{"paper_id":"2df031fc-9beb-4a83-aee7-83233380c9f8","body_text":"Sustainable Approaches to Leadership in Nursing and Patient Care in a Selected Hospital in Slovenia: A Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sustainable Approaches to Leadership in Nursing and Patient Care in a Selected Hospital in Slovenia: A Case Study Marjeta Logar Čuček This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6290182/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Leadership is a crucial factor for success and achieving goals in organizations and companies. The oscillation between established ways and active leadership, which is focused on people, the environment, and sustainable economy, needs to be overcome with a view to improving lives and the future of nursing and patient care. Methods In December 2022, non-experimental research was conducted using a structured questionnaire (SLQ) sent online to examine sustainable leadership practices in a selected hospital environment in Slovenia. The present case study, which included a convenience sample of 102 individuals employed at various management levels in nursing and patient care, was conducted to illustrate the use of sustainable leadership approaches in the organization. Results The research findings confirmed that leadership practices in the researched environment tend to align with the \"Honeybee\" leadership model (4-5), but more than half of the approaches fall in the neutral zone (3). These approaches need to be shifted towards the sustainable zones through the implementation of sustainable leadership practices. It should be emphasized that no approach or practice falls into the \"unsustainable\" zone. It has been demonstrated that the organization's performance is reflected in patient satisfaction, the organization's reputation, and long-term value for stakeholders. This can be achieved by focus on employee engagement, knowledge retention and sharing, team orientation, ethical behaviour of employees, shared goals and vision, staff recruiting and retention. Conclusion The research findings show that an understanding of the \"Honeybee\" leadership principles is present in the selected clinical environment. Gaps in the implementation of sustainable leadership approaches are highlighted, especially in the areas of leadership culture, environmental responsibility, established trust, self-management, innovation, and financial performance of the organization. These results can serve as a basis for further research into leadership in nursing and patient care in different hospital environments with the aim of measuring organization performance in a national and global context. leadership paradigms leadership profiles sustainable organization performance Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background In recent decades, there has been an increased interest in studying conceptual models that describe leadership in organizations and companies [1]. Despite numerous findings on surpassing established forms of leadership which are described by four leadership paradigms (Classical, Transactional, Visionary and Organic), effective leadership is still largely defined and measured based on the effects of actions taken within the organization, with an emphasis on employee satisfaction, commitment, organizational culture, task-solving performance, rather than organizational or company performance [1,2,3]. This understanding of leadership has been challenged by numerous changes in organizations, which have become a constant in modern times. Coping with uncertainty and risk management are particularly relevant after unexpected events, such as the recent COVID-19 crisis. The world is also facing constant geopolitical tensions, environmental pollution, depletion of natural resources, climate change, looming energy crisis, financial instability [3,4,5] As a result, organizations and companies need to redirect their operations or transform their business models, first due to existential reasons, and at the same time to achieve sustainability of systems for future generations [6,7]. In the future, the decision-making process in organizations and companies will be based on the integration of economic, environmental, and social concerns [5]. Thus, modern times require the expansion of the traditional understanding of leadership from the leader-follower relationship to relationships with multiple stakeholders within or outside the organization [8]. The new paradigm places at the forefront professionals who value human development and the environment without neglecting economic aspects [9]. These new trends change the expected behaviour of modern leaders and create a new type of leadership: sustainable leadership [6,10,11]. Sustainable leadership Sustainable leadership provides guidelines for preserving and creating a desired and long-lasting future for various stakeholders, including employees, users, in this case patients, financiers, society, and the environment [10,11]. It is characterized by numerous common starting points, such as systemic leadership, long-term vision, corporate responsibility, ethical behaviour, social responsibility of leaders and organizations, innovation, systemic change, and stakeholder involvement [3]. The interdependent nature of sustainable development is expressed in the sustainable flow of material goods, care for resources and biological systems of the planet, fair abundance and intergenerational justice, intercultural dialogue, and diversity [12,13,14]. Sustainable leadership, as described by the authors Avery and Bergsteiner, requires a long-term perspective in decision-making, the promotion of systemic innovation, the development of qualified and engaged staff, and the provision of high-quality products, services, and solutions [15]. Organizations that are led in this way follow the practices of \"Honeybee\" leadership. The Honeybee philosophy represents the positive side of sustainable leadership. It builds community, promotes collaboration, and contributes to the long-term sustainable outcomes of the organization. The opposite of the Honeybee approach to leadership is the philosophy of \"Locust\" leadership, which represents a more ruthless business philosophy of profit at any cost [10]. Given the dynamic nature of organizations and companies, it is rare to find only one form of leadership in terms of sustainable or traditional leadership [15]. Sustainable leadership pyramid The foundation for studying existing organizational practices is provided by the pyramid of sustainable leadership, as described by Avery and Bergsteiner in their 23 sustainable leadership practices [10]. They divided them into three structural levels that are interconnected, interdependent, and positively influence each other in all directions. Avery and Bergsteiner state that 14 foundation practices, focused on leadership, support the six practices at the second, higher level of the pyramid with a focus on employees [10]. These include intrinsic motivation of employees, self-management, team orientation, enabling culture, knowledge retention and sharing, and trust. The third level, focused on the customer, in this case the patient, consists of three key performance drivers which are combinations of foundation practices and higher-level practices. These include innovation integrated into culture, systems, and processes of the organization, followed by staff engagement, which reflects a positive opinion about the organization, a desire for long-term employment, and the effort invested in the organization's success. The final element of the third level is quality. All three elements influence the performance outcomes of the organization, such as reputation, user satisfaction, long-term financial performance, and value for stakeholders and shareholders [16,17]. Figure 1 shows 23 elements of sustainable leadership and five performance outcomes. Leadership in nursing and patient care Our future also includes nursing and patient care, which requires efficient leadership that is prepared for rapid changes, collaboration, adaptation, and seeking responses and solutions [18]. It is expressed through the abilities of individuals with a good insight and suitable behavioural response styles for various social situations. This includes having a vision that considers experience and transcends previous patterns, anticipating changes ahead of others, and aligning the values of employees at different levels [4,18]. Bogataj states that the goal should be an organizational culture of leadership that positively influences the well-being and creativity of employees and consequently increases the trust of patients [19]. Education plays a key role in effective nursing care leadership of 21st century [20,21,22,23,24]. Education regarding sustainable leadership also changes the characteristics and skills of leaders. By acquiring leadership competencies, leaders, together with their colleagues, can more effectively facilitate the process of change [25,26]. With an awareness that work in nursing and patient care requires collaboration with numerous stakeholders within and outside the hospital environment, responsible leadership can help create and sustain long-term sustainable leadership practices. As the authors Avery and Bergsteiner state, recognizing the benefits of sustainable leadership and evidence-based knowledge is the skill that will drive progress in the organization's operations, in this case, nursing care leadership [10]. Aim For these reasons and with the aim of understanding how leaders in nursing and patient care in a hospital environment experience leadership, we set the goal of identifying challenges in 23 leadership areas and implementing evidence-based practices into leadership work in the future. To achieve the research goal, the following research questions were posed: To what extent are the four established leadership paradigms replaced by sustainable leadership practices in the field of nursing and patient care? Where do different categories of respondents see the organization in relation to the 23 practices of sustainable leadership and the five performance outcomes? Where are the gaps in the organization's sustainable development journey? In the following the first research question is elaborated in the frame of Leadership Culture, while the second and third are elaborated in the frame of Sustainable Leadership Profiles. Methods Design A non-experimental research design was used. A quantitative research method, a case study was used [27]. Data was collected through online surveys using a structured questionnaire. The research process was divided into three phases. The first phase consisted of reviewing and studying various approaches to leadership in order to gain knowledge about different leadership models. In the second phase, using the Sustainable Leadership Questionnaire (SLQ), leadership approaches in the studied hospital environment were diagnosed. In the third phase, based on the findings collected from the analysis of responses, we examined which elements of sustainable leadership are already present in the hospital. The final conclusions of the research are based on the collected data, and shed light on any gaps that employees perceive in foundation practices and results obtained in the research environment. Instrument The Structured Questionnaire on Sustainable Leadership (SLQ), developed by Avery and Bergsteiner (2020) at the Institute for Sustainable Leadership TM (in the following: ISL) based in Australia, consisted of 87 questions: The first part of the questionnaire included 5 questions that encompassed demographic information (gender, age, educational level, length of service in the organization, employment level/role in the organization). Seven questions were used in order to ascertain the most prevalent leadership behaviour in the organization. Respondents were asked to choose only one answer out of 4 provided options. In the next section, consisting of 69 questions, we explored where different categories of respondents saw the organization in relation to the 23 practices of sustainable leadership and five performance outcomes (including leadership culture). Participants could choose one answer from six statements: 1 - Strongly Disagree, 2 - Disagree, 3 - Neutral, 4 - Agree, 5 - Strongly Agree, 6 - I don't know. Regarding organizational performance compared to other organizations, respondents were asked to select one of the six statements in a set of 6 questions: 1 - Much Worse, 2 - Worse, 3 - About the Same, 4 - Better, 5 - Much Better, 6 - I don't know. Additionally, responses to the 87th question \"How satisfied are you overall with your organization?\" were analysed based on gender, age, education, length of service, and role in the organization. Response options ranged from 1 - Extremely Dissatisfied, 2 - Dissatisfied, 3 - Neutral, 4 - Satisfied, 5 - Extremely Satisfied. Setting and participants Leaders in nursing and patient care in the selected hospital in Slovenia were invited to participate in the research. The convenience sample consisted of 123 individuals. Out of these, 102 questionnaires were correctly and completely filled in and were included in further analysis, while 21 were incomplete and had to be discarded. The majority of respondents were female (79%), aged 35 to 44 (43%), had a university education (48%), employed in the organization for over 16 years (56%), and held leadership positions that were non-executive (52%). 