Perceptions of Sustainable Leadership in Australian Healthcare

Abstract

Purpose

Sustainable leadership is essential for addressing workforce shortages, technological advancements, and increasing regulatory demands in Australian healthcare. Many healthcare leaders assume their roles based on clinical expertise rather than formal leadership training, highlighting the need for structured support. This study explores sustainable leadership in Australian healthcare, identifying key challenges, support mechanisms, and strategies for improvement.

Methods

A cross-sectional survey was conducted among 276 managers, leaders, and supervisors working in Australian healthcare organisations. Participants were recruited through professional networks, social media, and direct invitations. The survey, administered via Qualtrics, examined leadership training, characteristics of sustainable leadership, challenges, and available support systems. Quantitative data were analysed using IBM SPSS Statistics, while qualitative responses underwent thematic analysis.

Results

Leadership training was primarily informal, with limited access to structured programs due to time and financial constraints. Sustainable leadership was defined as balancing operational demands with long-term planning, ethical decision-making, and fostering a resilient workplace culture. Key challenges included staff retention, change management, and hierarchical structures limiting innovation. Support for leaders was inconsistent, with male leaders reporting higher perceived support. Systemic barriers, such as outdated leadership models and a focus on financial performance over workplace culture, restricted sustainable leadership implementation.

Conclusion

To enhance sustainable leadership, organisations must prioritize structured training, mentorship, and inclusive leadership pathways. Addressing systemic barriers and redefining leadership success beyond financial metrics will strengthen leadership resilience, reduce burnout, and improve healthcare outcomes.

Video abstract

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Introduction

Healthcare systems worldwide face chronic systemic stressors that jeopardise the effective delivery of care.¹ In Australia, the issue of workforce shortages are further compounded by rapid technological advancements, which require substantial training and integration efforts, increasing time demands on workers and intensifying healthcare systems challenges.^2,3 These complexities, combined with evolving practice environments, have created an increasingly demanding workplace for healthcare professionals. Effective leadership has been identified as a key factor in providing organizational support, promoting well-being, and fostering positive workplace cultures that attract and retain a diverse, high-performing workforce.⁴ Despite its importance, leadership in healthcare is fraught with challenges. Leaders must navigate competing priorities, including regulatory compliance, resource allocation, and ethical dilemmas.^5,6 Healthcare leaders also face significant challenges relating to staff attrition and turnover, and staff burnout, all of which complicate effective time management.^7–9 Leadership roles are often assigned based on clinical expertise or seniority rather than formal leadership training, leaving many leaders unprepared for the complexities of their role.¹⁰

To address these challenges, leadership models have been adapted from organizational management theory. These include situational leadership, transformational leadership, ethical leadership, and responsible leadership.¹¹ While these models have been successful in certain contexts, many remain focused on internal organizational outcomes such as employee satisfaction, commitment, and task performance.^11,12 In contrast, recent perspectives on effective leadership emphasise an open system approach that recognises the broader societal impact of leadership within national and global settings.^13–15 Contemporary leadership is increasingly evaluated using the triple bottom line framework, integrating social, environmental, and financial metrics to assess performance.^12,16,17 In line with this evolving understanding, the United Nations’ 17 Sustainable Development Goals (SDGs), established in 2015, encourage organizations, and individuals to integrate sustainability into their leadership and operational strategies.¹⁸

Sustainable leadership, also known as Rhineland or honeybee leadership, emphasizes collaboration, long-term thinking, and the wellbeing of organizations and their stakeholders. Unlike traditional hierarchical, profit-driven models, it prioritizes ethical behavior, innovation, and balance between economic, social, and environmental responsibilities.¹⁹ Sustainable leadership has evolved from educational principles²⁰ to enterprise management²¹ and has since been consolidated into a framework consisting of six core elements, including long-term vision, ethical behavior, social responsibility, innovation, systemic change, and stakeholder engagement.^12,20,21 McCann and Holt²² further contribute to this discourse by highlighting the need for clear, inclusive definitions that guide organizations in aligning short-term performance with long-term sustainability goals.

