The impact of digital transformational leadership on digital intensity among primary healthcare entities: a moderated mediation model

Abstract

Background

Uncertain times require healthcare entities to demonstrate strong leadership, develop digitalisation, and respond to change in a creative and flexible manner. Based on emerging new institutional theory, we developed and tested a model of how digital transformational leadership (DTL) affects digital intensity (DI) among healthcare entities through the mediating role of organisational agility (OA). In this article, we also examine the moderating role of the country in the studied relationship.

Methods

The study population consisted of 400 managers of primary healthcare entities from Poland and the Netherlands. Data was collected using a questionnaire method with a seven-point Likert scale. The gathered data was analysed using descriptive statistics and structural equation modelling (SEM). The analysis was performed using the statistical package SPSS with Andrew F. Hayes PROCESS macro and AMOS v. 29 (Predictive Solution, Poland).

Results

The results of structural equation modelling (SEM) revealed that DTL directly and indirectly affects DI, and OA mediates this relationship. Moreover, this indirect effect is moderated by a country.

Conclusion

This study contributes to the development of DI and offers practical insights for managers of primary healthcare entities navigating the uncertainty and volatility of the post-pandemic market. Ultimately, this work provides important insights into the leadership style and agility of healthcare organizations in relation to digital transformation, considering the healthcare system's role.

Background

In uncertain times, primary healthcare entities highlight the need for new global tools to break the cycle of "fear and neglect" by increasing the level of leadership attention devoted to preparedness and response to uncertainty. Digital technology offers such tools. The use of digital technologies in primary healthcare entities during uncertain times has grown exponentially, enabling organizations to coordinate internal resources, such as labor, information, and knowledge, more easily and flexibly to manage keystone vulnerabilities and continue operations against uncertainty [1]. Implementing digital technologies is the initial step in an organization's digital transformation, which involves changing traditional processes, structures, and management practices toward more agile processes and management practices [2]. Digital transformation represents a significant type of organizational change that requires deep and multidimensional reorganization of the organization. Digital intensity (DI) is an important aspect of digital transformation, which refers to the number of areas managed using digital solutions, transformation techniques, or strategies. Research suggests that effective transformational leadership is the foundation of digital transformation in organizations. Transformational leaders are proactive, drive change, enhance shared benefits, and support employees in achieving their unique goals [3, 4]. Transformational leaders possess the capacity to enhance organizational agility by fostering suitable connections with subordinates and motivating them to consider broader interests beyond their personal requirements. These leaders are adept at equipping themselves and their team members to take necessary action in response to challenges and potential opportunities [3, 4]. Transformational leaders are a crucial component of organizations because they must respond to diverse stakeholders' changing demands and uphold diverse values. Leaders with a digital transformation mindset build trust, encourage others to develop their leadership skills, demonstrate generosity, and act as ethical agents to focus on themselves and their followers on objectives beyond immediate workgroup needs [5]. Digital transformational leadership (DTL) emerges as a combination of transformational leadership styles and digital technology [6]. Existing research posits that DTL enhances an organization's innovation potential, which serves as the foundation for digital transformation [2, 7, 8]. Many health organizations struggle with digital transformation efforts because they merely implement technology rather than embrace a broader and more profound transformation that involves revamped services, re-engineered processes, an upskilled workforce, cultural shifts, and a heightened ability to adapt to change [9].

This study uses the new institutional theory (NIT) to examine digital transformation as a complex, radical, forced organisational change, emphasizing leadership and organizational agility. NIT is used to understand organizational change regarding the adoption of advanced digital technology by examining external pressures/factors on organizational practices and cultures [10, 11]. Despite growing interest in DTL, limited research has examined the impact of such leadership on DI in the service sector [2, 12–14], especially among healthcare providers [15].

Previous conceptual analyses have examined healthcare leadership in terms of implementation leadership [16] and succession planning [17]. However, research on transformational leadership has been limited, while the development of transformational leadership is currently particularly relevant due to the rapid digital innovation in healthcare [18]. Understanding the role of transformational leadership in the context of digital health services would be important because it can facilitate leaders in acquiring the required competencies and behaviours related to acquiring and using information and communication technologies (ICT) [19].

This study fills a theoretical and practical research gap based on the above. Considering that most of the studies on the impact of DTL on DI are mainly focused on the manufacturing sector, limited research is conducted in the service sector, especially in the healthcare field [15, 20, 21]. In addition, this study fills a gap in the literature by integrating OA into its model. The mediating role of OA in the effect of DTL on DI has not yet been well described in empirical studies. This study is the first to investigate such relationships in the healthcare sector. This study uses for the first time, data from two healthcare systems, Poland and the Netherlands, for analysis. These countries are at different levels of digital excellence in healthcare and at different stages of using digital technology to improve access and reduce costs for healthcare providers and patients. In the literature, research on the impact of the country where primary healthcare entities operate on DTL, OA, and DI is inconclusive[6, 22–24]. Therefore, this study is the first to investigate whether the healthcare system (state) moderates the effect of DTL on DI.