4.3. Description of the Process and Data Processing Research permission was granted by the UKC Ljubljana Working Group for Research in Healthcare and Midwifery, 2020. The invitation to participate was sent via email. Participation was voluntary. The survey was conducted in accordance with ethical guidelines [28,29] and the privacy policy of the ISL, which collected the data and ensured anonymity. Data collection was done using an online questionnaire, which was available at the Leadership Survey link during the research period from December 16, 2022 to December 23, 2022. The questionnaire was provided in English, with an added translation in Slovenian for assistance. The average time to complete the survey was 25 minutes. Data was collected and summarized by Survey Monkey, where averages and ranges were calculated. Graphs were created using ISL software based on Excel. Descriptive statistics were generated in summary tables using proprietary ISL software. Results Assessment Areas Using Sustainable Leadership Questionnaire (SLQ), the following areas were assessed: Leadership culture, Leadership behaviour, and Organizational systems. The questionnaire served as a diagnostic tool and points out a future course of action. Leadership Culture This section presents the results of the Sustainable Leadership Questionnaire in the hospital environment, starting with leadership culture, which represents the first aspect of sustainable leadership. It describes how leaders and followers interact in a specific context in terms of four leadership paradigms (Classical, Transactional, Visionary, and Organic) [30]. Figure 2 demonstrates leadership culture in the selected hospital environment based on seven characteristics (decision-making, vision, trust, innovation culture, communication, challenging the norm, organizational structure), which differentiate the four leadership paradigms Leadership culture in the researched hospital environment includes all leadership paradigms. As the results show, there are strong transactional components of decision-making, innovative culture, communication, challenging the norm, and organizational structure present in the organization. Further research is needed to create a sustainable leadership culture. These components contradict consensual decision-making, innovation, collaboration, and team empowerment. The relationship between leaders and followers is based on the exchange of rewards and expectations agreed upon with the leaders. The leaders make final decisions. Visionary leadership paradigm is also apparent. It is apparent in vision, decision-making, trust, and organizational structure. In line with the characteristics of visionary leadership, employees are inspired by a shared vision and collaboration, based on a set of collective values with strong emotional involvement of employees. There are also some noticeable elements of classical leadership in the organization, exceeding 20%. Classical leadership is particularly apparent in decision-making, communication, and organizational structure, in accordance with the fundamental principles of \"top-down\" leadership, through control and orders of individuals or groups. In the decision-making process, the inclusion of followers, two-way communication, and consequently influencing the results are minimized. In contrast, organic leadership is characterized by distributed leadership, where decision-making is delegated to employees. This leadership paradigm is present to a lesser extent in the researched hospital environment. Important cultural elements include trust, vision, and innovation, allowing interaction among all members. This approach attracts and retains highly skilled and competent staff, contributing to the value and performance of the organization. Sustainable Leadership Profiles Below is a collection of profiles of sustainable leadership in the selected hospital environment. The results were obtained using various variables. The profiles show where different categories of respondents see the organization in accordance with the 23 practices of sustainable leadership, including leadership culture, and five performance outcomes. Profile 1: Overall scores Figure 3 shows the overall assessment (all respondents) of sustainable leadership. The overall profile for our research environment shows a high level of consistency in the perception of sustainable leadership practices. Leadership approaches and outcomes are located in the \"Honeybee\" part of the sustainable leadership spectrum. None of the approaches fall into unsustainable zones (1-2). More than half of the practices are located in the neutral zone (3) and need to be shifted towards the sustainable zones (4-5). From the foundation practices, four elements of sustainable leadership are more prominently present in the overall assessment (4), while six elements have almost entirely shifted towards the sustainable leadership zones (3-4). The results also indicate that four foundation practices, i.e., independence from outside interference, environmental and social responsibility, and stakeholder focus, are more consistently placed in the average zone. Although the foundation practices have not fully reached the sustainable zones, some of them contribute to improving the six higher-level practices. Consequently, team orientation and knowledge retention and sharing are present in the sustainable zones, and influence staff retention. Intrinsic motivation, self-management, and trust are located in neutral zones, but are strongly interconnected. Mutual trust builds staff motivation and consequently leads to self-management in implementing ideas and innovation, which is one of the three key performance drivers. The authors of the sustainable pyramid, Avery and Bergsteiner, added quality and employee engagement as the other two factors, which are present in the sustainable range, with employee engagement being more prominent [10]. The respondents expressed positive beliefs and placed in the sustainable zones also patient satisfaction, the reputation of their organization, long-term shareholder value, and long-term shareholders returns. However, they are sceptical about the financial performance of the organization. Financial performance is average and depends on the implementation of sustainable practices at all three preceding levels. A supplementary analysis was carried out in this part to determine organizational satisfaction, with a view to explaining the extreme spread of results in each practice. The general results showed that 34% of respondents were satisfied with the organization and 26.5% were extremely satisfied. Additional research is required to shed light on the reasons for the high number of neutrals (18%); as well as 11% of those who reported being dissatisfied, with another 2% extremely dissatisfied. Dissatisfaction increases with age; older respondents are more dissatisfied than younger ones. Depending on their role in the organization, the least satisfied are decision-makers and full-time employees with more than 16 years of service (37%), while the most satisfied are volunteers, supervisors and group leaders. Regarding the level of education, the most dissatisfied are employees with the highest level education (half of them), while the most satisfied are those with secondary education. Profile 2: Age This profile shows the results for three age groups, 25-34 years, 35-44 years and 45-54 years. The results are shown in Figure 4 . The results cluster around the neutral-sustainable parts of the spectrum, leaning towards sustainable leadership, which is consistent with the overall profile. It is worth noting that the age group in the 45-54 age range perceives the organization as less sustainability-oriented compared to the younger generation (25-34 years). The middle generation has decided on the \"middle way\" and their opinions on the sustainable orientation of the organization rank them between the older and younger generations. The oldest surveyed group is the least convinced of the positive results of financial performance, whereas it seems that the younger generations are not so concerned about profit or worried about existential issues. All age groups tend to evaluate performance results in terms of reputation, satisfaction, and value for users as \"better\" compared to other related institutions. Profile 3: Education Figure 5 shows the perception of sustainable leadership practices according to the educational background of the respondents. the results display a tendency towards neutral parts of the leadership spectrum which, however, is moving towards sustainable leadership. Respondents holding a doctoral degree generally perceive the organization as significantly more sustainably oriented than those with an undergraduate or postgraduate degree. All three groups believe that employees in nursing and patient care are dedicated to their profession, manage their knowledge well, further their education and share the acquired knowledge, work according to high ethical standards and appreciate virtues. They focus on employee retention and can anticipate recruitment needs. Their views are similar in the area of trust, which is more in the neutral zone. They agree that their organization is reputable, and that users/patients are satisfied. They share the same opinion regarding the other two definitions of performance outcomes, the weakest result being financial performance, which is rated neutral (3). Profile 4: Length of service Figure 6 shows the respondents' perception of the sustainable leadership practices according to the length of service of the respondents in the organisation. There are few differences in the results based on length of service. All 23 practices of sustainable leadership cluster around neutral position; they are all partially expanding into the field of sustainable leadership. Regarding leadership culture and independence from outside interference, the responses lie in the neutral category (3). The success of the organization, which is reflected in the reputation and satisfaction of patients, is placed in the sustainable leadership zone (5). Profile 5: Organisational grouping Figure 7 below shows the scores according to organisational grouping. For the organizational grouping profile, respondents were classified into three groups, namely, Top team, Other leaders, and Followers. Leadership scores cluster around the neutral-sustainable zones of the leadership spectrum, but mostly heading towards sustainable leadership. Leadership culture was placed in the neutral zone (3), along with employee development, change management, independence from outside interference, environmental and social responsibility, a broad focus on stakeholders, motivation, self-management and trust. These practices should be reviewed and analysed further to make them more sustainable. Profile 6: Managers Figure 8 shows how managers view leadership in the clinical environment. The respondents identified themselves as Senior Executives, Middle Managers/Professionals, and First-line Supervisors/Team Leaders. Again, the scores consistently cluster around the neutral-sustainable parts of the spectrum (3-4), leaning towards sustainable leadership. Interestingly, Senior Executives see more practices as less sustainable than other levels of management, particularly in the areas of employee retention, recruitment, internal succession planning, vision and purpose, long-term vision and quality. Senior Executives assessed patient satisfaction in the zone of sustainable leadership (5). Discussion Going beyond conventional leadership practices is an important step in nursing care, which contributes to the implementation of sustainable practices in the health care system and greatly enhances professional competence [10]. The SLQ questionnaire served as a diagnostic tool and offered a pathway for action. Leadership Culture Leadership styles are expressed through a series of responsibility relationships [31]. Effective leadership is a skill that is expressed through leaders' abilities to influence employees, resolve ambiguity, adapt to rapid changes, and understand people and culture [23]. This highlights sustainable leadership, which is adaptable and applicable in any organizational context [6]. Leadership culture plays a significant role in the implementation of sustainable principles [19]. The results of this research show that four leadership paradigms, as described by Avery's typology [30], transactional, visionary, classical, and organic, are present in all studied areas of leadership culture. The transactional paradigm stands out, which, according to Martinčič and Biloslavo, implies improving leadership approaches and responding to environmental changes [32]. However, Burawat [33] and Jing and Avery [34] emphasize the focus on the exchange of benefits between leaders and followers. In creating and maintaining a sustainable leadership culture, it is necessary to examine the strong transactional components and develop them towards collaborative decision-making, team empowerment, innovation orientation, and collaboration [10]. Visionary leadership, as perceived in this research, is present in implementing vision, establishing trust, and (co)decision-making. In comparison to sustainable leadership, this style focuses on a charismatic leader with an added dimension of emotional involvement of employees [34,35] , whereas sustainable leadership focuses on promoting sustainability values at personal, environmental, and ecological levels, both present and future [36]. As stated by some authors, leadership styles are often intertwined [35]. Classical and organic leadership cultures were also observed in this research. Classical leadership is primarily leader-oriented, more pronounced in organizational