiliev, 2020; Mekonnen et al., 2022; Nkomo & Kalisz, 2023)

).

6. Resistance to Change: Resistance to change is a multifaceted challenge that affects both individual employees and organizational structures. Fear of disruption, loss of routine, and concerns about job security often contribute to this resistance. In healthcare, this challenge is further intensified by the rapid pace of technological innovation and the need for consistent service delivery (Sfakianaki & Kakouris, 2019). To mitigate these barriers, organizations must implement comprehensive change management strategies that prioritize clear communication, active involvement, and reassurance at all levels (see

Table 7. Resistance to change. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 4 References)
Resistance to Change	Resistance to new technologies is a major barrier. Causes include fear, routines, and job security concerns. Overcoming resistance requires communication, participation, and reassurance.	(Al-Alawi et al., 2023; Alwaely et al., 2024; Kraiwanit & Terdpaopong, 2024; Serna Gómez et al., 2021)

).

7. Ethical Considerations and Data Privacy: Digital transformation, which involves the extensive use of advanced technologies such as AI, increasingly raises ethical concerns, particularly regarding data privacy. Ensuring responsible data handling is not only a legal requirement but also crucial for maintaining stakeholder trust. Organizations must adopt robust policies and practices to address the ethical challenges of digital transformation (see

Table 8. Ethical considerations and data privacy. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 4 References)
Ethical Considerations and Data Privacy	Ethical and privacy issues are heightened in digital environments. Responsible data management ensures legal compliance and trust. Mishandling data risks improper use and reputational damage.	(Ananyin et al., 2018; Omol, 2023; Theotokas et al., 2024; Trautmann, 2017)

). This is especially important in healthcare, where sensitive patient data requires stringent protection (Üstgörül, 2023).

8. Talent Management: The ability to attract, retain, and develop digital talent is a key determinant of an organization’s digital maturity. However, competition for skilled professionals is fierce, and the rapid pace of technological advancements intensifies the challenge of maintaining a workforce that is up to date. Investing in continuous learning and fostering an environment that values innovation are crucial for effective talent management across all types of organizations, including those in healthcare (Williams et al., 2019) (see

Table 9. Talent management. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 4 References)
Talent Management	Attracting and developing digital talent is essential for success. Skill shortages and rapid tech changes make talent management competitive. Strategies must evolve to maintain workforce capabilities and competitive edge.	(Arabiun et al., 2024; Montero Guerra & Danvila-Del Valle, 2024; Kovrigin & Vasiliev, 2020; Thomas et al., 2023)

).

9. Human Resource Management (HRM) and Digitalization: Digital transformation in HRM is pivotal for streamlining processes, enhancing employee engagement, and optimizing talent management. Beyond automating tasks, digital HRM leverages analytics and AI to improve decision making in areas such as recruitment and training. However, in healthcare and other sectors, integrating these technologies requires overcoming challenges related to system compatibility, user adoption, and organizational readiness (Seddon & Currie, 2013) (see

Table 10. Human resource management (HRM) and digitalization. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 4 References)
Human Resource Management (HRM) and Digitalization	HRM digitalization boosts competitiveness through process innovation. Focuses on engagement, talent management, and informed decision making. Goes beyond automation, leveraging analytics and AI technologies.	(Ajigini & Chinamasa, 2023; Alos-Simo et al., 2017; Ananyin et al., 2018; Asfahani, 2024)

).

10. Integration of Advanced Technologies: Advanced technologies such as AI and Industry 4.0 tools offer immense potential for innovation and efficiency. However, their implementation is complex, requiring significant investments, technical expertise, and compatibility with existing systems. Successful integration demands meticulous planning, robust infrastructure, and a clear understanding of the technologies’ strategic value (see

Table 11. Integration of advanced technologies. The table was created by the authors of the article.

Topic	Key Points	Key References (Cited by 3 References)
Integration of Advanced Technologies	AI and Industry 4.0 offer major operational enhancements. Benefits include automation, real-time analytics, and better decision making. Implementation requires technical integration, compatibility, and investment management.	(Govindan, 2022; Hadi & Baskaran, 2021; Merten et al., 2022)

). In healthcare, balancing these investments with service quality objectives remains an ongoing challenge (Iyanna et al., 2022).