In view of the above gaps, this study aimed to contribute to the literature by examining the role of DTL in increasing DI among primary healthcare providers. Although these relationships have been identified in other sectors, more research is needed to shed light on the mediating mechanisms through which DTL influences DI in the healthcare sector [25]. Our second objective was to examine the mediating role of organizational agility (OA) in the relationship between DTL and DI. Furthermore, we investigated whether the country these entities operate in influences the relationship between these factors.

Building on previous research in the area of NIT, we propose a number of empirical hypotheses and test them using data from a survey of managers of primary healthcare entities in Poland and the Netherlands, which we analyze using structural equation modelling (SEM). This study contributes to understanding DTL's impact on DI in the healthcare sector.

DTL and DI

The attention given to DTL in relation to DI is particularly important in the face of the drastic changes in the functioning of the primary healthcare system initiated during the COVID-19 pandemic [26, 27]. The COVID-19 pandemic has accelerated the adoption of digital solutions in healthcare organizations, with many rapidly adopting advanced technology tools to ensure continuity of care and improve access to services [28]. The integration of digital technologies has revolutionized healthcare management [29]. This digital transformation is essential to provide high-quality healthcare services, improve patient outcomes, and solve existing challenges [30–32].

Digital transformation represents a significant organisational change requiring deep and multidimensional reorganization. An important aspect of digital transformation is DI, which refers to the number of areas that are managed using digital solutions, transformation techniques, or strategies. By prioritizing digital transformation and leveraging emerging technologies, primary healthcare entities can increase their DI and ultimately improve patient care and health outcomes. DI in primary healthcare entities refers to the level of integration and use of digital technologies and tools within an organization to improve patient care health outcomes and streamline healthcare processes. This concept encompasses the use of digital solutions, such as electronic health records, telemedicine, and other digital healthcare technologies to provide efficient and effective care [33]. Improving DI is essential for primary healthcare entities to improve service delivery and patient outcomes and remain relevant in an increasingly digital world.

Digital transformation literature has played a special role in studying transformational leadership in digital environments. NIT defines leadership capabilities as key activities in managing institutional transformations, including digital transformation [34]. From an NIT perspective, leadership is considered a fundamental element of organizational values and belief systems; as organizations change over time, leadership must also change and adapt [35]. DTL combines transformational leadership styles with digital technology [2]. The shift toward improved DI occurs when leaders adapt their actions to support a digital culture [36]. Organizations are transforming digitally, changing how they operate and deliver their services thanks to their leaders who promote digital culture and motivate employees to act using digital technologies [36–38]. Leaders can help organizations succeed in the digital era in three ways: (1) following emerging technology trends, (2) setting the direction of digital change, and (3) leading the team to rapid and precise changes [2].

The current literature indicates that DTL facilitates organizations' ability to innovate and improve performance, and this is the basis for digital transformation to increase DI [39–42]. Improving DI entails the responsibility of leaders to make decisions about implementing digital technologies and their efforts to acquire significant human and financial resources [43]. To improve DI, transformational leaders can provide intellectual stimulation that enables followers to take on new tasks, think critically, and implement new ideas to proactively solve problems [44]. Therefore, after reviewing the literature on leadership and digital transformation, we propose the following hypotheses:

H1: Digital transformational leadership (DTL) positively influences digital intensity (DI)

The role of OA in the relationship between DTL and DI

Previous studies suggest that NIT can be used to better understand the impact of OA on digital transformation [45]. This theory tried to explain the impact of change on DT by focusing on the socio-cultural aspects of the organization [46]. NIT has been used to study these aspects to understand the organizational changes associated with the implementation of advanced technology [10, 11]. The literature emphasizes that organizational change is a prerequisite for digital transformation [47]. To successfully implement digital transformation, organizations must change their traditional processes and structures towards more agile processes and management practices.

Agility refers to an organization's ability to develop and exploit its capabilities in a constantly changing and unpredictable environment [48, 49]. It enables organizations to replace existing processes by reconfiguring their resources, processes, and strategies [50] and fundamentally redesign organizational structures based on new conditions [51–53]. This enables primary healthcare entities to adapt to changing patient needs [54] and improve service delivery based on personalized needs [55].