structure, decision-making, communication, and to a lesser extent in perception of future, vision, and innovation. These, along with consistency in action, leading by example, and inclusion, are some of the foundations of sustainable leadership [15,4]. On the other hand, organic leadership is characterized by shifting leadership to employees [34] and was least recognized in our organization. The organisation is well on the way to sustainable leadership in several segments, such as trust and innovation, which can directly impact organizational performance. Overall Scores Overall scores, showing the distributions for all respondents, were obtained through the analysis of responses on the assessment of the 23 sustainable leadership practices by Avery and Bergsteiner [10]. It has been established that the leadership styles and outcomes fall within the sustainable zones, although more than half of the approaches are in the neutral zones. The organization's reputation and patient satisfaction are seen as more sustainable (4-5), which can be confirmed by the dynamic implementation of the 23 practices in various directions, for instance, employee commitment and service quality positively influence patient satisfaction. The organization's reputation can be partly explained by the hospital's social and professional significance, while financial performance represents one of the gaps on the path to sustainable development. Therefore, investing more in the environment, becoming more socially responsible, and operating based on sustainable principles could be beneficial. Additionally, it would strengthen other practices at all levels. At the level of foundation practices, there is a noticeable shift towards sustainable leadership in terms of long-term employee retention and recruiting, respect and inclusion, and employee ethics [2, 5, 6]. Measures such as developing workplace culture, creating a positive work environment, providing employee development opportunities, internal succession planning, implementing leadership training, and mentoring new employees contribute to improved staff retention and the integration of new colleagues [37]. Employees assess ethical conduct and virtues as most sustainable in their leaders [6], which constitutes the core of the organizational culture [10]. Researchers Dalcher [38], and Fernandez and Shaw [39] emphasize that a leader must be consistent in their actions and serve as a role model for employees, they should value inclusion and effective communication, which is undoubtedly evident in the research environment. Regarding higher-level practices, education, knowledge retention and sharing are moving towards sustainable areas (19). Due to constant changes, leadership requires educated staff, and education itself is an imperative for sustainable development. Other researchers also report the impact of investment in education and additional employee training on improved business performance [15,20]. If the development of education and training has so far focused on lifelong learning, in the future it must be supported by research and the transfer of findings into practice [40]. From the analysis of leadership culture in the researched organization, it is evident that the dominant leadership paradigm in the decision-making segment does not fully support \"self-management.\" This is a result of mutual mistrust between leaders and employees. Building trust depends on many foundation practices and time dedicated to growth and development [10]. For trust to move into the sustainable areas, employees need skills and knowledge and development of their competencies. They need to be able to see their future in an organization that respects and includes diverse employees, is ethical, and has good leadership. The organization should implement organizational changes in a consultative manner, and act responsibly towards the environment and society [3,38]. With established mutual trust, employees will demonstrate more self-initiative in performing their tasks. Empowered, they will approach their work more innovatively. Through \"self-management\", they will strive to find new approaches and appropriate solutions, innovations, in the process of their work, which will contribute to the organization's greater success. The role of leaders should be focused on considering improvement suggestions made by employees, improving communication, taking into account the interests of all stakeholders, and working towards a common goal and vision [41,42]. Markey et al. state in their research that leaders should act as moderators who recognize employees’ needs for support [43]. With established trust, employee empowerment, and their proactive approach to work, intrinsic motivation in the work environment will also increase, consequently leading to employee engagement, which impacts the quality of services rendered. In our case, it pertains to patient care and ensuring their recovery and return to work and family environment. The nature of work in nursing care requires teamwork. The culture established within the organization and in teamwork practices plays a significant role in pursuing sustainable principles. Hierarchical and controlling leadership practices should be redirected towards collaborative, inclusive, and participatory inclusion practices [44]. Encouraging participation in decision-making motivates employees, leading to their continuous education and resulting in high level of patient care [42]. This further increases employee engagement and the quality of work performed. Environmental responsibility is also a key factor in implementing sustainable nursing care. In this research, it was assessed as average. By integrating the principles of environmental health into practice, through education and research, employees will work in a way that does not jeopardize patients, employees, or the environment. According to Schenk [45], leaders should support the implementation of healthy environmental principles in nursing care practice, contributing to \"future-oriented\" leadership also in this organization. In the overall profile, satisfaction with the organization was also assessed. General satisfaction was compared based on gender, age, role, education level, and length of service in the organization. Concerningly, there is dissatisfaction among older employees, individuals with the highest level of education (doctorate), and permanent employees. Proposed measures for closing these gaps include job rotation, empowerment, career advancement opportunities, and awarding scholarships to the most innovative and talented employees [10]. These findings will undoubtedly lead to more detailed research into employee satisfaction. Comparison of other leadership profiles Based on the age of respondents, educational background, length of service in organizations, organizational groups, we comparatively interpret some practices that are moving towards sustainable leadership or, conversely, towards conventional leadership. Regardless of the dimensions studied, all respondents are unanimous regarding the organization's reputation. Considering respondents’ age, recruitment was assessed as sustainable. It is most satisfying for young people who also tend to stay in their positions (2). Avery and Bergsteiner cite as an example of long-term thinking in an organization, young people who are employed to develop and work together as a team [46]. They are responsive to changes (9) and aware that nursing care is a part of a cycle of rapid responses and adaptations to new situations, requiring responsible leadership regarding employees, the environment, and society, which ultimately leads to creating a sustainable and better future [31,38]. In contrast to younger employees, older employees do not perceive leadership in the organization as predominantly sustainable, but they agree regarding employee engagement, which all three age groups placed in the “Honeybee” zones. Regarding higher-level practices, younger generations are responsive, and value teamwork (15), which provides them with strong professional and moral support and builds a shared culture (18); these practices are also recognized by older generations. The assessment of knowledge retention and sharing is consistent regardless of age, level of education, length of employment, organizational grouping, and leadership role in the organization. The employees engage in sustainable education (19) and participate in numerous training and education programs. They share their knowledge through occasional lectures and the publication of professional and scientific articles. However, innovation is seen as average by all three age groups. Ideas may be dispersed and go unnoticed, or the work may be carried out in a routine manner. This sustainable practice should be further investigated, as innovation is the foundation of organizational progress and affects performance outcomes. Respondents of different age groups equally assess performance based on the institution's reputation and patient care; older employees have doubts about the organization's financial performance. Education also influences the perception of leadership as sustainable in the hospital environment. Employees with the highest level of education, a doctorate, view the organization as more sustainable compared to those with lower levels of education. This can be linked to the fact that leadership education should already be integrated during undergraduate studies, in line with research on the importance of education conducted by Rafiq and Mughalov, Daly et al., Sing and Havnes [20,21,22]. In support of education, researchers [24,46,47] state that nurses involved in research and continuous education significantly contribute to sustainable leadership by studying institutional barriers to enable more effective healthcare provision, testing organizational models, and rapidly disseminating information about the most effective and sustainable interventions. Regarding the period of service in the organization, respondents placed most of the 23 sustainable leadership practices in neutral zones. Employee care, such as continuous education, career advancement opportunities, workload reduction, inclusion of diverse opinions, and initiative creation, contributes significantly to sustainable leadership. Clear communication within the organization, both among employees and with leaders, and choosing the appropriate communication style for each recipient are of paramount importance. Fernandez and Shaw, Gao et al., Moor have also written about these leadership approaches [39,41,42]. By shifting foundation practices towards sustainable areas, the long-term interests of all stakeholders will be considered [10]. Organizational groupings, such as Top Team, Other Leaders, and Followers, agree in their assessment of staff development, change management, independence from outside interference, environmental and social responsibility, broad stakeholder focus, intrinsic motivation, self-management, and trust. They are placed around the neutral sustainable part of the spectrum but leaning towards sustainable leadership. In relation to established leadership paradigms in the organization, transactional and visionary, we highlight sustainable practices such as long-term time horizon, internal succession planning, and recruiting and retaining staff. To make these practices more sustainable, they should be further examined in terms of both leadership styles compared to the characteristics of sustainable leadership, which focuses on promoting sustainable values [36]. Development is not an isolated event but requires a transition from an \"egosystem\" to an \"ecosystem,\" where everything depends on the adaptability of the organization, leader, and employees. The perception of sustainable leadership has been comparatively interpreted among team leaders, middle management, and senior executives. Team leaders, as first-line supervisors, perceive more sustainable practices in their organizations. Managers or individuals in higher-level leadership positions reported fewer sustainable elements, while middle management partially transition into unsustainable territory when it comes to hiring new employees. They also approach it in the practice of internal succession planning, which is not in line with one of the foundation practices of sustainable leadership, since the development of leaders should be planned within an organization [10,46]. Leaders in nursing and patient care can demonstrate a clear vision and values through transparency, critical thinking, education, and commitment to sustainable leadership. This will prove to be a significant contribution to improving patient treatment, employee satisfaction, organizational reputation, and performance, and in this way greatly benefit future generations. There are several expected research limitations. The first potential limitation was the administration of the questionnaire in the English language. Although respondents had the option to use a translation into Slovenian, this language barrier may have limited the time available for completing the questionnaire or even deterred some from participating. The second limitation is related to the fact that the respondents provided their opinions and perceptions regarding sustainable leadership practices in the organization. Other individuals in different roles, positions, or other parts of the organization may have different perceptions of leadership practices. Therefore, long-term research is needed to provide a more comprehensive and definitive results. The third limitation is that this research did not