Sustainable leadership therefore promotes success by balancing economic, social, and environmental goals, while driving innovation, adaptability, and stakeholder trust. It enhances employee wellbeing and strengthens organizational reputation through ethical behavior and social responsibility. However, it also presents challenges such as balancing sustainability and profitability, managing complex systems, addressing short-term stakeholder pressures and measuring long-term outcomes across multiple indicators. Despite these obstacles, many organizations have successfully implemented sustainable leadership. BMW, for example, applied sustainable leadership principles during the global financial crises, prioritizing collaboration and adaptability by reskilling rather than laying off employees. This, combined with investments in sustainable innovation, helped the company recover and thrive.¹⁹ Similarly, WL Gore & Associates uses a decentralized, collaborative leadership approach with a flat structure that empowers employees to innovate, while emphasizing environmental sustainability by reducing waste and producing durable, resource-efficient products.²³

These cases highlight the potential for sustainable leadership in healthcare. Some healthcare organizations, such as Mayo Clinic, demonstrate sustainable leadership by prioritizing research, education, interdisciplinary teamwork, and patient-centered care.^24,25 Rather than distributing profits to investors, Mayo Clinic reinvests its revenue into medical research, education, and patient care.²⁴ Similarly, Novo Nordisk applies sustainable leadership by expanding healthcare access for underserved populations while promoting innovation, responsible supply chain management, and workforce wellbeing.^26,27

Despite its growing recognition, the application of sustainable leadership in healthcare remains underexplored. Uncertainties remain around the specific characteristics and practices that define sustainable leadership within healthcare settings, as well as the most effective strategies for supporting leaders at individual, organizational, and systemic levels. Additionally, there is limited understanding of how these strategies address persistent and healthcare specific challenges such as burnout, workforce retention, and time management. This gap in empirical research highlights the need for a deeper examination of sustainable leadership and its potential to drive meaningful improvements in healthcare leadership and outcomes. This study aims to explore the current state of sustainable leadership in Australian healthcare, focusing on the challenges faced by leaders and the support systems available to them. By examining the barriers to and opportunities for effective leadership, this research seeks to provide evidence-based insights to inform the development of more resilient and sustainable leadership practices within the healthcare sector.

Materials and Methods

Design

This study utilised a cross-sectional quantitative online survey design, to ascertain perceptions of the sustainability of healthcare leadership within Australia. Ethical approval was received by the Bond University Human Research Ethics Committee (ref #CH00253).

Participants

Participants were eligible to participate in this study if they worked in a supervisory, management, or leadership role within an Australian healthcare organisation. Survey recruitment materials were posted online via social media (eg LinkedIn) and disseminated to relevant professional associations for email circulation. Individuals who met the eligibility criteria for participation and known to the research team were sent survey recruitment materials. Participants were encouraged to share the online survey to other eligible people to increase sample size. As an incentive for survey completion, participants had the option of entering into a prize draw to win one of five $200 gift cards.

Materials

The aim of the survey was to investigate the characteristics of sustainable leadership, its implications for healthcare outcomes, and potential solutions to promote sustainable management and leadership. The online survey, designed by the research team, primarily comprised of multiple choice, scaling, or Likert-type questions, with several open-ended questions to provide further clarification. The main survey consisted of seven sections: 1) demographics (11 questions); 2) training and experience in leadership (3 questions); 3) characteristics of sustainable leadership (4 questions); 4) support in leadership (4 questions); 5) challenges in leadership (4 questions); 6) support strategies in leadership (3 questions); and 7) barriers and opportunities in leadership (3 questions). A copy of the survey is provided in the Appendix.

Procedure

The survey ran from June 2024 to August 2024, and was hosted online via the Qualtrics platform. Participants were first presented with a participant information and consent form. Consent to participate was implied by proceeding with the survey. Each section of the main survey was presented sequentially. At the end of the survey, participants were redirected to a separate form where they had the option to provide their contact details to either receive study results or enter the prize draw.