4.2. Validation and Expansion via Delphi Method

To validate and deepen the findings from the Systematic Literature Review (SLR), a Delphi study was conducted with 15 expert panelists drawn from healthcare and digital transformation domains (Oliver & Holzinger, 2008; Busch & Rajwade, 2024). Conducted across three iterative rounds, the Delphi process enabled the collection of expert consensus and context-specific insights regarding the challenges and enablers of digital transformation leadership.

4.2.1. Round 1 Findings

The initial round revealed strong consensus on the critical importance of organizational culture, leadership adaptability, and skills development as key enablers of digital transformation. The experts agreed that leadership vision often outweighed technological infrastructure as a determinant of success. Resistance to change emerged as a persistent challenge, with nuanced causes identified, such as fear of the unknown at the employee level and communication gaps at the leadership level.

4.2.2. Round 2 Clarifications

During the second round, panelists refined their evaluations based on aggregated feedback. A clearer distinction was drawn between general digital literacy needs and specialized healthcare technology skills. Moreover, ethical considerations—especially patient data privacy—rose in perceived importance, reflecting heightened awareness of regulatory and trust-related risks.

4.2.3. Round 3 Final Consensus

By the third round, the panel reached strong agreement on the primacy of organizational culture, leadership adaptability, workforce upskilling, and strategic alignment. Emerging factors such as internal branding, AI adoption, and regulatory compliance gained traction, although they remained secondary compared to foundational leadership competencies.

4.2.4. Key Outcomes and Diverging Views

Several important divergences surfaced. While the SLR emphasized technological readiness as a major challenge, the Delphi experts prioritized leadership vision as the decisive factor in overcoming technical obstacles. Opinions varied regarding the feasibility of large-scale reskilling of the healthcare workforce, with some experts expressing skepticism about pace and sustainability. Ethical governance became a prominent concern in later rounds, reinforcing the evolving importance of ethical leadership in healthcare digital transformation.

4.3. Integrated Insights from SLR and Delphi

The integration of the SLR and Delphi findings reveals important areas of convergence, new insights, and contradictions:

➢

Strong Consensus: Both studies consistently emphasized the critical role of organizational culture, leadership agility, workforce upskilling, and strategic alignment for digital transformation success.

➢

New Insights: The Delphi study elevated the importance of ethical considerations and internal branding, suggesting that real-world challenges—such as employee alignment with digital vision and managing AI adoption—are more complex and nuanced than the literature alone captures.

➢

Contradictions: While much of the academic literature frames technological infrastructure as a core barrier, practitioners stressed that leadership mindset and cultural adaptability are more decisive in driving transformation outcomes.

These integrated insights highlight that successful healthcare digital transformation demands not just technical investment but also deep organizational and human-centered shifts. Leaders must prioritize culture, ethical governance, and employee engagement as central pillars of their digital strategies.

4.4. Leadership 4.0 Framework for Healthcare Digital Transformation

Building upon the integrated findings from the Systematic Literature Review (SLR) and the Delphi study, this section introduces the Leadership 4.0 Framework for Healthcare Digital Transformation. The framework’s purpose is to provide healthcare leaders with a structured, actionable guide to successfully navigating digital transformation challenges. It synthesizes theoretical insights with practical validation to address the complex and evolving demands of the healthcare sector.

The Leadership 4.0 Framework was developed through a two-phase process. First, the SLR identified key leadership competencies, organizational enablers, and barriers to digital transformation. Then, the Delphi study validated and refined these findings through expert consensus. The resulting framework integrates these insights into five interconnected pillars, ensuring both theoretical robustness and practical applicability.

Figure 1 illustrates the sequential and interconnected nature of the Leadership 4.0 Framework. Strategic Digital Leadership sets the foundation, influencing Organizational Culture and Change Management as well as Technological Readiness and Workforce Development in parallel. These efforts drive Innovation and Ethical Considerations, culminating in Internal Branding and Stakeholder Engagement to reinforce digital transformation success.