discuss the mechanism of employee involvement, which influences the perception of leadership in the organization. However, the results of this study refer to a specific group of individuals, and help us to better understand the relationship between age, level of education, length of service in the organization, position within the organization, and the adoption of the 23 sustainable leadership practices. Further Research Recommendations The results of the research conducted in December 2022 in the selected hospital environment in Slovenia should be further examined through in-depth group interviews. These results serve as a measure upon which the effectiveness of potential interventions can be assessed and modified. Conducting focus groups would provide a thorough understanding of which approaches to sustainable leadership require action, enabling gradual adaptation to change in leadership. Another assessment of leadership perception based on the 23 sustainable leadership approaches should be conducted in a comparable-sized hospital environment in Slovenia. Based on the results, mechanisms influencing the greater or lesser presence of \"Honeybee\" leadership approaches can be further examined through in-depth interviews, investigating whether they stem from environmental needs, internal organizational orientations, or are influenced by trends. In the future, research should be conducted into the impact of leaders and organizations on society at large, in terms of measuring organizational performance through social, environmental, and economic results [13,14]. This conceptualization of goals and responsibilities of leaders and organizations will provide further insights into effective leadership, not only in \"closed systems\" [1] but also considering the interdependencies with numerous external factors [3,48,49,50,51]. The results of various studies indicate that adopting sustainable principles and implementing sustainable management in the operations of organizations contribute to their resilience, appropriate responses to unexpected situations, and positive outcomes [16,17,52], while other leadership principles may dominate in other areas, e.g. SMEs [53]. Conclusions The key contributions of this study can be summarized as follows: The research findings show that an understanding of the \"Honeybee\" leadership principles is present in the selected clinical environment. It has been demonstrated that the organization's performance is reflected in patient satisfaction, the organization's reputation, and long-term value for stakeholders. This can be achieved by focus on employee engagement, knowledge retention and sharing, team orientation, ethical behaviour of employees, shared goals and vision, staff recruiting and retention. Gaps in the implementation of sustainable leadership approaches are highlighted, especially in the areas of leadership culture, environmental responsibility, established trust, self-management, innovation, and financial performance of the organization. Practices that fall within the neutral zones need to be moved into the sustainable zone and implemented in nursing care practice. The results of this research demonstrate a positive attitude towards the perception of sustainable leadership practices. The interconnection of sustainable leadership practices is evident from various aspects. Within the framework of the 23 practices that lead to organizational success, a positive view of the organization's reputation and user (patient) satisfaction has been identified, and to a bit lesser extent, long-term stakeholder value. A positive correlation between employee engagement and quality of service has been identified, influenced by established ethical behaviour, understanding of cultural diversity, staff retention and recruitment, team organization, and knowledge retention and sharing. The respondents unanimously agree that the organization is average in terms of financial performance and consequently does not represent significant long-term value for shareholders. The diagnosis of sustainable leadership has highlighted some gaps where sustainable leadership should be strengthened. In addition to average financial performance, these gaps include environmental responsibility and the establishment of trust, which could further enhance employee empowerment. Consequently, this would result in greater innovation in their work and self-management, enabling employees to implement their ideas and improvements in services and the quality of work performed. List of abbreviations ISL : Institute for Sustainable Leadership TM Declarations Acknowledgements The author would like to thank all the respondents who participated in the research. The author would like to thank the Institute for Sustainable Leadership™ for permission to use the Structured Questionnaire on Sustainable Leadership (SLQ) and the ISL software. Author information Author and affiliations Dr. Marjeta Logar Čuček, B.Sc., M.Sc., specialist University Clinical Centre Ljubljana, Slovenia Contributions The author designed and prepared the study, as well as interpreted the data and prepared the article for publication. Corresponding author Correspondence to [email protected] . Funding The study was partially funded by the tertiary project Leadership and its Influence on the Quality of Health and Patient Care. The authorisation by the Institutional Review Board to conduct the study was obtained at the start of the project titled Leadership and its Influence on the Quality of Health and Patient care from the Working Group for Research in Healthcare and Midwifery at University Clinical Centre Ljubljana, 2020. Ethics declarations Ethics approval and consent to participate The need for special authorisation for the study from the ethics committee was waived by the Working group for research in nursing and midwifery at the University Clinical Centre Ljubljana, Slovenia, in December 2022. The study was conducted in accordance with the principles of the Helsinki-Tokyo Declaration (World Medical Association, 2013) and the Code of Ethics for Nurses and Nurse Assistants of Slovenia (2014). Participants gave their informed consent by confirming their willingness to participate in the online survey. Data were collected anonymously, and the IP addresses of participants were not saved. Consent for publication Not applicable. Competing Interest The author declares no competing interests. Clinical trial number: not applicable. Data Availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. References Yukl G. Efffective leadership behavior: What we know questions need more attention. Acad. Manag. Perspect. 2012, 26 , 66–85. https://doi.org/10.5465/amp.2012.0088 . Kim WG, Brymer RA. The effects of ethical leadership on manager job satisfaction, commitment, behavioral outcomes, and firm performance. Int. J. Hosp. Manag . 2011 , 30 , 1020–1026. https://doi.org/10.1016/j.ijhm.2011.03.008 . Hallinger P, Suriyankietkaew S. Science Mapping of the Knowledge base on Sustainable Leadership 1990–2018. Sustainability , 2018 , 10 , 4846.https://doi.org/10.3390/su10124846 . Logar Čuček M. 2022. Preventiva – trajnostno vodenje zdravstvene nege in oskrbe. 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Assur . 2011 , 24 , 67–80. https://doi.org/10.1108/09526861111098256 . Mihai L, Schiopoiu Burlea A, Mihai M, Comparison of the Leadership Styles Practiced by Romanian and Dutch SME Owners. International Journal of Organizational Leadership 2017;6;4-16, SSRN: https://ssrn.com/abstract=3333054. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6290182\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":463050955,\"identity\":\"3dfeeee2-6c46-4bca-a33d-237f6ad44990\",\"order_by\":0,\"name\":\"Marjeta Logar Čuček\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYJACAxDBB2ZWJAAZBxgYEghqAapgAzPPJAAZRGhhgGthbEuA6sUDdNvPPij4+MOOgY29/eLnynlp8myMB5g/PMCjxexMuoHhjIRkBjaeM8WSZ7flGLYxHGCTwOcwswNpDMY8CcwMbBI5CZKN2yoSgH5hw+sXs/PPGIz/JNSDtCT/bJwD1sL8Aa+WG0BbGBIOA7WkH5NsbMgBaWHA77AbzxgMe9KO8wD9wmbZcCwN6JeDbfi1nE9jM/hhUy3Hz97++GZDTbI8v8Thwx9/4NECBGyg2OcBIgMIX+JgA34NDAzMDyA0O5TmJ6hjFIyCUTAKRhgAADf7Sg8MQRPPAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Ljubljana University Medical Centre\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Marjeta\",\"middleName\":\"Logar\",\"lastName\":\"Čuček\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-03-23 21:08:12\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6290182/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6290182/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":83773588,\"identity\":\"9e633b0d-8994-4ff1-8c1f-3f92eaceb55a\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:22:35\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":153379,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSustainable leadership Pyramid (with permission from Harry Bergsteiner and the Institute for Sustainable Leadership™).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/caec6cba409241532f6884b5.png\"},{\"id\":83773490,\"identity\":\"1e8bb82d-d485-4c5c-80c6-07d0001f7c79\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:14:35\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":33548,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eLeadership Culture. The graph shows leadership paradigms from left to right for each characteristic: the grey colour represents classical leadership, yellow represents organic leadership, in the middle there is brown representing transactional leadership, and green representing visionary leadership.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/f9938364a4ca0fcc94f263ff.png\"},{\"id\":83772902,\"identity\":\"b2994d19-11da-400d-bd95-0c94a83e424d\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:06:35\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":160094,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOverall scores: spread of scores for all respondents. The circle represents the average score for a certain category of respondents. The horizontal grey lines show the distribution of responses and the range of scores in each category. The red line indicates the extreme distribution of responses that span three columns. The left side of the 5-level scale represents unsustainable leadership practices (Locust Leadership), the right side represents sustainable leadership practices (Honeybee Leadership).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig38.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/4b7542a87c7b879ec9285b9f.png\"},{\"id\":83772906,\"identity\":\"37e1b849-d8b4-4ff9-83e2-d46e9b858f51\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:06:35\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":160094,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThree age groups (25-34 years, 35-44 years and 45-54 years) and their views on sustainable leadership.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/2247b4260d4156d375648403.png\"},{\"id\":83773492,\"identity\":\"78928756-7e5d-45a1-915d-014de11ce9fc\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:14:35\",\"extension\":\"png\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":273725,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePerception of sustainable leadership practices according to the educational background of the respondents.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig5.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/b76288acd61b35573efcc975.png\"},{\"id\":83772911,\"identity\":\"66b0e27d-adad-4070-b9e1-db2b82c72534\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:06:35\",\"extension\":\"png\",\"order_by\":6,\"title\":\"Figure 6\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":294751,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe perception of the sustainable leadership practices according to the length of service of the respondents in the organisation.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig6.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/7eb8df2a676f46fddd1231de.png\"},{\"id\":83772917,\"identity\":\"25674366-e69e-4ea5-bbcc-895571d27a49\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:06:35\",\"extension\":\"png\",\"order_by\":7,\"title\":\"Figure 7\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":303476,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOrganisational grouping: For the organizational grouping profile, respondents were classified into three groups, namely, Top team, Other leaders, and Followers.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig7.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/a48421a199ff71b78504aa57.png\"},{\"id\":83772914,\"identity\":\"bc918c4f-a9ab-443f-a74b-216eb52ea655\",\"added_by\":\"auto\",\"created_at\":\"2025-06-02 13:06:35\",\"extension\":\"png\",\"order_by\":8,\"title\":\"Figure 8\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":328678,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eManager’s view on leadership in the clinical environment. The respondents identified themselves as Senior Executives, Middle Managers/Professionals, and First-line Supervisors/Team Leaders.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig8.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/d663bc37b366f1df8fcc94fb.png\"},{\"id\":103499730,\"identity\":\"43a828da-9085-44f4-a0a1-668675f422f0\",\"added_by\":\"auto\",\"created_at\":\"2026-02-26 11:56:18\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2719254,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6290182/v1/54acca90-d4f7-4f06-9a17-83eaf0f75de4.