Data Analysis

Quantitative survey data was analysed using IBM SPSS Statistics. Significantly incomplete responses (ie, where a participant had not responded beyond the demographics section) were excluded from the analysis. Frequency and descriptive statistics were computed for the main survey items. Inferential statistics (ie t-tests, one-way ANOVAs, and Pearson’s correlation coefficient) were used to examine relationships between variables. Responses to open-ended questions were summarised thematically to provide additional insights for each survey section. Three authors (CH, SG, RN) examined qualitative responses independently to identify key themes, which were discussed by the broader team before final analysis.

Results

Participant Demographics

A total of 473 survey responses were received. Responses which were not completed past participant demographics were removed from analysis. Therefore, 276 responses were included in the final analysis, comprising 192 (69.6%) females and 84 (30.4%) males, with an average age of 45.2 years (SD=12.4; Range: 19–77). The majority of participants were born in Australia or New Zealand (n=203, 73.4%), and worked primarily in Queensland (n=120, 43.5%) or New South Wales (n=61, 22.1%). Most participants worked in metropolitan areas (n=170, 61.6%), with a smaller proportion working in regional locations (n=82, 29.7%).

Diverse professional backgrounds were represented with the largest group being allied health (n=88, 31.9%), nursing (n=72, 26.1%), medical (n=58, 21.0%), and administrative/operational (n=50, 18.1%). Participants worked across a range of healthcare settings, including allied health (n=88, 31.9%), nursing (n=72, 26.1%), medical (n=58, 21.0%), administrative or operational (n=50, 18.1%), and technical (n=5, 1.8%), and held managerial, leadership, or supervisory positions. Reported working hours ranged from 4 to 84 hours per week (M=42.5, SD=26.0). A moderate, positive correlation was found between age and average hours worked per week, r=0.34 (p<0.005) indicating older participants tended to work longer hours. Full participant demographics are reported in Table 1. Most participants reported embarking on a career in healthcare leadership to improve the healthcare system or practice (n=169, 61.2%), to fulfill a personal career goal (n=103, 37.3%), or to help patients and staff through leadership (n=83, 30.1%) (Table 2).

Table 1.

Participant Demographics (n = 276)

Variable	N	%	M	SD
Age (years)^	250	90.6	45.2	12.4
Gender (male/female)	84/192	30.4/69.6
Region of birth
Australia/New Zealand	203	73.4
Europe	22	8.0
Asia	15	5.4%
Africa/Middle East	6	2.4
North/South America	5	1.8
Not reported	12	4.3
State of Current Workplace
Queensland	120	43.5
New South Wales	61	22.1
Victoria	37	13.4
South Australia	18	6.5
Australian Capital Territory	17	6.2
Western Australia	14	5.1
Tasmania	7	2.5
Northern Territory	2	0.7
Region of Current Workplace
Metropolitan	170	61.6
Regional	82	29.7
Rural/Remote	13	4.7
Not reported	1	0.4
Professional Stream/Background#
Allied Health	88	31.9
Nursing	72	26.1
Medical	58	21.0
Administrative/Operational	50	18.1
Technical	5	1.8
Other	31	11.2
Current Role in Workplace
Line Manager/Manager/Clinical Manager/Head of Department	44	15.9
Supervisor/Team Leader/Assistant Manager	42	15.2
Director/Senior Director	39	14.1
Executive Leader/C-Suite	31	11.2
Senior Manager	27	9.8
Educator/Trainer/Quality Assurance	21	7.6
Assistant/Associate Director	17	6.6
CEO	15	5.4
Business Owner	11	4.0
Board Member/Chair	4	1.4
Other	25	9.1
Area of Healthcare#
Hospital	134	48.6
Community Health Services	76	27.5
Education/Professional Development	36	13.0
Aged Care	31	11.2
Corporate Services	26	9.4
System Leadership	26	9.4
Home Care	25	9.1
NDIS	16	5.8
Policy/Advisory	16	5.8
Long-Term/Acute Care Services	15	5.4
Other	27	9.8
Not reported	1	0.4
Average hours worked per week^	265	96.0	42.5	26.0

Notes: ^N and SD relates to number of participants who reported this demographic. #Participants were able to select more than one option.