One of the greatest challenges primary healthcare entities have to overcome in the context of digital transformation is the need to adapt to economic, social, and medical changes while ensuring that the structure, facilities, and assets respond appropriately to the situation in the long term [56]. Essential in this process is OA, defined as the ability of an organization to quickly adapt and respond to changes in the environment [57, 58] by using and reconfiguring internal resources [59]. Moreover, studies have shown that OA promotes elements such as a culture of agility, collaboration, experimentation, continuous improvement, and organizational learning [60, 61], which facilitate digital transformation. According to the NIT approach, in order for an organization to move towards an institutionally new transformation and thus improve the level of digital intensity, it must have a high level of organizational agility, which requires the mobilization of appropriate competencies and resources in the organization [46]. An agile culture in healthcare organizations enables innovation and adaptation to digital change. Thus, OA is closely related to increasing digital innovation capabilities in primary healthcare entities, which can drive digital transformation initiatives and lead to increasing DI [62, 63]. Therefore, we propose the following research hypothesis:

H2: Organisational agility (OA) positively influences digital intensity (DI)

According to NIT, organizations can become agile and respond quickly to changes through appropriate leadership and human characteristics, introducing necessary changes in the organizational structure [46]. Therefore, an organization's agility can be conditioned by its leadership style. OA can be improved by the ability of leaders to adapt to changing organizational conditions [64]. An agile organization is represented by teams working together, motivated, talented, disciplined, and organized [65]. Motivating physicians and stakeholders in the process of organizational change depends on leaders who share power, responsibility, and decision-making with their subordinates to ensure the trust and motivation of the team [66]. Leaders must be able to understand their environment to engage staff in designing, redesigning, and implementing organizational changes [67]. A good leader should provide an appropriate model of activities and training for employees and expect high performance [68, 69]. However, the existing literature does not clearly establish whether the leadership style used in an organization can affect OA or the level of interdependence between these variables [2].

In this study, OA was viewed as a manifestation of continuous improvement, continuous execution, proper communication, and flexibility and maturity of a team of people characterized by self-awareness, enthusiasm, and self-discipline [70]. Support from top management is needed to implement changes and new processes in an organization [71]. Effective DTL is also required to lead and drive changes at all healthcare system levels [72].

DTL is the ability to manage and implement changes quickly and decisively, which is key to maintaining business continuity in today's extremely difficult times, such as the post-pandemic period, when trust and motivation of the team are essential for the continuity of the organization's operations [69]. It helps organizations develop organizational vision, strategic goals, and resource utilization based on changing needs. Healthcare entities with the right DTL often push the boundaries of what is possible and generate lasting organizational changes. Such organizations can become flexible and quickly adapt to changes, making necessary changes to the organizational structure [64]. Therefore, we propose the following hypothesis:

H3a. Digital transformational leadership (DTL) positively influences organisational agility (OA)

From the NIT perspective, organizational decisions are not entirely driven by rational performance goals but also by systemic factors, including social, cultural, and legal environments. Therefore, digital transformation (DT) should also be viewed through the prism of systemic pressures. Some pressures, including normative ones, can influence an organization to adopt DT [73]. An organization is more likely to implement DT due to external forces, such as competitors, customers, governments, government-backed agencies, resource-control institutions, and the promotion of specific environmental practices [38]. According to NIT, to strengthen and legitimize the implementation of organizational change, entities should adopt organizational practices and seek leaders with "desirable" characteristics and behaviors [74].

Organizational leaders can, therefore, be seen as agents of organizational change who, by helping employees integrate their knowledge, support the implementation of innovations and technologies [72]. Empirical cases of digital transformation have shown that entities creating digital ecosystems rely on strong digital, transformational leadership to change their operations and invest in technology-based initiatives [75, 76]. This leadership style, which is considered transformational, encourages innovation and creativity and motivates employees to contribute innovative ideas to achieve organizational goals [77]. Thus, DTL motivates the implementation of technology-based changes that can improve digital intensity [50]. DTL creates a cultural context for mission accomplishment and guides employee behavior to achieve the necessary skills to implement changes leading to digital transformation [78]. To support team creativity, leaders must create enabling conditions that inspire team members to question the status quo in a positive light of the change vision and be open to collective interaction to develop new ideas that improve DI [79]. An agile organization relies on four core employee skills: responsiveness, flexibility, speed, and competence [80]. To improve DI, all employees need to change their actions by implementing appropriate information systems precise and fast instructions with the support of top management [2]. Therefore, we propose that OA can mediate the relationship between DTL and DI:

H3b. Organisational agility (OA) mediates the relationship between digital transformational leadership (DTL) and digital intensity (DI)

The moderating role of the healthcare system

The healthcare system is a key element of the functioning of every country. However, depending on the level of financing, the number of medical personnel and their availability, there are significant differences in the healthcare systems of different countries, including in the area of ​​digital transformation, quality, accessibility, cost efficiency, health outcomes, and infrastructure [81]. In the healthcare systems ranking, which took into account 24 variables, including economic (including the number of nurses and doctors and healthcare expenditure as a percentage of GDP) and health (morbidity, life expectancy, lifestyle and mortality), the Netherlands was among the countries with the best healthcare systems, and Poland was ranked 22nd out of 28 countries [82]. These countries also differ in terms of the level of innovation. In the latest edition of the Global Innovation Index (GI), Poland was ranked 40th out of 133. In turn, the Netherlands was ranked 8th among the world's best innovators and maintained its position in the top ten in the world [83]. The cited studies indicate that the healthcare system in Poland significantly differs from the healthcare systems in the Netherlands, which may impact the analysis results. The Dutch healthcare system strongly focuses on implementing digital healthcare to effectively address healthcare challenges, such as improving the quality of care, logistics, training, communication, community engagement, and decision-making processes [84]. On the other hand, in the Polish healthcare system, there is a lack of support from policymakers and challenges in adapting the system to the recommendations of the European Union [85]. In summary, the Dutch healthcare system appears to have a higher level of digital maturity than the Polish healthcare system.