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Sustainable Approaches to Leadership in Nursing and Patient Care in a Selected Hospital in Slovenia: A Case Study \",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eIn recent decades, there has been an increased interest in studying conceptual models that describe leadership in organizations and companies [1]. Despite numerous findings on surpassing established forms of leadership which are described by four leadership paradigms (Classical, Transactional, Visionary and Organic), effective leadership is still largely defined and measured based on the effects of actions taken within the organization, with an emphasis on employee satisfaction, commitment, organizational culture, task-solving performance, rather than organizational or company performance [1,2,3].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis understanding of leadership has been challenged by numerous changes in organizations, which have become a constant in modern times. Coping with uncertainty and risk management are particularly relevant after unexpected events, such as the recent COVID-19 crisis. The world is also facing constant geopolitical tensions, environmental pollution, depletion of natural resources, climate change, looming energy crisis, financial instability [3,4,5]\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAs a result, organizations and companies need to redirect their operations or transform their business models, first due to existential reasons, and at the same time to achieve sustainability of systems for future generations [6,7]. In the future, the decision-making process in organizations and companies will be based on the integration of economic, environmental, and social concerns [5].\\u003c/p\\u003e\\n\\u003cp\\u003eThus, modern times require the expansion of the traditional understanding of leadership from the leader-follower relationship to relationships with multiple stakeholders within or outside the organization [8]. The new paradigm places at the forefront professionals who value human development and the environment without neglecting economic aspects [9]. These new trends change the expected behaviour of modern leaders and create a new type of leadership: sustainable leadership [6,10,11].\\u003c/p\\u003e\\n\\u003ch3\\u003eSustainable leadership\\u003c/h3\\u003e\\n\\u003cp\\u003eSustainable leadership provides guidelines for preserving and creating a desired and long-lasting future for various stakeholders, including employees, users, in this case patients, financiers, society, and the environment [10,11]. It is characterized by numerous common starting points, such as systemic leadership, long-term vision, corporate responsibility, ethical behaviour, social responsibility of leaders and organizations, innovation, systemic change, and stakeholder involvement [3].\\u003c/p\\u003e\\n\\u003cp\\u003eThe interdependent nature of sustainable development is expressed in the sustainable flow of material goods, care for resources and biological systems of the planet, fair abundance and intergenerational justice, intercultural dialogue, and diversity [12,13,14]. Sustainable leadership, as described by the authors Avery and Bergsteiner, requires a long-term perspective in decision-making, the promotion of systemic innovation, the development of qualified and engaged staff, and the provision of high-quality products, services, and solutions [15].\\u003c/p\\u003e\\n\\u003cp\\u003eOrganizations that are led in this way follow the practices of \\\"Honeybee\\\" leadership. The Honeybee philosophy represents the positive side of sustainable leadership. It builds community, promotes collaboration, and contributes to the long-term sustainable outcomes of the organization. The opposite of the Honeybee approach to leadership is the philosophy of \\\"Locust\\\" leadership, which represents a more ruthless business philosophy of profit at any cost [10]. Given the dynamic nature of organizations and companies, it is rare to find only one form of leadership in terms of sustainable or traditional leadership [15].\\u003c/p\\u003e\\n\\u003ch3\\u003eSustainable leadership pyramid\\u003c/h3\\u003e\\n\\u003cp\\u003eThe foundation for studying existing organizational practices is provided by the pyramid of sustainable leadership, as described by Avery and Bergsteiner in their 23 sustainable leadership practices [10]. They divided them into three structural levels that are interconnected, interdependent, and positively influence each other in all directions. Avery and Bergsteiner state that 14 foundation practices, focused on leadership, support the six practices at the second, higher level of the pyramid with a focus on employees [10]. These include intrinsic motivation of employees, self-management, team orientation, enabling culture, knowledge retention and sharing, and trust. The third level, focused on the customer, in this case the patient, consists of three key performance drivers which are combinations of foundation practices and higher-level practices. These include innovation integrated into culture, systems, and processes of the organization, followed by staff engagement, which reflects a positive opinion about the organization, a desire for long-term employment, and the effort invested in the organization's success. The final element of the third level is quality. All three elements influence the performance outcomes of the organization, such as reputation, user satisfaction, long-term financial performance, and value for stakeholders and shareholders [16,17]. Figure \\u003cstrong\\u003e1\\u003c/strong\\u003e shows 23 elements of sustainable leadership and five performance outcomes.\\u003c/p\\u003e\\n\\u003ch3\\u003eLeadership in nursing and patient care\\u003c/h3\\u003e\\n\\u003cp\\u003eOur future also includes nursing and patient care, which requires efficient leadership that is prepared for rapid changes, collaboration, adaptation, and seeking responses and solutions [18]. It is expressed through the abilities of individuals with a good insight and suitable behavioural response styles for various social situations. This includes having a vision that considers experience and transcends previous patterns, anticipating changes ahead of others, and aligning the values of employees at different levels [4,18]. Bogataj states that the goal should be an organizational culture of leadership that positively influences the well-being and creativity of employees and consequently increases the trust of patients [19].\\u003c/p\\u003e\\n\\u003cp\\u003eEducation plays a key role in effective nursing care leadership of 21st century [20,21,22,23,24]. Education regarding sustainable leadership also changes the characteristics and skills of leaders. By acquiring leadership competencies, leaders, together with their colleagues, can more effectively facilitate the process of change [25,26]. With an awareness that work in nursing and patient care requires collaboration with numerous stakeholders within and outside the hospital environment, responsible leadership can help create and sustain long-term sustainable leadership practices. As the authors Avery and Bergsteiner state, recognizing the benefits of sustainable leadership and evidence-based knowledge is the skill that will drive progress in the organization's operations, in this case, nursing care leadership [10].\\u003c/p\\u003e\\n\\u003ch2\\u003eAim\\u003c/h2\\u003e\\n\\u003cp\\u003eFor these reasons and with the aim of understanding how leaders in nursing and patient care in a hospital environment experience leadership, we set the goal of identifying challenges in 23 leadership areas and implementing evidence-based practices into leadership work in the future. To achieve the research goal, the following research questions were posed:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eTo what extent are the four established leadership paradigms replaced by sustainable leadership practices in the field of nursing and patient care?\\u003c/li\\u003e\\n \\u003cli\\u003eWhere do different categories of respondents see the organization in relation to the 23 practices of sustainable leadership and the five performance outcomes?\\u003c/li\\u003e\\n \\u003cli\\u003eWhere are the gaps in the organization's sustainable development journey?\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eIn the following the first research question is elaborated in the frame of Leadership Culture, while the second and third are elaborated in the frame of Sustainable Leadership Profiles.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003ch2\\u003eDesign\\u003c/h2\\u003e\\n\\u003cp\\u003eA non-experimental research design was used. A quantitative research method, a case study was used [27]. Data was collected through online surveys using a structured questionnaire.\\u003c/p\\u003e\\n\\u003cp\\u003eThe research process was divided into three phases. The first phase consisted of reviewing and studying various approaches to leadership in order to gain knowledge about different leadership models. In the second phase, using the Sustainable Leadership Questionnaire (SLQ), leadership approaches in the studied hospital environment were diagnosed. In the third phase, based on the findings collected from the analysis of responses, we examined which elements of sustainable leadership are already present in the hospital. The final conclusions of the research are based on the collected data, and shed light on any gaps that employees perceive in foundation practices and results obtained in the research environment.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eInstrument\\u003c/h2\\u003e\\n\\u003cp\\u003eThe Structured Questionnaire on Sustainable Leadership (SLQ), developed by Avery and Bergsteiner (2020) at the Institute for Sustainable Leadership\\u003csup\\u003e\\u0026nbsp;TM\\u003c/sup\\u003e (in the following: ISL) based in Australia, consisted of 87 questions:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eThe first part of the questionnaire included 5 questions that encompassed demographic information (gender, age, educational level, length of service in the organization, employment level/role in the organization).\\u003c/li\\u003e\\n \\u003cli\\u003eSeven questions were used in order to ascertain the most prevalent leadership behaviour in the organization. Respondents were asked to choose only one answer out of 4 provided options.\\u003c/li\\u003e\\n \\u003cli\\u003eIn the next section, consisting of 69 questions, we explored where different categories of respondents saw the organization in relation to the 23 practices of sustainable leadership and five performance outcomes (including leadership culture).\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eParticipants could choose one answer from six statements: 1 - Strongly Disagree, 2 - Disagree, 3 - Neutral, 4 - Agree, 5 - Strongly Agree, 6 - I don\\u0026apos;t know.\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding organizational performance compared to other organizations, respondents were asked to select one of the six statements in a set of 6 questions: 1 - Much Worse, 2 - Worse, 3 - About the Same, 4 - Better, 5 - Much Better, 6 - I don\\u0026apos;t know.\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, responses to the 87th question \\u0026quot;How satisfied are you overall with your organization?\\u0026quot; were analysed based on gender, age, education, length of service, and role in the organization. Response options ranged from 1 - Extremely Dissatisfied, 2 - Dissatisfied, 3 - Neutral, 4 - Satisfied, 5 - Extremely Satisfied.\\u003c/p\\u003e\\n\\u003ch2\\u003eSetting and participants\\u003c/h2\\u003e\\n\\u003cp\\u003eLeaders in nursing and patient care in the selected hospital in Slovenia were invited to participate in the research. The convenience sample consisted of 123 individuals. Out of these, 102 questionnaires were correctly and completely filled in and were included in further analysis, while 21 were incomplete and had to be discarded.\\u003c/p\\u003e\\n\\u003cp\\u003eThe majority of respondents were female (79%), aged 35 to 44 (43%), had a university education (48%), employed in the organization for over 16 years (56%), and held leadership positions that were non-executive (52%).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e4.3. Description of the Process and Data Processing\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eResearch permission was granted by the UKC Ljubljana Working Group for Research in Healthcare and Midwifery, 2020. The invitation to participate was sent via email. Participation was voluntary. The survey was conducted in accordance with ethical guidelines [28,29] and the privacy policy of the ISL, which collected the data and ensured anonymity.\\u003c/p\\u003e\\n\\u003cp\\u003eData collection was done using an online questionnaire, which was available at the Leadership Survey link during the research period from December 16, 2022 to December 23, 2022. The questionnaire was provided in English, with an added translation in Slovenian for assistance. The average time to complete the survey was 25 minutes. Data was collected and summarized by Survey Monkey, where averages and ranges were calculated. Graphs were created using ISL software based on Excel. Descriptive statistics were generated in summary tables using proprietary ISL software.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003ch2\\u003eAssessment Areas\\u003c/h2\\u003e\\n\\u003cp\\u003eUsing Sustainable Leadership Questionnaire (SLQ), the following areas were assessed:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eLeadership culture,\\u003c/li\\u003e\\n \\u003cli\\u003eLeadership behaviour, and\\u003c/li\\u003e\\n \\u003cli\\u003eOrganizational systems.