Elina LaukkapersName, Tarja PölkkipersName, Outi KanstepersName (2022date). “Leadership in the context of digital health services: A concept analysis.” Journal of Nursing Managementtitle·j.
Object of study — the concept of leadershipterm·dom in the context of digital health servicesterm·key
Research question — what the attributesterm·key, antecedentsterm·mth, consequencesterm·key and empirical referentsterm·mth of leadershipterm·dom in digital health servicesterm·key are
Contribution — a framework of leadershipterm·dom in digital health servicesterm·key built from 23 studies, with a recommendation to adopt the term e-leadershipterm·dom
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | leadership in digital health services — “Conceptualizing leadership in the context of digital health services is needed to deliver higher quality services and advance research.” | |
| claim-type | method — “Based on the results of our analysis, we created an initial framework of leadership, which may also be utilized when studying nursing leadership.” | |
| method — evidence | — “We used the concept analysis model by Walker and Avant ( 2019 ), a frequently used tool in health care settings (Nuopponen, 2010 ). To identify all relevant literature about leadership in the context of digital health services, a literature review was conducted in accordance with the Joanna Briggs Institute's (JBI) search protocol for scoping reviews (Peters, Godfrey, et al., 2020 ).” | |
| object of study — evidence | — “Thus, the aim of this paper was to define and clarify the concept of leadership in the context of digital health services using Walker's and Avant's concept analysis model.” | |
| research question — evidence | — “Because of the lack of clarity about leadership in digital health services, Walker and Avant's ( 2019 ) method of concept analysis was used to identify the attributes, antecedents, consequences and empirical referents of this concept.” | |
| contribution — evidence | — “Our concept analysis creates a foundation for further research with its robust definition for leadership in digital health services.” | |
| mechanism | knowledge‐oriented behaviour Knowledge-oriented behaviour enabled effective interpretation of organizational data. — “Based on an included study knowledge‐oriented behaviour enabled effective interpretation of data held by organizations (Ahonen et al., 2016 ; Ali et al., 2017 ).” | mechanisms[0] |
| mechanism | digitalization High digitalization makes health care organizations harder to lead, since every new service needs decisions, implementation and assessment. — “High levels of digitalization tend to make health care organizations even more challenging to lead: every new digital service requires decision‐making, implementation, assessment and secure usage among end‐users.” | mechanisms[1] |
| builds-on | Walker and Avant (2019) — “We used the concept analysis model by Walker and Avant ( 2019 ), a frequently used tool in health care settings (Nuopponen, 2010 ).” | claim_relations[0] |
| sense | leadership - three dictionary senses: characteristics of a good leader, the position of leader, the people in charge — “Leadership then again is defined as ‘the set of characteristics that make a good leader’, ‘the position or fact of being the leader’ and ‘the person or people in charge of an organization’.” | senses[0] |
| sense | e-leadership - the term the authors urge nursing research and practice to adopt — “To conclude, we urge use of the term e‐leadership in nursing research and in practice.” | senses[1] |
| sense | leadership - not fixed but developing over time and across contexts, now transformed by digitalization — “As leadership, also nursing leadership develops over time and in different contexts. During the past decade, the rapid digitalization of health care has transformed nursing leadership.” | senses[2] |
| evidential status | leadership —causes→ innovativeness — Earlier studies show that from an organizational perspective, good leadership seemed to increase — “Earlier studies show that from an organizational perspective, good leadership seemed to increase the successful implementation and innovativeness of digital solutions (Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kairy et al., 2014 ; Kolltveit et al., 2017 ; Sharpp et al., 2019 ), improve efficiency (Kahn et al., 2019 ; Mills et al., 2010 ) and enhance innovativeness (Chen, 2018 ; Liebe et al., 2016 ; Mills et al., 2010 ).” — “Earlier studies show that from an organizational perspective, good leadership seemed to increase” | concept_edges[0] |
| relation | leadership —causes→ innovativeness — good leadership seemed to increase the successful implementation and innovativeness of digital solutions — “Earlier studies show that from an organizational perspective, good leadership seemed to increase the successful implementation and innovativeness of digital solutions (Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kairy et al., 2014 ; Kolltveit et al., 2017 ; Sharpp et al., 2019 ), improve efficiency (Kahn et al., 2019 ; Mills et al., 2010 ) and enhance innovativeness (Chen, 2018 ; Liebe et al., 2016 ; Mills et al., 2010 ).” | concept_edges[0] |
| weight | leadership —causes→ innovativeness — 0.6 — “Earlier studies show that from an organizational perspective, good leadership seemed to increase the successful implementation and innovativeness of digital solutions (Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kairy et al., 2014 ; Kolltveit et al., 2017 ; Sharpp et al., 2019 ), improve efficiency (Kahn et al., 2019 ; Mills et al., 2010 ) and enhance innovativeness (Chen, 2018 ; Liebe et al., 2016 ; Mills et al., 2010 ).” | concept_edges[0] |
| replication | not-applicable | |
| no type for this | leadership → behaviours, roles and qualities — the attributes of leadership in this context fall into behaviours, roles and qualities — “The defining attributes associated with leadership in the study context were identified and categorized as behaviours, roles and qualities (Figure 3 ).” | unhoused_relations[0] |