NIT provides a framework for understanding how DTL influences DI and explains how organizations cope with their environment to survive and thrive amidst external changes [86]. According to this theory, three pillars shape organizations and their collective practices in response to environmental changes. The first is the coercive pillar, mainly from the government and legal regulations. The second is the cognitive or imitative pillar, which mainly results from the decision-maker's dependence on the behaviors of other organizations. The third is the normative pillar, which depends on societal expectations generated by professionals. These pillars depend on each country's healthcare system and can be used to understand the role of leadership in promoting and implementing digital technologies in primary healthcare entities [87]. Primary healthcare managers may respond to change by adopting digitalization in response to government regulations, such as during the COVID-19 pandemic when social distancing was a legal requirement (coercive), by imitating other organizations that have proven to be successful in implementing digital technologies in healthcare (imitative), or by meeting the needs and preferences of patients, employees, and other stakeholders (normative). Accordingly, regardless of how skilled leaders cope with change and uncertainty, digital transformation will not be effective if their actions and decisions are not aligned with the healthcare system in place in a given country [88]. Therefore, we propose the following hypothesis:

H4. Healthcare system (Country) moderates the indirect effect of digital transformation leadership (DTL) on digital intensity (DI) through organisational agility (OA)

Figure 1 shows the analytical framework representing the sum of the hypotheses proposed in this study.

Fig. 1.

Hypotheses overview

Methods

This study used a quantitative approach to investigate the relationship between DTL, OA, and DI in primary healthcare entities. The study also includes an understanding of the mediating role of the healthcare system in this relationship by collecting data using a structured questionnaire.

Survey participants

The study was conducted in primary healthcare entities because these entities are the backbone of any healthcare system and have faced extreme difficulties in coping with technology-related challenges resulting from uncertain times. As the study hypotheses concern frontline workers, observations from this group were used in the study. Therefore, our study included managers of primary healthcare entities. They were selected for this study because they are directly responsible for their organization's digital transformation. Still, they must also develop leadership skills and use OA to properly manage digital transformation in the face of extreme difficulties resulting from uncertain times.

The survey was conducted in the first half of 2024 with 400 managers of primary healthcare entities operating in Poland (200 respondents) and the Netherlands (200 respondents). This means that for each primary healthcare entity, one manager was interviewed. Conducting studies in both countries can be justified by the observed differences in the digital transformation approach, which has become increasingly important in uncertain times.

We surveyed in Poland by integrating computer-assisted Internet interviewing (CAWI) and computer-assisted telephone interviewing (CATI). The survey sample was randomly selected from the BISNODE database, which contains comprehensive information on all Polish primary healthcare entities. The survey in the Netherlands was conducted using CAWI method based on a purchased panel of respondents.

The survey implementation was supervised by certified survey companies in the surveyed countries, and quality control measures were rigorously observed. In the first stage, a survey was conducted among managers of 200 randomly selected entities in each country. In the next stage, the survey process included replacing entities that refused to participate with other randomly selected entities to ensure the integrity and representativeness of the sample. The procedure aimed to obtain data with full responses from 200 respondents in each country. This sample size is sufficient for structural equation modelling (SEM) according to the principles of (a) a minimum sample size of 100 or 200, (b) five or ten observations for each estimated parameter, and (c) ten cases per variable [89]. In general, sample sizes of 200 tend to meet the accepted structural equation modelling threshold [90].

We guaranteed respondents' anonymity and aggregated data to ensure compliance with privacy principles. Respondents took approximately 20 minutes to complete the questionnaire. The questionnaire and procedure for conducting the research were assessed from an ethical perspective by the Committee for Scientific Research Ethics at Warsaw University of Technology, which issued a Certificate of Ethical Assessment of Scientific Research (certificate no. 9/2024).

The sociodemographic characteristics of the participants are shown in Table 1. As can be seen, not all respondents provided information on the indicated characteristics, but this did not negatively affect the research results due to the lack of inclusion of the division into individual criteria.

Table 1.