Key Components of the Leadership 4.0 Framework:

• Strategic Digital Leadership is essential for ensuring organizations develop digital competencies and leverage emerging technologies to maintain competitiveness. Leaders must align their strategic objectives with digital transformation efforts, integrating new tools and processes while maintaining a focus on long-term goals. By fostering a vision that embraces technological advancements, leaders can guide their organizations through complex digital transitions.
• Organizational Culture and Change Management play a crucial role in digital transformation, as organizations with adaptable, learning-focused cultures are better positioned to handle change. Encouraging collaboration and fostering an environment that embraces innovation helps reduce resistance to change. Leaders must be proactive in managing transformation, ensuring that employees at all levels feel engaged and supported throughout the process.
• Technological Readiness and Workforce Development are necessary to bridge the gap between digital ambitions and operational reality. Ensuring that employees are upskilled and technologically literate across all organizational levels enables more effective adoption of digital tools. Training programs, continuous education, and hands-on experience with digital systems contribute to a workforce that is more capable and confident in handling emerging technologies.
• Innovation and Ethical Considerations highlight the need for leaders to promote digital creativity while upholding responsible data governance. The integration of AI, big data, and digital analytics must be balanced with ethical considerations, ensuring transparency, accountability, and security in digital healthcare operations. Ethical frameworks should be implemented to prevent data misuse and maintain public trust.
• Internal Branding and Stakeholder Engagement ensure that employees and stakeholders align with the organization’s digital vision. By integrating branding strategies that communicate the purpose and benefits of digital transformation, organizations can increase commitment and reduce resistance to change. Effective internal communication strategies and employee engagement initiatives strengthen organizational alignment and encourage active participation in transformation efforts.

The Leadership 4.0 Framework provides a comprehensive model to guide healthcare leaders through digital transformation. Future research can further refine this framework by applying it in diverse healthcare settings to assess its effectiveness in practice.

4.5. Overview

This chapter synthesized findings from the Systematic Literature Review (SLR) and the Delphi study to develop an integrated understanding of the critical challenges in healthcare digital transformation. The SLR, grounded in socio-technical systems theory and the dynamic capabilities framework (Iyanna et al., 2022; National Academies of Sciences, Engineering, and Medicine, 2018), identified 10 pivotal challenges: organizational culture, leadership and change management, technological infrastructure, skills gaps, strategic alignment, resistance to change, ethical considerations, talent management, digitalization of human resource management, and the integration of advanced technologies. These findings emphasized the complex interplay between technological advancement, organizational structures, and human capabilities, particularly in the healthcare context, where financial constraints, service quality imperatives, and workforce resistance are uniquely pronounced (Sfakianaki & Kakouris, 2019; Munsamy et al., 2023).

The Delphi study validated and expanded upon these findings by offering practical, context-specific insights from healthcare and digital transformation experts (Hasson et al., 2000; Shariff, 2015; Steurer, 2011). Strong consensus emerged around the primacy of organizational culture, leadership agility, workforce upskilling, and strategic digital alignment as the most critical factors for successful transformation. The study also highlighted evolving concerns around ethical governance and data privacy, which gained increased importance through successive rounds. While technological readiness was acknowledged as important, experts emphasized leadership vision and cultural adaptability as even more decisive enablers.

Notable divergences also surfaced: whereas the literature often stressed infrastructural barriers, practitioners prioritized leadership and human-centric strategies. Additionally, the feasibility of large-scale workforce reskilling and the timing of AI and big data adoption revealed differing views, emphasizing that transformation strategies must be highly adaptive to organizational contexts.

Drawing on these insights, the Leadership 4.0 Framework was proposed, offering healthcare leaders a structured, holistic guide for managing digital transformation by integrating strategic leadership, cultural change, workforce development, technological readiness, innovation, and ethical governance.

As the findings reveal, successful digital transformation in healthcare extends far beyond technological adoption; it requires strategic leadership, cultural adaptability, ethical governance, and continuous workforce development. These integrated insights set the stage for a deeper exploration of their practical, theoretical, and managerial implications. The following discussion critically examines how these factors interact, the challenges they present, and the pathways forward for healthcare organizations aiming to thrive in an increasingly digital landscape.