| no type for this | leaders → implementation — fully engaged leaders seem to improve the implementation of digital health services — “Second, the analysis reveals that leaders who are fully engaged in the context of digital health services seem to improve the implementation of those services; they release potential benefits or consequences to an organization.” | unhoused_relations[1] |
| limitation | Data extraction was completed by one researcher. — “Data extraction was completed by one researcher (although it was discussed in the research group).” | limitations[0] |
| limitation | Results may not transfer to lower income countries, since studies came from affluent, highly digitalized ones. — “The papers were conducted in affluent countries with high levels of digitalization; thus, the results might not be transferable to lower income countries.” | limitations[1] |
| limitation | The 10-year search limit may have excluded relevant articles. — “In addition, the database searchers had a limit of 10 years, which might have excluded some potential articles.” | limitations[2] |
| limitation | No validated metric measures the whole phenomenon. — “However, there exists no validated metrics to measure this complex phenomenon; instead, there is a metric that measures parts of it, namely, Nursing Informatics Competency Assessment for Nurse Leaders (Collins et al., 2017 ).” | limitations[3] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | Leadership attributes concerned behaviours, roles and qualities. — “Leadership attributes concerned leaders' behaviour, roles and qualities.” | content_tags.findings[0] |
| finding | Few authors provide an official definition of leadership in this context. — “Few authors provide an official definition for leadership, or its closely related terms, in the context of digital health services (Table 3 ).” | content_tags.findings[1] |
| finding | Successful leadership in this context makes organizations more resilient. — “When leadership in the context of digital health services is successful, it also makes organizations more resilient, allowing them to achieve goals and gain the full benefits of technology (Kujala, Hörhammer, et al., 2019 ; Mills et al., 2010 ).” | content_tags.findings[2] |
| quantity | 4037; 23 — — “Searching returned 4037 possible records. After removing 1176 duplicates, 2861 records underwent title and abstract screening, which included 2558 papers that did not meet the inclusion criteria. Full‐text assessment for eligibility was performed on 303 papers, of which 23 met the inclusion criteria (Figure 1 ).” | content_tags.quantities[0] |
| definition | Empirical referents — “Empirical referents are measurable ways to demonstrate the occurrence of leadership in the study context.” | content_tags.definitions[0] |
| key-terms | leadership, digital health services, e‐leadership, concept analysis, nurse leaders, eHealth, antecedents, consequences, attributes, implementation, digitalization |
| concept | complex adaptive systems — that can self‐organize, adapt and learn — “Health care organizations have been recognized as complex (Begun & Thygeson, 2015 ): they have been scrutinized as complex adaptive systems (CASs) that can self‐organize, adapt and learn (Paina & Peters, 2012 ).” | concepts[0] |
| concept | e‐leadership — a socially influential process mediated by advanced IT to produce a change in individual/group/organizational thinking, feelings and performance — “One of the most promising of these is the e‐leadership presented by Avolio et al. ( 2000 ); according to them, e‐leadership has been described as a socially influential process mediated by advanced IT to produce a change in individual/group/organizational thinking, feelings and performance.” | concepts[1] |
| concept | antecedents — events that occur before or because of leadership in the context of digital health services — “We also identified antecedents and consequences—events that occur before or because of leadership in the context of digital health services (Figure 2 ).” | concepts[2] |
| concept | Empirical referents — measurable ways to demonstrate the occurrence of leadership in the study context — “Empirical referents are measurable ways to demonstrate the occurrence of leadership in the study context.” | concepts[3] |
| concept | PCC — participants, concept and context — “A participants, concept and context (PCC) framework was applied when defining eligibility criteria (Table 1 ).” | concepts[4] |
| concept | EHRs — electronic health records — “For example, hospitals with electronic health records (EHRs) with basic capabilities (EHRs) have a 12% lower average cost than those hospitals that do not have EHR (Highfill, 2019 ).” | concepts[5] |
| concept | leadership — not defined in this paper's own words; in this context a cluster of behaviours, roles and qualities, as the analysis groups them — “The defining attributes associated with leadership in the study context were identified and categorized as behaviours, roles and qualities (Figure 3 ).” | concepts[6] |
| concept | innovativeness — not defined in this paper's own words; an organization's capacity to produce and take up new digital solutions — “Earlier studies show that from an organizational perspective, good leadership seemed to increase the successful implementation and innovativeness of digital solutions (Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kairy et al., 2014 ; Kolltveit et al., 2017 ; Sharpp et al., 2019 ), improve efficiency (Kahn et al., 2019 ; Mills et al., 2010 ) and enhance innovativeness (Chen, 2018 ; Liebe et al., 2016 ; Mills et al., 2010 ).” | concepts[7] |
Full text — tagged
Leadershipterm·dom in the context of digital health servicesterm·key: A concept analysisterm·key Abstract To define and clarify the concept of leadershipterm·dom in the context of digital health servicesterm·key using Walker's and Avant's concept analysisterm·key model.