Table 2.

Participants’ Motivations for Embarking on a Career in Healthcare Leadership

Why Did You Embark on a Career in Leadership in Healthcare?	N	%
I wanted to improve the healthcare system or practice.	169	61.2%
It was a personal career goal.	103	37.3%
I wanted to help patients and staff through leadership.	83	30.1%
I was inspired by other leaders.	67	24.3%
I was asked to apply for or backfill a position.	59	21.4%
Other	19	6.9%
Not reported	2	0.7%

Note: Participants were able to select more than one option.

Training and Experience in Leadership

Participants reported having between 0 and 40 years of experience in supervision, leadership or management (M=14.7, SD=9.7). A strong positive correlation was found between age and years of experience, r=0.78 (p<0.005) indicating that older participants generally have significantly more years of experience. Additionally, a moderate positive correlation was found between years of experience and the average number of hours worked per week, r=0.32 (p<0.005) where participants with more years of experience tended to work longer hours on average. Table 3 presents the types of training received by participants and their perceived helpfulness of each training type. The most commonly reported type of training was on-the-job training provided by a peer or line manager (n=196, 71.0%), which the majority of participants found either somewhat (n=104, 53.1%) or extremely (n=53, 27.0%) helpful. Internal training provided by the organization was the second most frequently reported type (n=159, 57.6%), with 74.8% of participants rating it as at least somewhat helpful. Training provided internally with external consultants (54.2%, n=152) and mentoring or coaching (55.1%, n=148) were also widely accessed, with high levels of perceived helpfulness. For these training types, 86.9% and 89.2% of participants, respectively, rated them as at least somewhat helpful.

Table 3.

Training Types Received by Participants and Perceived Helpfulness

What Types of Training in Supervision, Management and Leadership Have You Received?			Please Rate How Helpful You Perceive the Training You Have Received to Be (n, %).
Training Type	N	%	Extremely Unhelpful (1)	Somewhat Unhelpful (2)	Neither Helpful nor Unhelpful (3)	Somewhat Helpful (4)	Extremely Helpful (5)
On the job training by a peer or line manager	196	71.0%	7 (3.6%)	11 (5.6%)	7 (3.6%)	104 (53.1%)	53 (27.0%)
Internal training provided by organization	159	57.6%	3 (1.9%)	12 (7.5%)	24 (15.1%)	90 (56.6%)	29 (18.2%)
Internal training with external consultant	152	54.2%	2 (1.3%)	7 (4.6%)	15 (9.9%)	77 (50.7%)	55 (36.2%)
Mentoring or coaching	148	55.1%	3 (2.0%)	4 (2.7%)	6 (4.1%)	78 (52.7%)	54 (36.5%)
External/professional coach or mentor	124	44.9%	1 (0.8%)	2 (1.6%)	5 (4.0%)	43 (34.7%)	67 (54.0%)
Postgraduate/Master’s degree	105	38.0%	5 (4.8%)	2 (1.9%)	7 (6.7%)	37 (35.2%)	53 (50.5%)
Certificate or diploma	64	23.2%	2 (3.1%)	5 (7.8%)	4 (6.3%)	35 (54.7%)	18 (28.1%)
Undergraduate degree	59	21.4%	2 (3.4%)	2 (3.4%)	8 (13.6%)	31 (52.5%)	14 (23.7%)
Postgraduate certificate or diploma	58	21.0%	3 (5.2%)	1 (1.7%)	3 (5.2%)	29 (50.0%)	22 (37.9%)
PhD	12	4.3%	0 (0.0%)	0 (0.0%)	1 (8.3%)	7 (58.3%)	5 (41.7%)
Other	21	7.6%	1 (4.8%)	1 (4.8%)	2 (9.5%)	3 (14.3%)	9 (42.9%)

Note: Participants were able to select more than one option.