The sociodemographic characteristics of respondents

Characteristics	Classification	n	%
Gender	Female	270	67.50
	Male	129	32.25
	Other	1	0.25
Age	< 25	10	2.50
	25–35	101	25.25
	36–45	122	30.50
	46–55	97	24.25
	56–65	54	13.50
	> 65	16	4.00
Educational background	Medical background (e.g. doctors, nurses, midwives)	256	64.00
	Business, management & administrative background	116	29.00
	Other	28	7.00
Experience in a managerial position	1–5	141	35.25
	6–10	97	24.25
	11–20	98	24.50
	21 years or more	59	14.75
	No answer	5	1.25
Country	Poland	200	50.00
	The Netherlands	200	50.00

Source: Own elaboration

The sample was predominantly women (67.5%). Young managers aged 25–35 constituted ca. a quarter of the sample, slightly more than managers aged between 46 and 55 (24.25%). The most significant age group was between 36 and 45 (approximately 30%). Regarding the educational background, medical education managers dominated the sample (64%). Almost one-third of the respondents had business, management, or administrative backgrounds. Most respondents (35.25%) had little experience in a management position of up to five years. Their average managerial experience was approximately 11 years.

Measures

The questionnaire used in this study was divided into two parts. Part I consisted of questions to obtain information about the characteristics of managers of primary healthcare entities, including sociodemographic data (age, gender, education, years of experience in a managerial position) and data about the unit (number of employed GPs, form of ownership, country). Part II contained questions to obtain detailed information about the studied constructs, such as DTL, OA, and DI. The questionnaire items used in this study were derived from established research and validated scales. DTL was measured using the 6-item scale by AlNuaimi et al. [2], which was developed based on modifications of previous transformational leadership scales [91, 92]. For the OA, six items were selected from a study conducted by Cegarra-Navarro et al. [93]. DI was measured using six items based on the scale by Westerman et al. [76], which has also been validated in previous studies [1, 50, 94, 95]. DI refers to engaging in technology-based initiatives to change how an organization serves its internal operations and customers. Thus, increasing DI motivates primary healthcare entities to explore digital opportunities, engage patients, and conduct healthcare activities using digital technologies. All variables were measured on a seven-point Likert scale with values ranging from 1 – "Strongly disagree" to 7 – "Strongly agree" with a neutral midpoint 4 – "Neither agree nor disagree". A summary of the items and their corresponding constructs is presented in Table 2.

Table 2.

Summary of the items and the corresponding constructs

Construct	Source	Items
Digital transformational leadership (DTL)	[2]	DTL1: Our leaders inspire all members with the digital transformation plans for our organisation.
		DTL2: Our leaders provide a clear digital transformation vision for the organisation's members to follow.
		DTL3: Our leaders motivate team members to work together for the same digital transformation goals.
		DTL4: Our leaders encourage all members to achieve digital transformation goals for our organisation.
		DTL5: Leaders in my organisation act by considering the digital transformation beliefs of all members.
		DTL6: Our leaders stimulate all members to think about digital transformation ideas.
Organisational agility (OA)	[93]	OA1: We can rapidly respond to patients' and government's needs
		OA2: We can rapidly adapt services, processes, and activities to meet demand fluctuations.
		OA3: We can cope with problems from partners rapidly.
		OA4: We rapidly implement decisions to face external and government changes.
		OA5: We continuously search for forms to redesign our organisation.
		OA6: We see the external and government changes as opportunities for rapid development.
Digital intensity (DI)	[76]	DI1: We are using digital technologies to understand our patients better
		DI2: We use digital channels to provide patient service.
		DI3: Technology allows us to support patients and improve medical processes in new ways.
		DI4: Our core processes are automated.
		DI5: We have an integrated system to support key information for patients.
		DI6: We use digital technologies to increase the efficiency of our services.

Source: own elaboration

Data were analyzed using descriptive statistics and structural equation modelling (SEM). In all tests, p-values less than 0.05 were interpreted as statistically significant. The analysis was performed using the statistical package SPSS with the Andrew F. Hayes PROCESS macro and AMOS v. 29 (Predictive Solution, Poland).

Results

Scale reliability

Since the items of the measurement scales were slightly modified to adapt them to the primary healthcare entities' activities, Cronbach's alpha and factor analysis calculations were performed to establish the instrument's reliability in measuring the studied constructs. This methodological choice is based on an objective assessment of the robustness of the correlations between latent constructs and their respective observed variables as opposed to the interrelationships between the observed variables themselves [96]. This approach is a testament to the care and academic rigor required to ensure the reliability of the selected scales as tools for measuring the intended constructs in the research framework. This seems to be sufficient because the scales have been previously validated in the literature.

To ensure that it was possible to use the above-described constructs to build the model, an analysis of the reliability of the scales was carried out using IBM SPSS Statistics, ver. 29.0.0.0 (Table 3). The obtained results suggest that the scales are properly selected and well-fitted, indicating very good reliability, with a Cronbach's alpha above 0,8.

Table 3.