5. Discussion

5.1. Summary of Key Finding Significance

This study emphasizes the essential competencies required for Leadership 4.0 to thrive in the context of healthcare’s ongoing digital transformation. Leaders must not only possess digital literacy but also emotional intelligence, strategic foresight, and the ability to navigate complex organizational dynamics. These competencies empower leaders to foster innovation, manage organizational change, and cultivate a culture of continuous learning—critical factors in ensuring healthcare organizations remain adaptable in an era marked by rapid technological change.

A significant finding of this study is the vital role of organizational culture in supporting digital transformation. Healthcare organizations, often structured around traditional hierarchical systems, face substantial barriers to adopting new technologies. However, cultivating a culture that prioritizes resilience, collaboration, and openness to experimentation enables organizations to overcome resistance to change. Leaders play a pivotal role in embedding these values within the workforce, ensuring alignment between individual roles and broader organizational transformation goals. This cultural shift is crucial in healthcare, where the integration of advanced technologies must not compromise patient care and service delivery.

Furthermore, the study highlights several challenges inherent in the digital transformation process, such as workforce skills gaps, resistance to technological adoption, and infrastructural limitations. Addressing these challenges requires more than technological upgrades—it demands proactive leadership that fosters a culture of continuous professional development, provides upskilling opportunities, and ensures the scalability of technological investments. The research also addresses critical ethical concerns related to data privacy and governance, especially as AI and big data become integral to healthcare operations. These technologies offer profound opportunities for improving patient care and operational efficiency, but they also raise important ethical questions that must be managed with care.

Finally, internal branding has emerged as an effective strategy for aligning employees with an organization’s vision, fostering commitment, and ensuring sustained engagement with digital transformation initiatives. By promoting the organization’s goals and vision through strategic internal branding, leaders can reinforce the importance of digital initiatives and engage staff in the overall transformation process.

5.2. Navigating Challenges in Digital Transformation

Digital transformation in healthcare reveals a complex interplay of technological advancement, organizational dynamics, leadership behavior, and ethical responsibility. This section synthesizes the study’s findings with the existing literature to critically examine the challenges and enablers of digital transformation in healthcare organizations. It also identifies broader implications for cross-sectoral leadership in the digital era.

5.2.1. Aligning Technology with Organizational Structures

One of the core insights from this study is the imperative to align technological advancements with existing organizational structures and strategic objectives. While prior research emphasized technical integration—such as software upgrades and system overhauls—the current understanding highlights the need for a more holistic approach. Digital transformation must not only update technology but also reshape the structural and strategic architecture of organizations to ensure coherence and sustainability.

This study supports the view that digital transformation success hinges on aligning digital tools with the organization’s vision, workflows, and human capabilities. Gadzali (2023), among others, emphasizes that leaders must integrate digital systems into the fabric of the organization, embedding them within a culture that is prepared for change and innovation (Serpa et al., 2022; Henriette et al., 2016).

5.2.2. Shaping Organizational Culture and Leadership

Organizational culture emerges as a pivotal factor in either facilitating or hindering digital innovation. The hierarchical nature and routine dependency of many healthcare organizations can create resistance to technological change. Traditional change models, like those proposed by Lewin in Hussain et al. (2018) and Kotter in Alhaderi (2021) underscore the need to address cultural inertia as part of the transformation journey.

Leadership 4.0, as introduced in this study, acts as a critical agent in reshaping culture to support digital change. Leaders equipped with emotional intelligence, strategic foresight, and digital fluency are better positioned to drive behavioral shifts. Rather than simply managing systems, they lead people through uncertainty, cultivating a learning-oriented, adaptable environment where transformation is sustainable and employee engagement is high.

5.2.3. Developing Strategic Digital Competencies

The alignment between digital strategies and organizational goals is essential for impactful transformation. This study found that a major challenge in healthcare is the misalignment between ambitious digital projects and the practical objectives of improving patient care or increasing operational efficiency. When digital initiatives are implemented without strategic grounding, they often result in fragmentation and underutilization.

Frameworks like socio-technical systems theory and dynamic capabilities theory provide lenses to understand how healthcare institutions can build internal competencies to better support digital transformation (Schwab, 2017; Kergroach, 2020; Ulrich et al., 2017). This includes embedding decision-making structures that integrate data-driven insights into everyday operations and ensuring that technology investments serve patient outcomes and organizational resilience.