Less commonly reported training types included certificates or diplomas (23.2%, n=64), undergraduate degrees (21.4%, n=59), and postgraduate certificates or diplomas (21.0%, n=58). Although less frequently accessed, these training types were positively perceived, with over 80% of participants across all categories finding them at least somewhat helpful.

Characteristics of Sustainable Leadership

On a scale of one to ten, participants respectively scored the support and sustainability of Australian healthcare leadership as an average of 5.5/10 (SD=1.9) and 5.0/10 (SD=2.0). A low negative correlation was identified between perceptions of sustainability, and participants’ age, r=−.16 (p <0.05), and years of experience, r=−.14 (p <0.05), indicating that as age and years of experience increases, perceptions of sustainability decrease slightly. A high positive correlation was also identified between perceptions of sustainability and support, r =0.77 (p <0.005), showing that participants who perceive sustainability more positively tend to feel more supported. Male participants reported feeling significantly greater levels of support than females, t (263) = 1.708, p =0.044.

Participants’ ratings of the importance of various characteristics in sustainable leadership and management are presented in Table 4. Ethical decision-making and responsibility were rated as very important by the largest proportion of participants (n=173, 62.7%), followed by continuous learning and improvement (n=156, 56.5%), promoting staff wellbeing and work-life balance (n = 150, 54.3%), and cultivating transparency and accountability (n=149, 54.0%).

Table 4.

Participants’ Ratings of Importance of Characteristics of Sustainable Management and Leadership

Please Rate the Importance of the Following Characteristics of Sustainable Management and Leadership from 1 (Not Important) to 5 (Very Important) (n, %)
	Not Important (1)	Slightly Important (2)	Moderately Important (3)	Important (4)	Very Important (5)	No Response
Characteristics
Promoting staff wellbeing and work-life balance	0 (0.0%)	18 (6.5%)	19 (6.0%)	85 (30.8%)	150 (54.3%)	4 (1.4%)
Prioritizing long-term goals over short-term goals	4 (1.4%)	6 (2.2%)	73 (26.4%)	120 (43.5%)	70 (25.4%)	3 (1.1%)
Cultivating transparency and accountability	0 (0.0%)	6 (2.2%)	13 (4.7%)	106 (38.4%)	149 (54.0%)	2 (0.7%)
Fostering organizational resilience	2 (0.7%)	8 (2.9%)	34 (12.3%)	118 (42.8%)	111 (40.2%)	3 (1.1%)
Integrating environmental stewardship into decision-making	3 (1.1%)	29 (10.5%)	75 (27.2%)	106 (38.4%)	60 (21.7%)	3 (1.1%)
Encouraging strategic ideas	0 (0.0%)	3 (1.1%)	37 (13.4%)	117 (42.4%)	115 (41.7%)	4 (1.4%)
Ethical decision-making and responsibility	1 (0.4%)	5 (1.8%)	16 (5.8%)	79 (28.6%)	173 (62.7%)	2 (0.7%)
Stakeholder engagement and collaboration	0 (0.0%)	1 (0.4%)	33 (12.0%)	100 (36.2%)	139 (50.4%)	3 (1.1%)
Continuous learning and improvement	0 (0.0%)	5 (1.8%)	19 (6.0%)	94 (34.1%)	156 (56.5%)	2 (0.7%)
Innovation and adaptation	0 (0.0%)	6 (2.2%)	28 (10.1%)	99 (35.9%)	139 (50.4%)	4 (1.4%)
Resource efficiency (waste reduction)	0 (0.0%)	11 (4.0%)	51 (18.5%)	120 (43.5%)	92 (33.3%)	2 (0.7%)
Implementation of evidence in practice	1 (0.4%)	5 (1.8%)	26 (9.4%)	98 (35.5%)	141 (51.1%)	5 (1.8%)