Scale reliability results

Construct	Items	Alpha-Cronbach	KMO (sig. <.001)	Factor Analysis
DTL	6	0.938	0.899	76.354
OA	6	0.851	0.862	58.050
DI	6	0.891	0.890	65.074

Source: own elaboration

Hypothesis testing – mediation

In the next analysis stage, the research hypotheses (H1 to H3) were tested using structural equation modelling (SEM) in AMOS v.29.0.0. The model was constructed using DTL as the independent variable, OA as the intermediate variable, and DI as the dependent variable. The model was used to test the reliability and validity of the relationship between the variables through a confirmatory analysis.

The final model contained 18 items with three hidden variables. This model met the criteria for reliability, validity, and goodness of fit. The model fit statistics were Cmin/df = 2.029, GFI = 0.936, AGFI = 0.911, CFI = 0.973, RMSEA = 0.051, and NFI = 0.948 (Table 4).

Table 4.

Summary of Model-fit indices for Structural model

Model-fit indexa	χ2/df	GFI	AGFI	RMSEA	CFI	NFI
Results	2.029	0.936	0.911	0.051	0.973	0.948
Recommended value	<5	>0.9	>0.9	<0.08	>0.9	>0.9

Source: own elaboration

^aGFI Goodness-of-Fit Index, AGFI adjusted GFI, RMSEA root-mean-square error of approximation, CFI Comparative Fit Index, NFI Normed Fit Index

The model was found to have a very good fit, and all values were within the acceptable range. Table 5 and Fig. 2 present the results of the hypothesis tests using SEM. The results indicated that the path coefficients were statistically significant.

Table 5.

Pathway coefficients of structural equation model (n=400)

Hypothesis	Path	Standardised estimate	S.E.	C.R.	P-value	Hypothesis acceptance
H1	DTL to DI	0.383	0.075	5.732	<0.001	Accepted
H2	OA to DI	0.334	0.117	4.600	<0.001	Accepted
H3a	DTL to OA	0.658	0.055	8.238	<0.001	Accepted
H3b	DTL to DI through OA	0.220	LB 0.111	UB 0.392	0.004	Accepted

S.E. Standard Error, C.R. Critical Ratio, P p-value

Fig. 2.

SEM results. Source: own elaboration

The results of the hypothesis testing revealed a significant direct effect of DTL on DI (b=0.383, p<0.001), supporting H1. H2 and H3a were also confirmed, as the results showed a positive and significant direct effect of OA on DI (b=0.334, p<0.001) and a positive and significant direct effect of DTL on OA (b=0.658, p<0.001). Moreover, an indirect effect of DTL on DI was found (b=0.22, p=0.004), thus supporting H3b. Hence, OA partially mediates the relationship between DTL and DI.

Hypothesis testing – moderation

In the last stage of the analysis, H4 hypothesis testing was conducted using SPSS version 29.0.0.0 with the Andrew Hayes PROCESS macro (version 4.2 beta). The model was constructed with DTL as the independent variable, OA as the intermediate variable, DI as the dependent variable, and country as a variable moderating the relationship between DTA and DI through OA. The calculations were based on Model 7, enabling testing of moderated mediation.

Hypothesis H4 suggests that the indirect effect of DTL on DI through OA is moderated by the country. This hypothesis was supported, as the index of moderated mediation was proven to be statistically significant since the 95% CI did not include zero (index=0.069, BootLLCI=0.010, BootULCI=0.139). The mediator effect of countries is presented in Fig. 3.

Fig. 3.

Mediator effect of countries

Discussion

These results are consistent with NIT analysis, indicating that DTL is better prepared to manage organizational change to improve digital intensity [46]. The results show that digital transformational leadership positively influences digital intensity, thus supporting H1. This finding is consistent with previous studies conducted in the enterprise sector, suggesting that transformational leaders are better equipped to promote digital values and implement organisational changes to strengthen digital intensity [37, 97–99]. The confirmation of this relationship in the healthcare sector suggests that the primary healthcare entities also need to seek leaders with transformational leadership skills to digitally transform their operations to improve service delivery and patient outcomes and remain relevant in an increasingly digital world [33].

Similarly, H2, which proposed that organizational agility positively influences digital intensity, was also supported. This means that organizational agility facilitates and accelerates the transition to digitalization, as previously demonstrated in the SME sector [51, 100]. Organizational agility helps these entities achieve a greater alignment between data, employee utilization, business operations, and customer requirements. Akenroye and Kuenne [101] used agility as one of the five competencies required to promote service innovation in primary healthcare. Improving digital intensity and achieving digital transformation requires an agile structure as well as a digital culture that strengthens risk-taking, agility, and collaboration. Aligning information technology management with the organizational structure is a major contemporary challenge for organizations in general and the healthcare industry in particular [102]. Primary healthcare entities operate in a dynamic environment, need to be agile and flexible and coordinate their actions to meet the demand for new digital technologies [72] to ensure the continuity of healthcare service delivery [103]. Thus, organizational change is a fundamental factor of digital transformation and can be a barrier to digitalization if not properly addressed [104]. For this reason, primary healthcare entities need to modernize their structure, traditional methods, and strategic tactics to become more agile and responsive [105].