5.2.4. Closing Workforce Skills Gaps

A recurring concern is the mismatch between the rapid advancement of digital technologies and the skill levels of healthcare staff. This study affirms the growing consensus that technical training alone is insufficient. Instead, workforce development should encompass strategic capabilities such as data literacy, change management, and system thinking (Sfakianaki et al., 2023; Cortellazzo et al., 2019; Tsekouropoulos et al., 2022; Wrede et al., 2020).

Organizations need to establish continuous professional development frameworks. Short-term upskilling efforts must give way to long-term learning ecosystems that evolve alongside technological innovation. This approach fosters not only competence but also confidence among healthcare professionals navigating digital tools and platforms (Serpa et al., 2022; Henriette et al., 2016; Heavin & Power, 2018; Shin et al., 2023).

5.2.5. Ensuring Ethical Governance and Data Privacy

As healthcare becomes increasingly digitized, ethical concerns—particularly regarding data governance and patient privacy—take center stage. This study found that ethical governance is not peripheral but foundational to digital transformation, especially as organizations begin to leverage AI and big data analytics.

Robust ethical frameworks are required to safeguard patient data and ensure regulatory compliance. Without such governance, healthcare institutions risk undermining public trust and facing serious legal repercussions (Hu, 2023). Leaders must champion transparency and ethical responsibility in all stages of digital implementation, ensuring that innovation does not compromise patient rights or data integrity (Brunetti et al., 2020; Nambisan et al., 2019).

5.2.6. Broader Applications of Leadership 4.0

The conceptual framework of Leadership 4.0, while rooted in healthcare, offers transferable lessons for other sectors undergoing digital transformation. Leadership 4.0 emphasizes emotional intelligence, digital agility, and ethical decision making—traits that are critical not only in healthcare but across industries such as education, manufacturing, public administration, and finance.

By reimagining leadership as a human-centered, adaptive process, this model encourages organizations to embrace uncertainty and foster innovation. For example, educational institutions may benefit from agile leadership when integrating AI into learning environments, while manufacturing sectors can leverage emotional intelligence to manage workforce automation transitions.

Furthermore, Leadership 4.0 has societal relevance. As governments and organizations confront global challenges like data inequality, misinformation, and algorithmic bias, leadership grounded in empathy, transparency, and ethics becomes indispensable. Leaders capable of navigating these complex, systemic issues can ensure that technological progress aligns with public values and long-term social welfare.

Through its human-centric and strategically agile approach, Leadership 4.0 equips leaders across sectors to respond not only to technological change but also to the ethical and societal challenges it generates.

5.3. Practical Implications

5.3.1. Leadership Approaches in the Digital Age

The digital age presents leaders with unprecedented challenges that demand agility and strategic foresight. The VUCA (Volatility, Uncertainty, Complexity, Ambiguity) environment has reshaped leadership expectations, requiring approaches that prioritize resilience (Halim, 2023; Barbazzeni et al., 2022). In the current labor market, managers face pressures to adapt to digital communication tools, which, while enhancing connectivity, can reduce their direct influence over employees. Building trust and adaptability is essential. Trust emerges as a cornerstone of effective leadership, particularly in virtual environments where traditional face-to-face interactions are diminished. Leaders must cultivate strong communication skills and trust-building abilities to foster collaboration and cohesion across dispersed teams.

At the heart of these challenges is the need for a cultural shift within organizations. Leadership theories emphasize creating environments that encourage cooperation and shared ownership of goals. By embedding trust-centric practices, such as transparency and consistent feedback, leaders can align team dynamics with the broader objectives of digital transformation.

Ultimately, leaders must hone their ability to navigate cultural and geographical differences, ensuring that their teams remain connected and committed despite the barriers of virtual work. Training programs focusing on communication, media flexibility, and trust building are essential to equip leaders with the tools necessary to manage this transition effectively.

5.3.2. Transformational Leadership 4.0 and Internal Branding

In this VUCA landscape, transformational leadership emerges as a model ideally suited for fostering meaningful engagement, surpassing traditional management approaches. This model emphasizes trust-based collaboration and adaptability, empowering leaders to inspire their teams to exceed perceived potential by setting ambitious goals, promoting personal growth, and addressing individual needs. Through motivational structures, transformational leadership not only supports employees in navigating constant change but also reinforces a resilient and collaborative culture (Barbazzeni et al., 2022; Mack & Khare, 2016; Pathak & Joshi, 2021; Norman, 2024).