Participants’ views on the importance of investing in healthcare leadership to achieve specific outcomes showed that workplace culture was rated as very important by the highest proportion of participants (n=198, 71.7%), followed by safety and quality of care (n=176, 63.8%), trust and engagement (n=176, 63.8%), and staff wellbeing (n=170, 61.6%), as summarized in Table 5. While outcomes such as productivity and efficiency (n=107, 38.8%), interdisciplinary collaboration (n=109, 39.5%), and performance management (n=100, 36.2%) were less frequently rated as very important, a majority still considered them important.

Table 5.

Participants’ Ratings of Importance Investing in Healthcare Leadership on Varying Outcomes

Please Rate the Importance of Investing in Healthcare Leadership on the Following Outcomes from 1 (Not Important) to 5 (Very Important) (n, %)
	Not Important (1)	Slightly Important (2)	Moderately Important (3)	Important (4)	Very Important (5)	No Response
Characteristics
Workforce recruitment and retention	0 (0.0%)	15 (5.4%)	16 (5.8%)	79 (28.6%)	160 (58.0%)	6 (2.2%)
Staff wellbeing	0 (0.0%)	0 (0.0%)	30 (10.9%)	71 (25.7%)	170 (61.6%)	5 (1.8%)
Productivity and efficiency	0 (0.0%)	1 (0.4%)	22 (8.0%)	142 (51.4%)	107 (38.8%)	4 (1.4%)
Safety and quality of care	1 (0.4%)	1 (0.4%)	29 (10.5%)	66 (23.9%)	176 (63.8%)	3 (1.1%)
Interdisciplinary collaboration	1 (0.4%)	17 (6.2%)	27 (9.8%)	119 (43.1%)	109 (39.5%)	3 (1.1%)
Innovation and adaptability	0 (0.0%)	2 (0.7%)	36 (13.0%)	103 (37.3%)	129 (46.7%)	6 (2.2%)
Succession planning	0 (0.0%)	2 (0.7%)	29 (10.5%)	119 (43.1%)	122 (44.2%)	4 (1.4%)
Employee engagement	0 (0.0%)	2 (0.7%)	26 (9.4%)	93 (33.7%)	153 (55.4%)	2 (0.7%)
Systems improvement	1 (0.4%)	10 (3.6%)	23 (8.3%)	122 (44.2%)	117 (42.4%)	3 (1.1%)
Trust and engagement	0 (0.0%)	6 (2.2%)	21 (7.6%)	70 (25.4%)	176 (63.8%)	3 (1.1%)
Performance management	2 (0.7%)	6 (2.2%)	35 (12.7%)	128 (46.4%)	100 (36.2%)	5 (1.8%)
Workplace culture	0 (0.0%)	1 (0.4%)	20 (7.2%)	55 (19.9%)	198 (71.7%)	2 (0.7%)

Furthermore, a total of 227 participants (82.2%) shared their views on sustainable leadership in an open-ended question, describing it as balancing immediate operational needs with long-term organisational and systemic resilience. Such leaders were seen as having a clear vision that addresses global trends and system complexity while fostering a positive workplace culture to enhance morale and reduce burnout. Participants emphasised the importance of organisational support, including training, mentorship, and succession planning. Participants described effective leaders as resilient, adaptable, ethical, and authentic, fostering trust, inclusion, and a balance between personal well-being and professional demands. Additionally, innovation, continuous improvement, and efficient resource use were highlighted as integral components of sustainable leadership.

Support in Leadership

Overall, on a scale of one to ten, participants rated their overall wellbeing as 6.7/10 (SD=1.8). Male participants reported significantly higher levels of overall wellbeing than females, t (256) = 2.509, p =0.006.