Conceptualizing leadershipterm·dom in the context of digital health servicesterm·key is needed to deliver higher quality services and advance research.
Searches were conducted of MEDLINE (Ovid), Scopus, CINAHL (EBSCO) and ProQuest (ABI/INFORM). Empirical articles were included if they reported attributesterm·key , antecedentsterm·mth or consequencesterm·key of leadershipterm·dom in the study context. A total of 4037 references were identified; 23 were included.
Leadershipterm·dom attributesterm·key concerned leaders' behaviour, roles and qualities. Antecedentsterm·mth concerned informatics skills and competence, information and tools, understanding care systems and their complexity and education. Consequencesterm·key related to organization, professionals and patient and care.
Based on our results, the term ‘e‐leadershipterm·dom’ should be more widely utilized in nursing practice and research.
Nurse leadersterm·key need to be strong leaders; they need to be visionary and use strategic thinking to develop existing and new digital solutions. By becoming e‐leaders, nurse leadersterm·key may increase the successful development and implementationterm·key of eHealthterm·key and benefit clinicians and patients.
Keywords: concept analysisterm·key, digital, health care, leadershipterm·dom, telemedicine INTRODUCTION Digital health care is important because its meaningfulness has often been emphasized due to problems in modern health care, such as increasing costs (De La Torre‐Diéz et al., 2015 ) and COVID‐19 (Wind et al., 2020 ). For example, hospitals with electronic health records (EHRsterm·dom) with basic capabilities (EHRsterm·dom) have a 12% lower average cost than those hospitals that do not have EHRterm·dom (Highfill, 2019 ). However, despite their potential and heavy investment, implementationterm·key of digital health servicesterm·key often fails (Herrmann et al., 2018 ; Öberg et al., 2018 ), with poor leadershipterm·dom cited as one reason (Abbott et al., 2014 ; Mair et al., 2012 ); leaders often seem ill‐prepared to handle future challenges (Day, 2000 ), and it may be that leaders are not conscious of what leadershipterm·dom actually is in the context of digital health servicesterm·key.
Although health care leaders traditionally lead clinical health services (Sood et al., 2017 ), leadershipterm·dom develops over time and in different contexts (Day, 2000 ). Recently, health care leadershipterm·dom has been transformed by digital services; nurse leadersterm·key' responsibilities have expanded into digitalizing health care (Cowan, 2014 ; Sandström et al., 2011 ) and even artificial intelligence (Chen & Decary, 2020 ). As Cowan ( 2014 ) noted, nurse leadersterm·key have more commonly been tasked with coordinating digital health care, and their role seems to be more emphasized in leading digital health servicesterm·key than physician leaders (Keijser et al., 2016 ). According to Strudwick, Nagle, Morgan, et al. ( 2019 ), leaders were likely unaware of the gaps they have in their informatics knowledge and skills. In addition, the literature provides little clarity as to what leadershipterm·dom in the context of digital health servicesterm·key entails (Lulu, 2019 ; Tremblay, 2017 ), and it has been suggested that research should focus on continuously transforming leadershipterm·dom (Dickson, 2009 ). Because of the lack of clarity about leadershipterm·dom in digital health servicesterm·key, Walker and Avant's ( 2019 ) method of concept analysisterm·key was used to identify the attributesterm·key, antecedentsterm·mth, consequencesterm·key and empirical referentsterm·mth of this concept. Understanding the concept of leadershipterm·dom in the context of digital health servicesterm·key would be important, since it may ease leaders to obtain required competencies and behaviours related to information and communication technology (ICT) acquisition and use (Strudwick, Nagle, Morgan, et al., 2019 ).