A fundamental component of transformational leadership is trust building. Leaders build trust by acting with integrity and fairness, empowering employees with responsibility and autonomy. In the context of digital transformation, trust becomes even more crucial, as virtual work often reduces personal contact, challenging traditional trust dynamics. Research suggests that transformational leadership can foster trust within virtual teams, enhancing satisfaction and cohesion (Bruch & Berenbold, 2017; Winkler et al., 2020; Maciariello, 2006; Liebermeister & Köchling, 2017).

The role of transformational leadership in digital transformation warrants further exploration in the academic literature, particularly regarding its impact on employee motivation and engagement in virtual teams. Theoretical models should consider how digitalization alters the traditional dynamics of trust and influence within organizations.

Organizations should integrate transformational leadership principles into leadership development programs to enhance trust, motivation, and adaptability in digital environments. Managers should be trained in the Four Elements of Transformational Leadership (Bass & Riggio, 2006; Tsekouropoulos et al., 2023; Hoyt & Blascovich, 2003):

• Idealized Influence: Leaders act as role models, embodying commitment and integrity, inspiring admiration and respect.
• Individualized Consideration: Leaders provide personalized coaching and feedback, supporting employees’ unique strengths and professional growth.
• Intellectual Stimulation: Leaders encourage innovative thinking and problem solving, fostering a culture that embraces new ideas.
• Inspirational Motivation: Leaders articulate a compelling vision that motivates employees toward shared goals, significantly boosting performance (Hoyt & Blascovich, 2003).

Moreover, Leadership 4.0 requires not only digital competence but also the ability to cultivate a shared sense of purpose among employees. One key approach to achieving this is internal branding, which ensures alignment between employees’ values and the organization’s digital transformation objectives. By effectively communicating the digital vision and reinforcing core values, leaders can foster engagement and cohesion, essential for navigating digital disruption (Hoyt & Blascovich, 2003; Hoxha et al., 2024; Fauzi et al., 2023).

Theoretical insights highlight the importance of brand authenticity in building employee trust and alignment. When leaders effectively communicate the organization’s values and objectives, employees are more likely to internalize and embody these principles. This alignment is especially critical in sectors like healthcare, where the stakes of transformation directly impact service quality and performance (Sfakianaki et al., 2018; Bravo et al., 2021; Raj, 2020; Biedenbach et al., 2022). Internal branding in the context of digital transformation remains an underexplored area in leadership studies. Future research should investigate how internal branding strategies influence employee commitment and organizational adaptability in the digital age.

Leaders must champion internal branding initiatives that resonate with both employees and organizational objectives. This includes crafting messages that authentically reflect the brand’s values and ensuring these messages are consistently reinforced through actions and decisions. Training programs designed to integrate internal branding strategies into leadership practices can further enhance employee engagement and commitment, driving success in digital transformation efforts (Ngo et al., 2019; Yu et al., 2022; Sfakianaki et al., 2023; Jeste et al., 2010). By incorporating internal branding into Leadership 4.0, organizations can strengthen employee alignment with digital transformation goals, ensuring a smoother and more engaged transition into the future of work.

5.4. Theoretical Contributions

This study advances the theoretical landscape of Leadership 4.0 by integrating emerging competencies essential for navigating the complexities of digital transformation, particularly within the healthcare sector. Traditional leadership models, characterized by hierarchical structures and command-driven approaches, are increasingly inadequate in addressing the dynamic challenges posed by rapid technological advancements. Leadership 4.0 introduces a paradigm shift towards decentralized, collaborative, and agile leadership frameworks that align with the digitization of industries.

A significant theoretical contribution of this study is the redefinition of emotional intelligence within digital leadership contexts. While emotional intelligence has long been recognized as a critical leadership trait, its application in digital environments necessitates the development of “digital empathy”. This involves leaders’ capacity to understand and address the emotional and psychological impacts of digital tools and virtual communication on employees, thereby fostering a supportive and inclusive digital workplace. Such an approach is vital in mitigating technostress and enhancing employee well-being during digital transformation initiatives.