Participants’ ratings of their perceived level of support as a leader showed that at an organizational level, 140 participants (48.6%) reported feeling moderately (n=97, 33.0%) or extremely (n=43, 15.6%) supported, while 62 (22.4%) felt only slightly (n=47, 17.0%) or not at all (n=15, 5.4%) supported, as displayed in Table 6. Over half of participants felt either moderately (n=78, 28.3%) or extremely (n=74, 26.8%) supported by their line manager. Overall, most participants indicated moderate satisfaction with the general leadership and management within their workplace.

Table 6.

Participants’ Ratings of Perceived Level of Support

Please Select the Option Which Best Suits Your Beliefs to the Following Questions.
	Not at All (1)	Slightly (2)	Somewhat (3)	Moderately (4)	Extremely (5)	No Response
How well supported do you feel as a leader by your organization?	15 (5.4%)	47 (17.0%)	65 (23.6%)	91 (33.0%)	43 (15.6%)	15 (5.4%)
How well supported do you feel as a leader by your line manager?	28 (10.1%)	24 (8.7%)	60 (21.7%)	78 (28.3%)	74 (26.8%)	12 (4.3%)
How satisfied are you with the general leadership and management of your workplace?	30 (10.9%)	31 (11.2%)	69 (25.0%)	105 (38.0%)	31 (11.2%)	10 (3.6%)

An open-ended question asked participants how effective leadership is currently measured within their organization. Participants reported that effective leadership was either not measured or were unsure if or how it was measured. Key performance indicators (KPIs), financial outcomes, and performance appraisals were identified as common methods for measuring effective leadership, though these were perceived to prioritize financial goals over qualitative metrics such as workplace culture and team satisfaction. Staff surveys were also cited as a method for assessing leadership, but participants noted these may be unreliable due to low response rates. Participants indicated a need for more robust measures of leadership effectiveness, aligned with qualities such as innovation, adaptability, ability to achieve goals, and create a positive organizational culture.

Participants also reported on training, support, and systems they perceived to be helpful to support their leadership journey. They emphasized the importance of continuous mentoring, coaching, and regular feedback to identify strengths and areas for improvement. Peer networking was identified as a valuable way to foster shared learning and collaboration. Participants reported a desire for leadership training programs and opportunities to pursue postgraduate qualifications, highlighting the need for funding and time to support professional development. Participants stressed the importance of leadership training tailored to specific challenges in healthcare, such as clinical governance, managing workforce burnout, and building a positive workplace culture. Other key areas identified included improving organizational systems to facilitate transparency, accountability, and communication, as well as providing tools to enhance team collaboration and manage change. Participants also called for a shift in workplace culture from blame-based environments to one that fosters trust, psychological safety, and innovation.

Challenges in Leadership

Participants’ ratings of the difficulty of various challenges in healthcare leadership and management showed that managing poor performance was identified as the most difficult challenge, with 117 participants (42.4%) rating it as either difficult or extremely difficult, as outlined in Table 7. Creating organizational culture was another prominent challenge, frequently rated as difficult (n=71, 25.7%) or extremely difficult (n=42, 15.2%). Additional highly rated challenges included staff recruitment and rostering, change management, staff wellbeing, and implementing change management. In contrast, procedural knowledge was rated as the least challenging, with 63 participants (22.8%) rating it as not at all difficult and 106 (38.4%) as slightly difficult.

Table 7.