BACKGROUND Health care organizations have been recognized as complex (Begun & Thygeson, 2015 ): they have been scrutinized as complex adaptive systemsterm·dom (CASs) that can self‐organize, adapt and learn (Paina & Peters, 2012 ). Digitalizationterm·key transforms the context in which leaders operate (Hernez‐Broome & Hughes, 2004 ). High levels of digitalizationterm·key tend to make health care organizations even more challenging to lead: every new digital service requires decision‐making, implementationterm·key, assessment and secure usage among end‐users. Avolio et al. ( 2014 ) have suggested that organizational structures, including leadershipterm·dom, may transform due to the implementationterm·key of Advanced Information Technology (AIT). Thus, every digital health solution may be understood as a complex innovation, which according to Chuang et al. ( 2012 ) means that the implementationterm·key process requires systematic organizational changes in structure, staffing, workflows, and/or policies, as well as coordinated innovation use by multiple organizational members —all of which concern leaders. Digital innovations then again may transform the work of professionals and enable virtual or geographically dispersed units and teams (Hernez‐Broome & Hughes, 2004 ). The interdisciplinary literature shows that leadershipterm·dom in digital environment requires different kinds of leadershipterm·dom behaviours such as transformational behaviour, strategic‐oriented behaviour and servant leadershipterm·dom (Avolio et al., 2014 ; Larjovuori et al., 2016 ).
Successful implementationterm·key of digital services would be important since their costs are extremely high. For example, in the United Kingdom EHRterm·dom implementationterm·key costs £200 million (EUR 275 million, USD 293 million), and in Denmark DKK 2.8 billion (EUR 375 million, USD 400 million). The implementationterm·key of the new EHRterm·dom has not been trouble‐free in the United Kingdom or Denmark, and in Norway, managers have been recognized to play an important part in the implementationterm·key process (Hertzum & Ellingsen, 2019 ). According to a scoping review by LaukkapersName et al. ( 2020 ), health care leaders need to adopt certain behaviours to support the implementationterm·key of health information technology; leaders need to act as supporters, change managers, advocates, project managers, decision‐makers, facilitators and champions. Another review shows that leaders also need several informatics competencies such as informatics knowledge, informatics skills and computer skills (Strudwick, Nagle, Kassam, et al., 2019 ).
However, leaders cannot fully act in expected roles since their understanding of digitalizationterm·key and its implementationterm·key may not be any better than their subordinates' understanding of it (LaukkapersName et al., 2020 ). This may be because there is a lack of understanding about leadershipterm·dom in the context of digital health servicesterm·key, and thus, health care leaders may be ill‐prepared to lead in a transformed digital environment. As it appears, prior reviews synthesized leadershipterm·dom roles and competencies but making the most of HIT requires proper health care leadershipterm·dom in other processes as well (Simpson, 2004 ). For a health care leader managing technology is an issue about the three ‘Ps’: People, processes and (computer) programmes (Simpson, 2004 ).
Previous concept analyses have scrutinized health care leadershipterm·dom, for example, in terms of implementationterm·key leadershipterm·dom (Castiglione, 2020 ), transformational leadershipterm·dom (Fischer, 2016 ) and succession planning (Titzer & Shirey, 2013 ). Since research on leadershipterm·dom in this context is limited and developing transforming leadershipterm·dom is currently challenged by rapid digital innovation (Dickson, 2009 ), conceptualizing leadershipterm·dom may provide guidance for service development and future research. The conceptualization of leadershipterm·dom in the context of digital health servicesterm·key provides a better understanding of today's health care leadershipterm·dom and how it supports digitalizationterm·key and improves implementationterm·key. In addition, conceptualization may facilitate further research and thus help reshape existing and emerging leadershipterm·dom models. Precise conceptualization of leadershipterm·dom in the context of digital health servicesterm·key is therefore needed to support leaders working on the frontline and at middle and senior management levels, to improve digital health servicesterm·key, facilitate evolving leadershipterm·dom and advance research. Thus, the aim of this paper was to define and clarify the concept of leadershipterm·dom in the context of digital health servicesterm·key using Walker's and Avant's concept analysisterm·key model.