Furthermore, this research underscores the imperative of integrating ethical considerations and sustainability into the Leadership 4.0 framework. As technologies like artificial intelligence, machine learning, and big data analytics become integral to organizational operations, leaders are confronted with complex ethical dilemmas concerning data privacy, algorithmic bias, and equitable access to digital resources. The study advocates for a leadership model that not only embraces technological proficiency but also upholds ethical responsibility and social accountability, ensuring that digital innovation does not compromise human dignity or societal trust.

By situating these theoretical developments within the context of healthcare, the study extends existing frameworks of Leadership 4.0, offering a nuanced understanding of how digital competencies, emotional intelligence, and ethical leadership converge to drive effective digital transformation. This holistic perspective provides a foundation for future research and practical applications aimed at cultivating resilient, adaptive, and ethically grounded leadership in the digital era.

5.5. Summary

The discussion has underscored that digital transformation in healthcare is a deeply complex and multidimensional process. Success depends not only on technological advancement but also on how well organizations align digital tools with strategic goals, cultivate adaptive cultures, and equip their workforce with relevant skills. Leadership emerges as a central force in this transition—particularly when grounded in values such as trust, agility, and ethical responsibility.

Effective leadership in the digital era requires a shift from traditional command-and-control models to more human-centered and flexible approaches. Leaders must be capable of building trust across virtual teams, managing cultural and generational diversity, and fostering environments of continuous learning. In this context, transformational leadership—supported by clear communication, emotional intelligence, and shared vision—becomes essential for guiding teams through change.

The rise of Leadership 4.0 signals a new leadership paradigm, one that emphasizes digital fluency, emotional sensitivity, and ethical governance. This study contributes to the understanding of how these competencies interact to support innovation and resilience. Moreover, it highlights the importance of aligning internal branding with transformation goals, ensuring that employees not only understand but also embody the values driving digital change.

As digitalization accelerates, leaders must navigate not just technical challenges but also broader societal concerns, including data privacy, equity, and the psychological impacts of digital work. Addressing these issues requires a leadership approach that is both strategically agile and ethically grounded.

Taken together, these insights point to a future where digital transformation is not merely a technological upgrade but a profound cultural and organizational evolution—one that demands visionary, empathetic, and principled leadership at every level.

6. Conclusions

6.1. General Conclusions

In conclusion, this study underscores the transformative potential of Leadership 4.0 as a critical framework for guiding healthcare organizations through the complexities of digital transformation. Effective leadership in this context requires a combination of digital proficiency, emotional intelligence, and adaptability, enabling leaders to address the multifaceted challenges posed by technological advancements. These leadership qualities foster a culture of innovation and resilience, which is essential for organizations to thrive in the rapidly evolving digital landscape.

A key finding from this research is the importance of cultivating an organizational culture that prioritizes adaptability and continuous innovation. Such a culture mitigates resistance to change and creates an environment where experimentation, collaboration, and learning are embedded within the organization’s fabric. Leaders play a crucial role in shaping this culture, ensuring it aligns with organizational goals while keeping employees engaged and motivated to embrace digital change.

The ethical challenges associated with digital transformation also emerged as a significant concern, particularly in healthcare, where the protection of sensitive patient data is paramount. Leaders must adopt robust governance frameworks that prioritize data privacy and the ethical use of technology. This not only helps maintain trust among patients and stakeholders but also ensures compliance with legal and professional standards, which is essential for the long-term success of digital initiatives.

Furthermore, the study highlights the importance of internal branding as a strategic tool for aligning employees with the organization’s mission and digital transformation vision. By creating a shared sense of purpose, internal branding strengthens employee commitment and cohesion, which is vital for navigating the uncertainties and challenges posed by digital disruption.

Ultimately, Leadership 4.0 offers actionable strategies for healthcare leaders to embrace digital transformation while maintaining a human-centered approach. By addressing technological, cultural, and ethical challenges comprehensively, leaders can effectively guide their organizations toward sustainable success in the digital age. Future research should further explore the application of these principles across different healthcare systems to refine and enhance their effectiveness in diverse real-world contexts.