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe questionnaire served as a diagnostic tool and points out a future course of action.\\u003c/p\\u003e\\n\\u003ch2\\u003eLeadership Culture\\u003c/h2\\u003e\\n\\u003cp\\u003eThis section presents the results of the Sustainable Leadership Questionnaire in the hospital environment, starting with leadership culture, which represents the first aspect of sustainable leadership. It describes how leaders and followers interact in a specific context in terms of four leadership paradigms (Classical, Transactional, Visionary, and Organic) [30].\\u003c/p\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e2\\u0026nbsp;\\u003c/strong\\u003edemonstrates leadership culture in the selected hospital environment based on seven characteristics (decision-making, vision, trust, innovation culture, communication, challenging the norm, organizational structure), which differentiate the four leadership paradigms\\u003c/p\\u003e\\n\\u003cp\\u003eLeadership culture in the researched hospital environment includes all leadership paradigms. As the results show, there are strong transactional components of decision-making, innovative culture, communication, challenging the norm, and organizational structure present in the organization. Further research is needed to create a sustainable leadership culture. These components contradict consensual decision-making, innovation, collaboration, and team empowerment. The relationship between leaders and followers is based on the exchange of rewards and expectations agreed upon with the leaders. The leaders make final decisions.\\u003c/p\\u003e\\n\\u003cp\\u003eVisionary leadership paradigm is also apparent. It is apparent in vision, decision-making, trust, and organizational structure. In line with the characteristics of visionary leadership, employees are inspired by a shared vision and collaboration, based on a set of collective values with strong emotional involvement of employees.\\u003c/p\\u003e\\n\\u003cp\\u003eThere are also some noticeable elements of classical leadership in the organization, exceeding 20%. Classical leadership is particularly apparent in decision-making, communication, and organizational structure, in accordance with the fundamental principles of \\u0026quot;top-down\\u0026quot; leadership, through control and orders of individuals or groups. In the decision-making process, the inclusion of followers, two-way communication, and consequently influencing the results are minimized.\\u003c/p\\u003e\\n\\u003cp\\u003eIn contrast, organic leadership is characterized by distributed leadership, where decision-making is delegated to employees. This leadership paradigm is present to a lesser extent in the researched hospital environment. Important cultural elements include trust, vision, and innovation, allowing interaction among all members. This approach attracts and retains highly skilled and competent staff, contributing to the value and performance of the organization.\\u003c/p\\u003e\\n\\u003ch2\\u003eSustainable Leadership Profiles\\u003c/h2\\u003e\\n\\u003cp\\u003eBelow is a collection of profiles of sustainable leadership in the selected hospital environment. The results were obtained using various variables. The profiles show where different categories of respondents see the organization in accordance with the 23 practices of sustainable leadership, including leadership culture, and five performance outcomes.\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 1: Overall scores\\u003c/h3\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e3\\u0026nbsp;\\u003c/strong\\u003eshows the overall assessment (all respondents) of sustainable leadership.\\u003c/p\\u003e\\n\\u003cp\\u003eThe overall profile for our research environment shows a high level of consistency in the perception of sustainable leadership practices. Leadership approaches and outcomes are located in the \\u0026quot;Honeybee\\u0026quot; part of the sustainable leadership spectrum. None of the approaches fall into unsustainable zones (1-2). More than half of the practices are located in the neutral zone (3) and need to be shifted towards the sustainable zones (4-5).\\u003c/p\\u003e\\n\\u003cp\\u003eFrom the foundation practices, four elements of sustainable leadership are more prominently present in the overall assessment (4), while six elements have almost entirely shifted towards the sustainable leadership zones (3-4). The results also indicate that four foundation practices, i.e., independence from outside interference, environmental and social responsibility, and stakeholder focus, are more consistently placed in the average zone. Although the foundation practices have not fully reached the sustainable zones, some of them contribute to improving the six higher-level practices. Consequently, team orientation and knowledge retention and sharing are present in the sustainable zones, and influence staff retention. Intrinsic motivation, self-management, and trust are located in neutral zones, but are strongly interconnected. Mutual trust builds staff motivation and consequently leads to self-management in implementing ideas and innovation, which is one of the three key performance drivers. The authors of the sustainable pyramid, Avery and Bergsteiner, added quality and employee engagement as the other two factors, which are present in the sustainable range, with employee engagement being more prominent [10]. The respondents expressed positive beliefs and placed in the sustainable zones also patient satisfaction, the reputation of their organization, long-term shareholder value, and long-term shareholders returns. However, they are sceptical about the financial performance of the organization. Financial performance is average and depends on the implementation of sustainable practices at all three preceding levels.\\u003c/p\\u003e\\n\\u003cp\\u003eA supplementary analysis was carried out in this part to determine organizational satisfaction, with a view to explaining the extreme spread of results in each practice. The general results showed that 34% of respondents were satisfied with the organization and 26.5% were extremely satisfied. Additional research is required to shed light on the reasons for the high number of neutrals (18%); as well as 11% of those who reported being dissatisfied, with another 2% extremely dissatisfied.\\u003c/p\\u003e\\n\\u003cp\\u003eDissatisfaction increases with age; older respondents are more dissatisfied than younger ones. Depending on their role in the organization, the least satisfied are decision-makers and full-time employees with more than 16 years of service (37%), while the most satisfied are volunteers, supervisors and group leaders. Regarding the level of education, the most dissatisfied are employees with the highest level education (half of them), while the most satisfied are those with secondary education.\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 2: Age\\u003c/h3\\u003e\\n\\u003cp\\u003eThis profile shows the results for three age groups, 25-34 years, 35-44 years and 45-54 years. The results are shown in Figure \\u003cstrong\\u003e4\\u003c/strong\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eThe results cluster around the neutral-sustainable parts of the spectrum, leaning towards sustainable leadership, which is consistent with the overall profile.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is worth noting that the age group in the 45-54 age range perceives the organization as less sustainability-oriented compared to the younger generation (25-34 years). The middle generation has decided on the \\u0026quot;middle way\\u0026quot; and their opinions on the sustainable orientation of the organization rank them between the older and younger generations.\\u003c/p\\u003e\\n\\u003cp\\u003eThe oldest surveyed group is the least convinced of the positive results of financial performance, whereas it seems that the younger generations are not so concerned about profit or worried about existential issues. All age groups tend to evaluate performance results in terms of reputation, satisfaction, and value for users as \\u0026quot;better\\u0026quot; compared to other related institutions.\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 3: Education\\u003c/h3\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e5\\u003c/strong\\u003e shows the perception of sustainable leadership practices according to the educational\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ebackground of the respondents. the results display a tendency towards neutral parts of the leadership spectrum which, however, is moving towards sustainable leadership. Respondents holding a doctoral degree generally perceive the organization as significantly more sustainably oriented than those with an undergraduate or postgraduate degree.\\u003c/p\\u003e\\n\\u003cp\\u003eAll three groups believe that employees in nursing and patient care are dedicated to their profession, manage their knowledge well, further their education and share the acquired knowledge, work according to high ethical standards and appreciate virtues. They focus on employee retention and can anticipate recruitment needs.\\u003c/p\\u003e\\n\\u003cp\\u003eTheir views are similar in the area of trust, which is more in the neutral zone.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThey agree that their organization is reputable, and that users/patients are satisfied. They share the same opinion regarding the other two definitions of performance outcomes, the weakest result being financial performance, which is rated neutral (3).\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 4: Length of service\\u003c/h3\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e6\\u003c/strong\\u003e shows the respondents\\u0026apos; perception of the sustainable leadership practices according to the length of service of the respondents in the organisation. There are few differences in the results based on length of service. All 23 practices of sustainable leadership cluster around neutral position; they are all partially expanding into the field of sustainable leadership. Regarding leadership culture and independence from outside interference, the responses lie in the neutral category (3).\\u003c/p\\u003e\\n\\u003cp\\u003eThe success of the organization, which is reflected in the reputation and satisfaction of patients, is placed in the sustainable leadership zone (5).\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 5: Organisational grouping\\u003c/h3\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e7\\u003c/strong\\u003e below shows the scores according to organisational grouping. For the organizational grouping profile, respondents were classified into three groups, namely, Top team, Other leaders, and Followers. Leadership scores cluster around the neutral-sustainable zones of the leadership spectrum, but mostly heading towards sustainable leadership.\\u003c/p\\u003e\\n\\u003cp\\u003eLeadership culture was placed in the neutral zone (3), along with employee development, change management, independence from outside interference, environmental and social responsibility, a broad focus on stakeholders, motivation, self-management and trust.\\u003c/p\\u003e\\n\\u003cp\\u003eThese practices should be reviewed and analysed further to make them more sustainable.\\u003c/p\\u003e\\n\\u003ch3\\u003eProfile 6: Managers\\u0026nbsp;\\u003c/h3\\u003e\\n\\u003cp\\u003eFigure \\u003cstrong\\u003e8\\u003c/strong\\u003e shows how managers view leadership in the clinical environment. The respondents identified themselves as Senior Executives, Middle Managers/Professionals, and First-line Supervisors/Team Leaders. Again, the scores consistently cluster around the neutral-sustainable parts of the spectrum (3-4), leaning towards sustainable leadership.\\u003c/p\\u003e\\n\\u003cp\\u003eInterestingly, Senior Executives see more practices as less sustainable than other levels of management, particularly in the areas of employee retention, recruitment, internal succession planning, vision and purpose, long-term vision and quality. Senior Executives assessed patient satisfaction in the zone of sustainable leadership (5).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eGoing beyond conventional leadership practices is an important step in nursing care, which contributes to the implementation of sustainable practices in the health care system and greatly enhances professional competence [10]. The SLQ questionnaire served as a diagnostic tool and offered a pathway for action.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eLeadership Culture\\u003c/h2\\u003e\\n\\u003cp\\u003eLeadership styles are expressed through a series of responsibility relationships [31]. Effective leadership is a skill that is expressed through leaders' abilities to influence employees, resolve ambiguity, adapt to rapid changes, and understand people and culture [23]. This highlights sustainable leadership, which is adaptable and applicable in any organizational context [6]. Leadership culture plays a significant role in the implementation of sustainable principles [19].\\u003c/p\\u003e\\n\\u003cp\\u003eThe results of this research show that four leadership paradigms, as described by Avery's typology [30], transactional, visionary, classical, and organic, are present in all studied areas of leadership culture. The transactional paradigm stands out, which, according to Martinčič and Biloslavo, implies improving leadership approaches and responding to environmental changes [32]. However, Burawat [33] and Jing and Avery [34] emphasize the focus on the exchange of benefits between leaders and followers. In creating and maintaining a sustainable leadership culture, it is necessary to examine the strong transactional components and develop them towards collaborative decision-making, team empowerment, innovation orientation, and collaboration [10].