METHODS The detailed protocol for this concept analysisterm·key has been published (LaukkapersName et al., 2021 ). We used the concept analysisterm·key model by Walker and Avant ( 2019 ), a frequently used tool in health care settings (Nuopponen, 2010 ). To identify all relevant literature about leadershipterm·dom in the context of digital health servicesterm·key, a literature review was conducted in accordance with the Joanna Briggs Institute's (JBI) search protocol for scoping reviews (Peters, Godfrey, et al., 2020 ).
Eligibility criteria A participants, concept and context (PCCterm·mth) framework was applied when defining eligibility criteria (Table 1 ).
Eligibility criteria Peer‐reviewed empirical studies were considered. The study participants comprised all positional health care leaders; we included nursing and physician leaders, since one may safely generalize about leadershipterm·dom in the context of digital health servicesterm·key (Keijser et al., 2016 ). Publications eligible for inclusion must either define or clarify the concept of leadershipterm·dom in the relevant context.
Search strategy A three‐step search strategy was used to retrieve both published and unpublished studies. An information specialist helped develop the initial and final search strategies. An initial limited search of MEDLINE (Ovid) was undertaken on 19 October 2020 as part of a concept analysisterm·key protocol (LaukkapersName et al., 2021 ). On 31 November 2020, four databases (MEDLINE (Ovid), Scopus, CINAHL (EBSCO) and ProQuest (ABI/INFORM)) were searched using indexing and keywords with a limit of 10 years (Appendix S1 ). Keywords were truncated where appropriate.
Screening and synthesis The Covidence systematic review software package (v2422) was used for screening purposes and removing duplicates. Two team members (EL & OK) screened the articles independently following the eligibility criteria. After title and abstract screening, potentially relevant studies were retrieved in full. Disagreements were resolved through consensus. Search and screening results are presented in a PRISMA flow diagram (Figure 1 ) (Peters, Marnie, et al., 2020 ).
PRISMA flow diagram adapted for scoping review Searching returned 4037 possible records. After removing 1176 duplicates, 2861 records underwent title and abstract screening, which included 2558 papers that did not meet the inclusion criteria. Full‐text assessment for eligibility was performed on 303 papers, of which 23 met the inclusion criteria (Figure 1 ).
Extraction was undertaken by one researcher (EL) and confirmed by another (OK). Data included publishing information, design, purpose, sample and instrument (if mentioned). Extraction also included main findings and stated definitions of leadershipterm·dom in the context of digital health servicesterm·key, attributesterm·key, antecedentsterm·mth and consequencesterm·key (Walker & Avant, 2019 ) (Table 2 and Appendix S2 ). Similar themes and trends were discovered and grouped iteratively by the end of data collection (Appendix S2 ).
Summary of the research studies RESULTS Uses of the concept of leadershipterm·dom in the context of digital health servicesterm·key According to Cambridge Dictionary ( n.d ., May 23), digitalizationterm·key is defined as ‘to change something such as a document to a digital form (= a form that can be stored and read by computers)’. Leadershipterm·dom then again is defined as ‘the set of characteristics that make a good leader’, ‘the position or fact of being the leader’ and ‘the person or people in charge of an organization’. Closely related or surrogate terms for leadershipterm·dom were also used. Few authors provide an official definition for leadershipterm·dom, or its closely related terms, in the context of digital health servicesterm·key (Table 3 ).
Closely related terms and their definitions Attributesterm·key, antecedentsterm·mth, consequencesterm·key and empirical referentsterm·mth According to Walker and Avant ( 2019 ), the defining attributesterm·key of a concept are the heart of a concept analysisterm·key. We defined the key attributesterm·key of leadershipterm·dom in the study context and generated them as clusters. We also identified antecedentsterm·mth and consequencesterm·key—events that occur before or because of leadershipterm·dom in the context of digital health servicesterm·key (Figure 2 ).
Framework of leadershipterm·dom in the context of digital health servicesterm·key Attributesterm·key The defining attributesterm·key associated with leadershipterm·dom in the study context were identified and categorized as behaviours, roles and qualities (Figure 3 ).
Attributesterm·key of leadershipterm·dom in the context of digital health servicesterm·key Leadershipterm·dom as a set of behaviours The following nine attributesterm·key concerned leadershipterm·dom behaviour: acting as a strong and effective leader; visionary and innovative behaviour; supportive behaviour; strategic‐oriented behaviour; IT‐oriented behaviour; transformational and change‐oriented behaviour; knowledge‐oriented behaviour; responsible behaviour; and competence‐orientated behaviour.