The results of the data analysis confirmed a positive relationship between digital transformational leadership and organizational agility (H3a). This is in line with the New Institutional Theory, which assumes that leaders' skills are the basis for implementing changes at the institutional level because organizations need transformational leaders who promote change and ensure that their subordinates are well prepared to take the necessary actions in response to challenges in an unstable work environment [87, 106]. According to previous studies, transformational leaders can promote organisational agility by building relationships with subordinates and encouraging employees to think beyond their personal needs, act effectively in complex and risky situations, be creative and innovative in the face of challenges and potential opportunities [2, 80, 106–108]. Hypothesis H3b was also empirically supported. This confirms the research conducted in other organizations, which established that digital transformational leadership positively affects digital transformation through organizational agility [2]. Managers and leaders are responsible for making better decisions for the organization, which means the ability to implement changes to achieve the best results in digital technology implementation [75]. Transformational leaders can influence organizational agility and digital transformation in many ways, such as teaching and inspiring subordinates to be creative promoting digital innovation, collaboration, and a culture of continuous improvement [109]. Previous studies have shown that by fostering a culture of agility and innovation, digital leaders can drive digital transformation initiatives in primary healthcare entities, thereby improving organizational performance and sustainability. Organizational agility shaped by leadership is particularly important for the successful implementation of digital transformation as it influences the functionality and structure of the organization [110]. In the context of healthcare, adopting digital transformation leadership can enable teams to explore value-creating ideas, establish agile systems, support organizational capacity building, and drive innovation and digital transformation[111]. By leveraging digital leadership, primary healthcare entities can increase their agility, adaptability, and responsiveness to digital changes, ultimately improving their digital intensity [15].

Finally, the last hypothesis examines the moderating effect of the healthcare system on the relationship between digital transformation leadership and digital intensity (H4). This hypothesis is supported. The moderating effect of the healthcare system on the relationship between digital transformation leadership and digital transformation has not yet been studied. With its unique regulatory requirements, patient-centricity, and complex operational structures, the healthcare system may act as a moderating factor in the relationship between digital transformation leadership and the actual implementation of digital initiatives in primary healthcare entities. The system's intricacies may affect the formulation, implementation, and integration of digital transformation strategies into existing healthcare practices [111]. The impact of digital transformation leadership on digital intensity may differ significantly between Poland and the Netherlands, mainly because of different technological and infrastructural development levels and approaches to implementing modern technologies in healthcare systems. Poland is in a phase of intensive modernization of its primary healthcare. Various initiatives are being introduced to increase digitalization and to introduce Poland to the technologically advanced future of healthcare. This suggests that Poland is actively working on digital health strategies and initiatives to develop its healthcare system through digital transformation [112]. Despite the ongoing digitalization, many primary healthcare entities still struggle with infrastructure limitations and the lack of a unified information technology system, affecting these organizations' digital intensity [113]. Health policy emphasizes the development of e-health; however, the legislative process can be lengthy and does not always keep up with rapid technological progress. In turn, the Netherlands is one of the leaders in healthcare digitalization.

Health systems are well-integrated, and patients can easily access their medical data online. Telemedicine, remote consultations, and digital diagnostic tools are widely used [114]. The Netherlands has invested significantly in developing information technology infrastructure and staff training. These systems are technologically advanced, and the integration of different health tools and platforms is smooth. It also has a well-developed legal and regulatory framework that supports the digitalization of healthcare [115, 116]. The differences in the approach to digital transformation in primary healthcare between Poland and the Netherlands are mainly due to the level of infrastructure development, government policy, and degree of integration of IT technologies. Poland is at a stage of dynamic development, while the Netherlands is already an advanced leader in the digitalization of healthcare.

Study limitation

Although this study had some encouraging results, it had some limitations that must be considered First, it was conducted on a sample of managers from primary healthcare entities. Therefore, the generalizability of these findings to all healthcare entities is limited. Moreover, asking hospital managers about the DTL scale may cause a risk of the Bayesian effect. Future studies could access a larger sample from other healthcare entities, such as hospitals and should be conducted among medical personnel. Asking subordinates about this scale could have provided data that better reflects health organizations.Second, it is worthwhile to investigate the mediating or moderating effects of other variables between digital leadership and digital intensity that were not included in this study, such as organizational culture, knowledge management, and innovation. Third, the data for this study were collected from only two countries. Future studies could extend this study by collecting data from countries with different levels of digital transformation implementation maturity and by considering other cultural factors. Fourth, this study used cross-sectional data, which does not allow us to draw causal conclusions from the findings. Furthermore, there may be a problem with reverse causality between the study variables. It would be useful to use case studies or qualitative research with interviews with managers in the future to gain insights into the management challenges that hinder the digital transformation process in the post-pandemic era.