\\u003c/p\\u003e\\n\\u003cp\\u003eVisionary leadership, as perceived in this research, is present in implementing vision, establishing trust, and (co)decision-making. In comparison to sustainable leadership, this style focuses on a charismatic leader with an added dimension of emotional involvement of employees [34,35] , whereas sustainable leadership focuses on promoting sustainability values at personal, environmental, and ecological levels, both present and future [36].\\u003c/p\\u003e\\n\\u003cp\\u003eAs stated by some authors, leadership styles are often intertwined [35]. Classical and organic leadership cultures were also observed in this research. Classical leadership is primarily leader-oriented, more pronounced in organizational structure, decision-making, communication, and to a lesser extent in perception of future, vision, and innovation. These, along with consistency in action, leading by example, and inclusion, are some of the foundations of sustainable leadership [15,4]. On the other hand, organic leadership is characterized by shifting leadership to employees [34] and was least recognized in our organization. The organisation is well on the way to sustainable leadership in several segments, such as trust and innovation, which can directly impact organizational performance.\\u003c/p\\u003e\\n\\u003ch2\\u003eOverall Scores\\u003c/h2\\u003e\\n\\u003cp\\u003eOverall scores, showing the distributions for all respondents, were obtained through the analysis of responses on the assessment of the 23 sustainable leadership practices by Avery and Bergsteiner [10]. It has been established that the leadership styles and outcomes fall within the sustainable zones, although more than half of the approaches are in the neutral zones. The organization's reputation and patient satisfaction are seen as more sustainable (4-5), which can be confirmed by the dynamic implementation of the 23 practices in various directions, for instance, employee commitment and service quality positively influence patient satisfaction. The organization's reputation can be partly explained by the hospital's social and professional significance, while financial performance represents one of the gaps on the path to sustainable development. Therefore, investing more in the environment, becoming more socially responsible, and operating based on sustainable principles could be beneficial. Additionally, it would strengthen other practices at all levels.\\u003c/p\\u003e\\n\\u003cp\\u003eAt the level of foundation practices, there is a noticeable shift towards sustainable leadership in terms of long-term employee retention and recruiting, respect and inclusion, and employee ethics [2, 5, 6]. Measures such as developing workplace culture, creating a positive work environment, providing employee development opportunities, internal succession planning, implementing leadership training, and mentoring new employees contribute to improved staff retention and the integration of new colleagues [37]. Employees assess ethical conduct and virtues as most sustainable in their leaders [6], which constitutes the core of the organizational culture [10]. Researchers Dalcher [38], and Fernandez and Shaw [39] emphasize that a leader must be consistent in their actions and serve as a role model for employees, they should value inclusion and effective communication, which is undoubtedly evident in the research environment.\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding higher-level practices, education, knowledge retention and sharing are moving towards sustainable areas (19). Due to constant changes, leadership requires educated staff, and education itself is an imperative for sustainable development. Other researchers also report the impact of investment in education and additional employee training on improved business performance [15,20]. If the development of education and training has so far focused on lifelong learning, in the future it must be supported by research and the transfer of findings into practice [40].\\u003c/p\\u003e\\n\\u003cp\\u003eFrom the analysis of leadership culture in the researched organization, it is evident that the dominant leadership paradigm in the decision-making segment does not fully support \\\"self-management.\\\" This is a result of mutual mistrust between leaders and employees. Building trust depends on many foundation practices and time dedicated to growth and development [10]. For trust to move into the sustainable areas, employees need skills and knowledge and development of their competencies. They need to be able to see their future in an organization that respects and includes diverse employees, is ethical, and has good leadership. The organization should implement organizational changes in a consultative manner, and act responsibly towards the environment and society [3,38].\\u003c/p\\u003e\\n\\u003cp\\u003eWith established mutual trust, employees will demonstrate more self-initiative in performing their tasks. Empowered, they will approach their work more innovatively. Through \\\"self-management\\\", they will strive to find new approaches and appropriate solutions, innovations, in the process of their work, which will contribute to the organization's greater success. The role of leaders should be focused on considering improvement suggestions made by employees, improving communication, taking into account the interests of all stakeholders, and working towards a common goal and vision [41,42]. Markey et al. state in their research that leaders should act as moderators who recognize employees’ needs for support [43].\\u003c/p\\u003e\\n\\u003cp\\u003eWith established trust, employee empowerment, and their proactive approach to work, intrinsic motivation in the work environment will also increase, consequently leading to employee engagement, which impacts the quality of services rendered. In our case, it pertains to patient care and ensuring their recovery and return to work and family environment.\\u003c/p\\u003e\\n\\u003cp\\u003eThe nature of work in nursing care requires teamwork. The culture established within the organization and in teamwork practices plays a significant role in pursuing sustainable principles. Hierarchical and controlling leadership practices should be redirected towards collaborative, inclusive, and participatory inclusion practices [44]. Encouraging participation in decision-making motivates employees, leading to their continuous education and resulting in high level of patient care [42]. This further increases employee engagement and the quality of work performed.\\u003c/p\\u003e\\n\\u003cp\\u003eEnvironmental responsibility is also a key factor in implementing sustainable nursing care. In this research, it was assessed as average. By integrating the principles of environmental health into practice, through education and research, employees will work in a way that does not jeopardize patients, employees, or the environment. According to Schenk [45], leaders should support the implementation of healthy environmental principles in nursing care practice, contributing to \\\"future-oriented\\\" leadership also in this organization.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the overall profile, satisfaction with the organization was also assessed. General satisfaction was compared based on gender, age, role, education level, and length of service in the organization. Concerningly, there is dissatisfaction among older employees, individuals with the highest level of education (doctorate), and permanent employees. Proposed measures for closing these gaps include job rotation, empowerment, career advancement opportunities, and awarding scholarships to the most innovative and talented employees [10]. These findings will undoubtedly lead to more detailed research into employee satisfaction.\\u003c/p\\u003e\\n\\u003ch2\\u003eComparison of other leadership profiles\\u003c/h2\\u003e\\n\\u003cp\\u003eBased on the age of respondents, educational background, length of service in organizations, organizational groups, we comparatively interpret some practices that are moving towards sustainable leadership or, conversely, towards conventional leadership.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eRegardless of the dimensions studied, all respondents are unanimous regarding the organization's reputation. Considering respondents’ age, recruitment was assessed as sustainable. It is most satisfying for young people who also tend to stay in their positions (2). Avery and Bergsteiner cite as an example of long-term thinking in an organization, young people who are employed to develop and work together as a team [46]. They are responsive to changes (9) and aware that nursing care is a part of a cycle of rapid responses and adaptations to new situations, requiring responsible leadership regarding employees, the environment, and society, which ultimately leads to creating a sustainable and better future [31,38]. In contrast to younger employees, older employees do not perceive leadership in the organization as predominantly sustainable, but they agree regarding employee engagement, which all three age groups placed in the “Honeybee” zones.\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding higher-level practices, younger generations are responsive, and value teamwork (15), which provides them with strong professional and moral support and builds a shared culture (18); these practices are also recognized by older generations.\\u003c/p\\u003e\\n\\u003cp\\u003eThe assessment of knowledge retention and sharing is consistent regardless of age, level of education, length of employment, organizational grouping, and leadership role in the organization. The employees engage in sustainable education (19) and participate in numerous training and education programs. They share their knowledge through occasional lectures and the publication of professional and scientific articles.\\u003c/p\\u003e\\n\\u003cp\\u003eHowever, innovation is seen as average by all three age groups. Ideas may be dispersed and go unnoticed, or the work may be carried out in a routine manner. This sustainable practice should be further investigated, as innovation is the foundation of organizational progress and affects performance outcomes.\\u003c/p\\u003e\\n\\u003cp\\u003eRespondents of different age groups equally assess performance based on the institution's reputation and patient care; older employees have doubts about the organization's financial performance.\\u003c/p\\u003e\\n\\u003cp\\u003eEducation also influences the perception of leadership as sustainable in the hospital environment. Employees with the highest level of education, a doctorate, view the organization as more sustainable compared to those with lower levels of education. This can be linked to the fact that leadership education should already be integrated during undergraduate studies, in line with research on the importance of education conducted by Rafiq and Mughalov, Daly et al., Sing and Havnes [20,21,22]. In support of education, researchers [24,46,47] state that nurses involved in research and continuous education significantly contribute to sustainable leadership by studying institutional barriers to enable more effective healthcare provision, testing organizational models, and rapidly disseminating information about the most effective and sustainable interventions.\\u003c/p\\u003e\\n\\u003cp\\u003eRegarding the period of service in the organization, respondents placed most of the 23 sustainable leadership practices in neutral zones. Employee care, such as continuous education, career advancement opportunities, workload reduction, inclusion of diverse opinions, and initiative creation, contributes significantly to sustainable leadership. Clear communication within the organization, both among employees and with leaders, and choosing the appropriate communication style for each recipient are of paramount importance. Fernandez and Shaw, Gao et al., Moor have also written about these leadership approaches [39,41,42]. By shifting foundation practices towards sustainable areas, the long-term interests of all stakeholders will be considered [10].\\u003c/p\\u003e\\n\\u003cp\\u003eOrganizational groupings, such as Top Team, Other Leaders, and Followers, agree in their assessment of staff development, change management, independence from outside interference, environmental and social responsibility, broad stakeholder focus, intrinsic motivation, self-management, and trust. They are placed around the neutral sustainable part of the spectrum but leaning towards sustainable leadership. In relation to established leadership paradigms in the organization, transactional and visionary, we highlight sustainable practices such as long-term time horizon, internal succession planning, and recruiting and retaining staff. To make these practices more sustainable, they should be further examined in terms of both leadership styles compared to the characteristics of sustainable leadership, which focuses on promoting sustainable values [36]. Development is not an isolated event but requires a transition from an \\\"egosystem\\\" to an \\\"ecosystem,\\\" where everything depends on the adaptability of the organization, leader, and employees.