According to earlier studies (Ahonen et al., 2016 ; Avdagovska et al., 2020 ; Gjellebæk et al., 2020 ; Kahn et al., 2019 ; Kujala, Heponiemi, & Hilama, 2019 ; Simon et al., 2013 ), leaders in the study context had to act as strong, effective leaders, meaning, for example, that they had to stand behind the implementationterm·key of digital health servicesterm·key. Visionary and innovative behaviour (Avdagovska et al., 2020 ; Chen, 2018 ; Ennis‐Cole et al., 2018 ; Kujala, Heponiemi, & Hilama, 2019 ; Kujala, Hörhammer, et al., 2019 ; Simon et al., 2013 ) was also seen as relevant in the implementationterm·key and development of digital health servicesterm·key among earlier studies. According to Kujala, Heponiemi, and Hilama ( 2019 ) and Ahonen et al. ( 2016 ), leader's clear vision associated with support for digital health servicesterm·key and was also seen as relevant when developing client‐centred eHealthterm·key. Several papers also highlighted the importance of supportive behaviour (Amlung et al., 2020 ; Avdagovska et al., 2020 ; Chen, 2018 ; Collins et al., 2017 ; Kahn et al., 2019 ; Kolltveit et al., 2017 ; Kujala, Hörhammer, et al., 2019 ; Simon et al., 2013 ; Strudwick, Nagle, Morgan, et al., 2019 ), meaning that leaders had to either provide support or create a supportive culture when professionals utilized digital services (Kujala, Hörhammer, et al., 2019 ). Leaders' transformational and change‐oriented behaviour broadened their leadershipterm·dom practices (Ali et al., 2017 ; Avdagovska et al., 2020 ; Gjellebæk et al., 2020 ; Hansen & Nørup, 2017 ; Liebe et al., 2016 ). Based on an included study knowledge‐oriented behaviour enabled effective interpretation of data held by organizations (Ahonen et al., 2016 ; Ali et al., 2017 ). By strategic‐orientated behaviour the included papers suggested that nurse leadersterm·key contribute to their organizations' strategic development and ensure that eHealthterm·key policies are followed (Andreassen et al., 2015 ; Avdagovska et al., 2020 ; Chen, 2018 ; Collins et al., 2017 ; Kahn et al., 2019 ; Kolltveit et al., 2017 ; Kujala, Hörhammer, et al., 2019 ; Simon et al., 2013 ; Strudwick, Nagle, Morgan, et al., 2019 ). Leaders' IT‐oriented behaviour included e‐leadershipterm·dom (Ennis‐Cole et al., 2018 ) and remote leadershipterm·dom practices (Sharpp et al., 2019 ). According to the included studies, competence‐orientated leaders for example recognized those who needed more education concerning eHealthterm·key (Ahonen et al., 2016 ; Collins et al., 2017 ; Sharpp et al., 2019 ; Simon et al., 2013 ; Strudwick, Nagle, Morgan, et al., 2019 ). Finally, leaders had to adopt responsible behaviour styles (Kolltveit et al., 2017 ).
Leadershipterm·dom as a set of roles Seven attributesterm·key encapsulated leadershipterm·dom roles: resource allocator; decision‐maker; developer; informer; advocate; collaborator; and facilitator. Ahonen et al. ( 2016 ) suggested that leaders are responsible for allocating resources when implementing and using digital services. According to Strudwick, Booth, Bjarnadottir, et al. ( 2019 ) leaders also act as decision‐makers and select technologies to be implemented. The included paper also suggested that as informers and communicators, leaders share information in an organization (Kujala, Heponiemi, & Hilama, 2019 ) and also act as advocates for personnel, patients and digital health (Strudwick, Nagle, Morgan, et al., 2019 ). For example, leaders must stand behind the implemented digital health system, but they also need to advocate for personnel and patients when implementing or developing digital health solutions (Strudwick, Booth, Bjarnadottir, et al., 2019 ).
Leadershipterm·dom as a set of qualities Three particular leadershipterm·dom qualities were emphasized in earlier studies: commitment and engagement (Ahonen et al., 2016 ; Amlung et al., 2020 ; Andreassen et al., 2015 ; Mills et al., 2010 ; Simpson, 2013 ); being active (Kolltveit et al., 2017 ) and authoritativeness (Chen, 2018 ). According to Kolltveit et al. ( 2017 ) leaders' commitment and engagement seem to be especially important: for example, there seems to be a definite need for a leader to support unequivocally the conditions that support digitalizationterm·key. Among other things, leader's authoritativeness is relevant to a eHealthterm·key project's success (Chen, 2018 ).