This study contributes valuable insights to the growing body of knowledge on digital transformation and leadership, offering practical recommendations for organizations across sectors seeking to succeed in an increasingly digital world. The competencies and strategies identified here are not only relevant to healthcare but also applicable across various industries navigating the challenges and opportunities of the digital era.

6.2. Limitations and Future Research

This study, while offering valuable insights into leadership in healthcare during times of digital transformation, has several limitations that may affect the interpretation and generalization of its findings. First, the sample size of only 15 participants in leadership positions within the public healthcare sector limits the broader applicability of the results. Although the participants were carefully selected to reflect the context of the research, a larger sample or the inclusion of leaders from diverse areas of healthcare would provide a more comprehensive understanding of the challenges and strategies involved. Moreover, the focus on public hospitals, while intentional for studying telework within this specific context, restricts the findings to public sector settings and may not fully capture the challenges or practices of private healthcare organizations.

Additionally, the use of the qualitative Delphi method, while effective for building consensus among experts, may not fully capture the individual perspectives or the nuances of leadership across various healthcare settings. The method’s reliance on a small, senior leadership cohort also means it does not represent the broader spectrum of experiences from frontline staff or leaders in other healthcare sectors, whose perspectives could differ significantly in the face of digital transformation.

Despite these limitations, the study offers valuable insights into the competencies needed for effective leadership in healthcare under the Leadership 4.0 paradigm. It underscores the importance of digital literacy and adaptability, but further empirical research is needed to assess how these competencies translate into tangible organizational outcomes and affect employee experiences over time. Additionally, while the study synthesizes expert knowledge on leadership, it highlights the need for a more diverse range of experiences and perspectives to better understand the challenges and opportunities within different healthcare contexts.

Future research could address these gaps by expanding the sample to include a broader range of healthcare roles and organizations, encompassing both public and private sectors, as well as non-clinical environments. This would not only validate the findings but also enrich the understanding of leadership in the digital age. Furthermore, exploring the long-term effects of digital transformation on organizational culture, employee well-being, and patient outcomes would help assess the sustained impact of Leadership 4.0. As issues such as data privacy and equitable access to digital resources remain critical, future studies could also explore frameworks that guide healthcare leaders in balancing technological advancements with ethical considerations, ensuring the respect and protection of human rights throughout the process.

An additional and promising avenue for future research lies in examining how Digital Leadership can incorporate Green Lean Six Sigma (GLSS) methodologies to foster sustainable and efficient transformation in hospital environments. Leadership 4.0 emphasizes data-driven innovation and strategic foresight, which align closely with the continuous improvement and resource optimization goals of GLSS. Investigating how digital leaders utilize technologies such as advanced analytics, automation, and real-time monitoring to support lean and green initiatives could provide new insights into how sustainability and digital transformation can be jointly pursued. This integrated approach has the potential to strengthen operational efficiency, environmental stewardship, and patient-centered care, offering a holistic framework for healthcare leadership in the digital era.

6.3. Call to Action for Further Exploration of Digital Leadership

The profound impact of digital technologies on leadership styles, organizational culture, and ethical considerations highlights the urgent need for further exploration of the competencies required to navigate this evolving landscape. Key attributes, such as digital literacy, adaptability, and strategic foresight, form the foundation of effective digital leadership. However, significant opportunities remain to explore how these competencies can be systematically developed, sustained, and adapted across different healthcare environments.

To meet the demands of the 4IR, healthcare leaders must prioritize both technological advancements and ethical frameworks, ensuring that patient rights, data privacy, and equitable access are central to digital transformation initiatives. Further research is necessary to assess how leaders can balance these priorities while fostering an organizational culture that is open to innovation and resilient to change. Such studies could provide insights into best practices for training and upskilling programs, which are essential for building a workforce capable of addressing the complexities of digital transformation.

Additionally, examining the role of cross-functional leadership collaboration in digital transformation efforts may yield valuable strategies for overcoming resistance to change and ensuring the smooth implementation of new technologies. As we continue to transition into the digital age, further exploration of digital leadership is essential to equip organizations with the skills, strategies, and ethical considerations necessary for a successful and human-centered transformation.