\\u003c/p\\u003e\\n\\u003cp\\u003eThe perception of sustainable leadership has been comparatively interpreted among team leaders, middle management, and senior executives. Team leaders, as first-line supervisors, perceive more sustainable practices in their organizations. Managers or individuals in higher-level leadership positions reported fewer sustainable elements, while middle management partially transition into unsustainable territory when it comes to hiring new employees. They also approach it in the practice of internal succession planning, which is not in line with one of the foundation practices of sustainable leadership, since the development of leaders should be planned within an organization [10,46].\\u003c/p\\u003e\\n\\u003cp\\u003eLeaders in nursing and patient care can demonstrate a clear vision and values through transparency, critical thinking, education, and commitment to sustainable leadership. This will prove to be a significant contribution to improving patient treatment, employee satisfaction, organizational reputation, and performance, and in this way greatly benefit future generations.\\u003c/p\\u003e\\n\\u003cp\\u003eThere are several expected research limitations.\\u003c/p\\u003e\\n\\u003cp\\u003eThe first potential limitation was the administration of the questionnaire in the English language. Although respondents had the option to use a translation into Slovenian, this language barrier may have limited the time available for completing the questionnaire or even deterred some from participating.\\u003c/p\\u003e\\n\\u003cp\\u003eThe second limitation is related to the fact that the respondents provided their opinions and perceptions regarding sustainable leadership practices in the organization. Other individuals in different roles, positions, or other parts of the organization may have different perceptions of leadership practices. Therefore, long-term research is needed to provide a more comprehensive and definitive results.\\u003c/p\\u003e\\n\\u003cp\\u003eThe third limitation is that this research did not discuss the mechanism of employee involvement, which influences the perception of leadership in the organization. However, the results of this study refer to a specific group of individuals, and help us to better understand the relationship between age, level of education, length of service in the organization, position within the organization, and the adoption of the 23 sustainable leadership practices.\\u003c/p\\u003e\\n\\u003ch2\\u003eFurther Research Recommendations\\u003c/h2\\u003e\\n\\u003cp\\u003eThe results of the research conducted in December 2022 in the selected hospital environment in Slovenia should be further examined through in-depth group interviews. These results serve as a measure upon which the effectiveness of potential interventions can be assessed and modified. Conducting focus groups would provide a thorough understanding of which approaches to sustainable leadership require action, enabling gradual adaptation to change in leadership.\\u003c/p\\u003e\\n\\u003cp\\u003eAnother assessment of leadership perception based on the 23 sustainable leadership approaches should be conducted in a comparable-sized hospital environment in Slovenia. Based on the results, mechanisms influencing the greater or lesser presence of \\\"Honeybee\\\" leadership approaches can be further examined through in-depth interviews, investigating whether they stem from environmental needs, internal organizational orientations, or are influenced by trends.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the future, research should be conducted into the impact of leaders and organizations on society at large, in terms of measuring organizational performance through social, environmental, and economic results [13,14]. This conceptualization of goals and responsibilities of leaders and organizations will provide further insights into effective leadership, not only in \\\"closed systems\\\" [1] but also considering the interdependencies with numerous external factors [3,48,49,50,51].\\u003c/p\\u003e\\n\\u003cp\\u003eThe results of various studies indicate that adopting sustainable principles and implementing sustainable management in the operations of organizations contribute to their resilience, appropriate responses to unexpected situations, and positive outcomes [16,17,52], while other leadership principles may dominate in other areas, e.g. SMEs [53].\\u003c/p\\u003e\"},{\"header\":\"Conclusions \",\"content\":\"\\u003cp\\u003eThe key contributions of this study can be summarized as follows:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eThe research findings show that an understanding of the \\u0026quot;Honeybee\\u0026quot; leadership principles is present in the selected clinical environment.\\u003c/li\\u003e\\n \\u003cli\\u003eIt has been demonstrated that the organization\\u0026apos;s performance is reflected in patient satisfaction, the organization\\u0026apos;s reputation, and long-term value for stakeholders. This can be achieved by focus on employee engagement, knowledge retention and sharing, team orientation, ethical behaviour of employees, shared goals and vision, staff recruiting and retention.\\u003c/li\\u003e\\n \\u003cli\\u003eGaps in the implementation of sustainable leadership approaches are highlighted, especially in the areas of leadership culture, environmental responsibility, established trust, self-management, innovation, and financial performance of the organization.\\u003c/li\\u003e\\n \\u003cli\\u003ePractices that fall within the neutral zones need to be moved into the sustainable zone and implemented in nursing care practice.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eThe results of this research demonstrate a positive attitude towards the perception of sustainable leadership practices. The interconnection of sustainable leadership practices is evident from various aspects. Within the framework of the 23 practices that lead to organizational success, a positive view of the organization\\u0026apos;s reputation and user (patient) satisfaction has been identified, and to a bit lesser extent, long-term stakeholder value. A positive correlation between employee engagement and quality of service has been identified, influenced by established ethical behaviour, understanding of cultural diversity, staff retention and recruitment, team organization, and knowledge retention and sharing. The respondents unanimously agree that the organization is average in terms of financial performance and consequently does not represent significant long-term value for shareholders. The diagnosis of sustainable leadership has highlighted some gaps where sustainable leadership should be strengthened. In addition to average financial performance, these gaps include environmental responsibility and the establishment of trust, which could further enhance employee empowerment. Consequently, this would result in greater innovation in their work and self-management, enabling employees to implement their ideas and improvements in services and the quality of work performed.\\u003c/p\\u003e\"},{\"header\":\"List of abbreviations\",\"content\":\"\\u003cp\\u003eISL : Institute for Sustainable Leadership\\u003csup\\u003e\\u0026nbsp;TM\\u003c/sup\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eAcknowledgements\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe author would like to thank all the respondents who participated in the research. The author would like to thank the Institute for Sustainable Leadership\\u0026trade; for permission to use the Structured Questionnaire on Sustainable Leadership (SLQ)\\u0026nbsp;and the ISL software.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAuthor information\\u003c/p\\u003e\\n\\u003cp\\u003eAuthor and affiliations\\u003c/p\\u003e\\n\\u003cp\\u003eDr. Marjeta Logar Čuček, B.Sc., M.Sc., specialist\\u003c/p\\u003e\\n\\u003cp\\u003eUniversity Clinical Centre Ljubljana, Slovenia\\u003c/p\\u003e\\n\\u003cp\\u003eContributions\\u003c/p\\u003e\\n\\u003cp\\u003eThe author designed and prepared the study, as well as interpreted the data and prepared the article for publication.\\u003c/p\\u003e\\n\\u003cp\\u003eCorresponding author\\u003c/p\\u003e\\n\\u003cp\\u003eCorrespondence to marjeta.logar@kclj.si.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was partially funded by the tertiary project Leadership and its Influence on the Quality of Health and Patient Care. The authorisation by the Institutional Review Board to conduct the study was obtained at the start of the project titled Leadership and its Influence on the Quality of Health and Patient care from the Working Group for Research in Healthcare and Midwifery at University Clinical Centre Ljubljana, 2020.\\u003c/p\\u003e\\n\\u003cp\\u003eEthics declarations\\u003c/p\\u003e\\n\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe need for special authorisation for the study from the ethics committee was waived by the Working group for research in nursing and midwifery at the University Clinical Centre Ljubljana, Slovenia, in December 2022. The study was conducted in accordance with the principles of the Helsinki-Tokyo Declaration (World Medical Association, 2013) and the Code of Ethics for Nurses and Nurse Assistants of Slovenia (2014). Participants gave their informed consent by confirming their willingness to participate in the online survey. Data were collected anonymously, and the IP addresses of participants were not saved.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting Interest\\u003c/p\\u003e\\n\\u003cp\\u003eThe author declares no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003eClinical trial number: not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003eData Availability\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. \\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eYukl G. Efffective leadership behavior: What we know questions need more attention. \\u003cem\\u003eAcad. Manag. 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International Journal of Organizational Leadership 2017;6;4-16, SSRN: https://ssrn.com/abstract=3333054. \\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"leadership paradigms, leadership profiles, sustainable organization, performance\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6290182/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6290182/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground\\u003c/p\\u003e\\n\\u003cp\\u003eLeadership is a crucial factor for success and achieving goals in organizations and companies. The oscillation between established ways and active leadership, which is focused on people, the environment, and sustainable economy, needs to be overcome with a view to improving lives and the future of nursing and patient care.\\u003c/p\\u003e\\n\\u003cp\\u003eMethods\\u003c/p\\u003e\\n\\u003cp\\u003eIn December 2022, non-experimental research was conducted using a structured questionnaire (SLQ) sent online to examine sustainable leadership practices in a selected hospital environment in Slovenia. The present case study, which included a convenience sample of 102 individuals employed at various management levels in nursing and patient care, was conducted to illustrate the use of sustainable leadership approaches in the organization.\\u003c/p\\u003e\\n\\u003cp\\u003eResults\\u003c/p\\u003e\\n\\u003cp\\u003eThe research findings confirmed that leadership practices in the researched environment tend to align with the \\\"Honeybee\\\" leadership model (4-5), but more than half of the approaches fall in the neutral zone (3). These approaches need to be shifted towards the sustainable zones through the implementation of sustainable leadership practices. It should be emphasized that no approach or practice falls into the \\\"unsustainable\\\" zone. It has been demonstrated that the organization's performance is reflected in patient satisfaction, the organization's reputation, and long-term value for stakeholders. This can be achieved by focus on employee engagement, knowledge retention and sharing, team orientation, ethical behaviour of employees, shared goals and vision, staff recruiting and retention.\\u003c/p\\u003e\\n\\u003cp\\u003eConclusion\\u003c/p\\u003e\\n\\u003cp\\u003eThe research findings show that an understanding of the \\\"Honeybee\\\" leadership principles is present in the selected clinical environment. Gaps in the implementation of sustainable leadership approaches are highlighted, especially in the areas of leadership culture, environmental responsibility, established trust, self-management, innovation, and financial performance of the organization. These results can serve as a basis for further research into leadership in nursing and patient care in different hospital environments with the aim of measuring organization performance in a national and global context.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Sustainable Approaches to Leadership in Nursing and Patient Care in a Selected Hospital in Slovenia: A Case Study \",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-02 13:06:30\",\"doi\":\"10.21203/rs.3.rs-6290182/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"7865c454-1ec6-42d4-a186-c2a8051fa218\",\"owner\":[],\"postedDate\":\"June 2nd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-26T11:55:46+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-06-02 13:06:30\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6290182\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6290182\",\"identity\":\"rs-6290182\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}