Antecedentsterm·mth Four antecedentsterm·mth must exist before leadershipterm·dom in digital services can occur (Figure 2 ): digital health servicesterm·key must already exist or be on the point of introduction if leaders are to lead in this respect. According to the included studies, when leaders make decisions concerning digital health servicesterm·key, they need informatics skills and competence, which may for example through education (Chen, 2018 ; Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kujala, Hörhammer, et al., 2019 ; Sharpp et al., 2019 ; Simpson, 2013 ; Strudwick, Nagle, Morgan, et al., 2019 ). Prior to leading digital health servicesterm·key, have sufficient information and tools (Kujala, Hörhammer, et al., 2019 ) and understand complex health care systems (Sharpp et al., 2019 ). Finally, according to Gjellebæk et al. ( 2020 ) and Sharpp et al. ( 2019 ) leaders need to have sufficient education to lead digital health servicesterm·key.
Consequencesterm·key Leadershipterm·dom in the context of digital health servicesterm·key exhibited characteristics desirable for health care organizations, professionals and patients and their care (Figure 2 ). Earlier studies show that from an organizational perspective, good leadershipterm·dom seemed to increase the successful implementationterm·key and innovativenessterm·dom of digital solutions (Ennis‐Cole et al., 2018 ; Gjellebæk et al., 2020 ; Kairy et al., 2014 ; Kolltveit et al., 2017 ; Sharpp et al., 2019 ), improve efficiency (Kahn et al., 2019 ; Mills et al., 2010 ) and enhance innovativenessterm·dom (Chen, 2018 ; Liebe et al., 2016 ; Mills et al., 2010 ). When leadershipterm·dom in the context of digital health servicesterm·key is successful, it also makes organizations more resilient, allowing them to achieve goals and gain the full benefits of technology (Kujala, Hörhammer, et al., 2019 ; Mills et al., 2010 ). Due to the leadershipterm·dom in our context, organizations may also achieve better financial performance (Mills et al., 2010 ) and greater level of sustainability (Strudwick, Booth, Bjarnadottir, et al., 2019 ).
According to earlier studies, the outcomes for professionals related to flexible working (Ahonen et al., 2016 ), improved workflows (Collins et al., 2015 ; Simpson, 2013 ; Strudwick, Nagle, Kassam, et al., 2019 ) and higher levels of commitment and satisfaction with digital services (Ahonen et al., 2016 ; Collins et al., 2017 ; Gjellebæk et al., 2020 ; Kujala, Hörhammer, et al., 2019 ; Liebe et al., 2016 ; Mills et al., 2010 ). According to included studies, leadershipterm·dom in this context also increased professionals' informatics competency (Strudwick, Nagle, Morgan, et al., 2019 ) and development (Ennis‐Cole et al., 2018 ). Earlier studies showed that several different consequencesterm·key related to patients; leadershipterm·dom seemed to advance patient‐centredness (Ahonen et al., 2016 ; Collins et al., 2015 ), improve the quality (Ahonen et al., 2016 ; Collins et al., 2015 ; Mills et al., 2010 ; Simon et al., 2013 ; Strudwick, Nagle, Morgan, et al., 2019 ), safety (Ahonen et al., 2016 ; Simon et al., 2013 ) and efficiency of care (Ennis‐Cole et al., 2018 ).
Model case, borderline and contrary cases We developed one model case to represent a real‐life example of leadershipterm·dom using the defining attributesterm·key discussed earlier. We also represented borderline and contrary cases (Table 4 ).
Model, borderline and contrary cases of leadershipterm·dom in the context of digital health servicesterm·key Empirical referentsterm·mth Empirical referentsterm·mth are measurable ways to demonstrate the occurrence of leadershipterm·dom in the study context. However, there exists no validated metrics to measure this complex phenomenon; instead, there is a metric that measures parts of it, namely, Nursing Informatics Competency Assessment for Nurse Leadersterm·key (Collins et al., 2017 ).
LIMITATIONS This concept analysisterm·key has several limitations. Data extraction was completed by one researcher (although it was discussed in the research group). Few papers provided an implicit definition for leadershipterm·dom in the context of digital health servicesterm·key, and these definitions were context‐specific. The papers were conducted in affluent countries with high levels of digitalizationterm·key; thus, the results might not be transferable to lower income countries. In addition, the database searchers had a limit of 10 years, which might have excluded some potential articles.