Practical implication

The findings of this study have several practical implications for primary healthcare entities seeking to enhance their digital transformation. Leadership plays an important role as a catalyst for digital transformation. Primary healthcare entities should prioritize recruiting and developing leaders with transformational leadership skills. These leaders are instrumental in fostering digital innovation, promoting collaboration, and ensuring that the organization can adapt to the rapidly changing digital landscape. To support this, managers and leaders must be equipped with the necessary tools, knowledge, and authority to effectively initiate and manage digital transformation initiatives. This involves fostering creativity and innovation among the staff to address complex challenges and seize opportunities for improvement.

Organizational agility is another critical factor that drives digital transformation. Healthcare entities must focus on building agile organizational structures and fostering a culture that embraces change, risk-taking, and collaboration. This agility allows for a better alignment of data, processes, and employee capabilities to meet patient and operational needs. Training programs that enhance employee flexibility and responsiveness to digital changes are essential, as is the modernization of workflows and adoption of flexible IT systems to ensure that digital tools facilitate rather than hinder operations. Aligning IT management with organizational agility is key to achieving a successful digital transformation.

The findings also highlight the need to tailor digital transformation strategies to the healthcare system dynamics within which an organization operates. Different healthcare systems, such as those in Poland and the Netherlands, exhibit varying levels of digital maturity and infrastructure readiness. Strategies for digital transformation should account for these contextual differences. For countries like Poland, which is in the development phase, there is a need to invest in robust IT infrastructure, create supportive regulatory frameworks, and promote staff training to accelerate digital transformation. On the other hand, advanced systems, such as the Netherlands, can focus on optimizing existing digital tools and exploring innovations such as telemedicine and predictive analytics.

The findings also underscore the importance of expanding the research on digital transformation in healthcare. Future studies should include diverse healthcare entities such as hospitals and explore additional factors such as organizational culture, knowledge management, and innovation to better understand their roles in digital transformation. Cross-national collaboration can also provide valuable insights, as countries with varying levels of digital maturity can benefit from sharing the best practices and technologies. Research should also consider the cultural factors influencing digital transformation efforts in different contexts.

Conclusion

The use of digital technologies in primary care entities in uncertain times enables organizations to respond to change in an innovative and flexible manner. This study examined in detail how digital transformation leadership influences digital transformation through organizational agility in primary healthcare settings. The study results suggest that digital transformation leadership indeed has a positive impact on digital transformation through organizational agility, emphasizing the critical role of leadership in driving digital initiatives and supporting agility in organizations.

By promoting a culture of innovation, collaboration, and continuous improvement, digital leaders can enhance organizational agility, drive digital transformation initiatives, and position primary healthcare entities for success in the rapidly evolving digital landscape. Therefore, we emphasize the role of managers of primary healthcare entities and organizational systems in providing the necessary culture and work environment for the agility pillar, which, in turn, enables the adoption of digital change to better cope with external changes and uncertainties that have emerged as a result of the challenges posed by the post-pandemic era.

The effectiveness of digital leadership in driving digital transformation initiatives in primary healthcare entities may also be shaped by the characteristics and dynamics of a country's healthcare system. Understanding how the healthcare system influences digital leadership practices and digital transformation initiatives is important for the successful digitalization of primary healthcare entities. Further research is required in this area.

This study makes several important contributions to healthcare literature. First, it enriches the literature by examining the effectiveness of DTL on DI in relation to the primary care sector and highlighting the influence of OA and the healthcare system on this relationship.

Abbreviations

DTL

Digital transformational leadership

DI

Digital intensity

OA

Organisational agility

SEM

Structural equation modelling

NIT

New institutional theory

CAWI

Techniques of computer-assisted Internet interviewing

CATI

Computer-assisted telephone interviewing

Authors' contributions

Conceptualization and design:, M.K., and L.H.; Data curation: M.K; Methodology: M.K., L.H., and KZ, Software, K. Z.; Statistical analysis and visualisation: K. Z, interpretation of data: M.K., L.H., and WZ; Writing—original draft preparation, L.H., M.K., K.Z, and WZ.; Writing—review and editing, M.K., L.H., KZ; and WZ; Funding acquisition: MK and L.H. All authors have read and agreed to the published version of the manuscript.

Funding

The research was co-financed from the university’s own funds and from the budget of the city of Płock, in connection with the Competition of the Mayor of Płock for financing research grants implemented as part of the task "Cooperation with universities".

Data availability

All de-identified participant datasets will be available for research purposes to researchers affiliated with academic institutions and others upon reasonable request from the corresponding author immediately after the results are published

Declarations

Ethics approval and consent to participate

The research was conducted in accordance with the Code of Ethics for research workers of the Polish Academy of Sciences. The study was approved by the Committee for Scientific Research Ethics at the Warsaw University of Technology, which issued a Certificate of Ethical Assessment of Scientific Research (certificate no. 9/2024). During data collection, informed verbal consent was obtained from all respondents. All participants were informed that they had the right to withdraw from the study at any time. All responses and study sites were anonymized.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.