CONCLUSIONS Our concept analysisterm·key creates a foundation for further research with its robust definition for leadershipterm·dom in digital health servicesterm·key. We encourage redefining and developing the term e‐leadershipterm·dom within the field. The constantly shifting context will doubtless influence leadershipterm·dom and leaders' behaviour. The increasing role of artificial intelligence may alter leadershipterm·dom in health care in the coming years—indeed, understanding leadershipterm·dom in the era of AI is surely a subject ripe for future study. To conclude, we urge use of the term e‐leadershipterm·dom in nursing research and in practice.
IMPLICATIONS FOR NURSING MANAGEMENT The literature lacks a comprehensive understanding of leadershipterm·dom in the context of digital health servicesterm·key. Based on the results of our analysis, we created an initial framework of leadershipterm·dom, which may also be utilized when studying nursing leadershipterm·dom. As leadershipterm·dom, also nursing leadershipterm·dom develops over time and in different contexts. During the past decade, the rapid digitalizationterm·key of health care has transformed nursing leadershipterm·dom.
Based on the results, there exist several different concepts through which leadershipterm·dom in our context may be defined. One of the most promising of these is the e‐leadershipterm·dom presented by Avolio et al. ( 2000 ); according to them, e‐leadershipterm·dom has been described as a socially influential process mediated by advanced IT to produce a change in individual/group/organizational thinking, feelings and performance. This definition fits with the attributesterm·key, antecedentsterm·mth and consequencesterm·key represented in our concept analysisterm·key: for example, both our concept analysisterm·key and Avolio et al. ( 2014 ) definition include similar leadershipterm·dom behaviours; more specifically, we both highlight the importance of transformational leadershipterm·dom and effective e‐leaders. They also stated that effective e‐leaders understand the expectations of followers and communicate a clear vision, which was also seen as relevant within literature concerning health care leaders in the context of digital health servicesterm·key.
Second, the analysis reveals that leaders who are fully engaged in the context of digital health servicesterm·key seem to improve the implementationterm·key of those services; they release potential benefits or consequencesterm·key to an organization. As stated earlier, digital health servicesterm·key implementationterm·key often fails (Herrmann et al., 2018 ; Öberg et al., 2018 ), and poor leadershipterm·dom might be one reason for that (Abbott et al., 2014 ; Mair et al., 2012 ). It might be that health care leaders, including nursing leaders, are ill‐prepared to handle digitalizationterm·key; however, if they are fully engaged it seems—based on this work—that they might be more successful. This responsibility seems to fall especially on nurse leadersterm·key (Cowan, 2014 ), who based on our results work in an important role in a workgroup consisting of several different stakeholders (e.g., IT management, staff, IT vendors and patients).
Strudwick, Nagle, Kassam, et al. ( 2019 ) noted that leaders have to be more savvy with regard to IT. We recommend educating nurse leadersterm·key to become e‐leaders who adopt the necessary behaviours and roles and emphasize certain qualities when leading digital health servicesterm·key. Nurse leadersterm·key need to be visionary and use strategic thinking to develop existing and new digital solutions. Nurse leadersterm·key also need to listen to clinicians, evaluate their digital competence and provide support for frequent IT‐related changes. Nurse leadersterm·key need to advocate for clinicians and patients when developing digital health solutions. By becoming such e‐leaders, nurse leadersterm·key may increase the successful development and implementationterm·key of eHealthterm·key and benefit clinicians and patients.
CONFLICT OF INTEREST None.
ETHICS STATEMENT No ethical approval needed (no research with humans).
Supporting information Appendix S1. Search strategy Click here for additional data file.
Appendix S2. Supporting Information Click here for additional data file.
ACKNOWLEDGEMENTS We would like to thank information specialist Sirpa Grekula (University of Oulu Library) who helped us with the search strategy. We would also like to acknowledge Sees‐Editing Ltd for improving the language and helping us communicate our findings to readers of the journal.
LaukkapersName, E. , PölkkipersName, T. , & KanstepersName, O. (2022). Leadershipterm·dom in the context of digital health servicesterm·key: A concept analysisterm·key. Journal of Nursing Management, 30(7), 2763–2780. 10.1111/jonm.13763 DATA AVAILABILITY STATEMENT Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
REFERENCES Associated Data Supplementary Materials Appendix S1. Search strategy Click here for additional data file.
Appendix S2. Supporting Information Click here for additional data file.
Data Availability Statement Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.