Participants’ Ratings of Challenges in Leadership and Management

Please Rate the Following Challenges in Leadership and Management, from 1 (Not at All Difficult) to 5 (Extremely Difficult) (n, %)
	Not at All Difficult (1)	Slightly Difficult (2)	Moderately Difficult (3)	Difficult (4)	Extremely Difficult (5)	No Response
Challenges
Staff recruitment/rostering	15 (5.4%)	68 (24.6%)	69 (25.0%)	72 (26.1%)	37 (13.4%)	15 (5.4%)
Staff management/managing poor performance	14 (5.1%)	48 (17.4%)	82 (29.7%)	85 (30.8%)	32 (11.6%)	15 (5.4%)
Staff wellbeing	30 (10.9%)	72 (26.1%)	81 (29.3%)	64 (23.2%)	14 (5.1%)	15 (5.4%)
Staff training and delegation	49 (17.8%)	82 (29.7%)	88 (31.9%)	39 (14.1%)	3 (1.1%)	15 (5.4%)
Accreditation	41 (14.9%)	106 (38.4%)	72 (26.1%)	33 (12.0%)	8 (2.9%)	16 (5.8%)
Time management	29 (10.5%)	77 (27.9%)	81 (29.3%)	53 (19.2%)	21 (7.6%)	15 (5.4%)
Meeting management	44 (15.9%)	76 (27.5%)	80 (29.0%)	44 (15.9%)	19 (6.9%)	13 (4.7%)
Budget management	32 (11.6%)	83 (30.1%)	71 (25.7%)	53 (19.2%)	21 (7.6%)	16 (5.8%)
Influencing	28 (10.1%)	78 (28.3%)	87 (31.5%)	59 (21.4%)	9 (3.3%)	15 (5.4%)
Creating organizational culture	29 (10.5%)	57 (20.7%)	63 (22.8%)	71 (25.7%)	42 (15.2%)	14 (5.1%)
Having difficult conversations and conflict resolution	21 (7.6%)	80 (29.0%)	62 (22.5%)	71 (25.7%)	29 (10.5%)	13 (4.7%)
Implementing change management/managing resistance to change	20 (7.2%)	63 (22.8%)	69 (25.0%)	78 (28.3%)	31 (11.2%)	15 (5.4%)
Engaging in inter-department/interdisciplinary collaboration	42 (15.2%)	82 (29.7%)	70 (25.4%)	48 (17.4%)	21 (7.6%)	13 (4.7%)
Maintaining personal wellbeing	40 (14.5%)	64 (23.2%)	84 (30.4%)	51 (18.5%)	23 (8.3%)	14 (5.1%)
Developing business cases/rationale for resources	46 (16.7%)	85 (30.8%)	71 (25.7%)	42 (15.2%)	19 (6.9%)	13 (4.7%)
Having procedural knowledge	63 (22.8%)	106 (38.4%)	64 (23.2%)	25 (9.1%)	4 (1.4%)	14 (5.1%)

An open-ended question allowed participants to identify additional challenges, such as a lack of time and resources to focus on strategic planning and leadership tasks due to operational demands. Participants reported a constant need to balance organizational demands with clinical workloads, making it difficult to implement change or to innovate. They also described difficulties in navigating inter-professional dynamics, particularly when clinical leaders, such as medical professionals, overshadow contributions from non-clinical leaders. Other participants identified challenges such as the negative influence of outdated leadership styles, resistance to change, and tolerance of poor behaviors within teams. Additionally, participants emphasized the need for evidence-based leadership practices, noting that leaders were often promoted based on technical expertise rather than leadership capability, resulting in inconsistent leadership quality.

Participants’ ratings of external factors impacting sustainable leadership indicated that budgetary constraints and the political climate were the most significant factors, rated as somewhat or significantly impacting by 189 participants (68.5%) and 171 participants (62.0%), respectively, as highlighted in Table 8. Findings from the open-ended question identified a wide range of additional external factors, including workforce shortages, competition with other sectors, generational differences in expectations, limitations in state and federal funding, increasing cost of living, the rapid pace of technological advancements exceeding organizational capacity, and challenges in intercultural communication.

Table 8.

Participants’ Ratings of the Impact of External Factors on Sustainable Leadership

Please Rate the Following External Factors Impacting Sustainable Leadership Beyond the Control of the Leaders, from 1 (Not at All Impacting) to 5 (Significantly Impacting) (n, %)
	Not at All Impacting (1)	Slightly Impacting (2)	Moderately Impacting (3)	Somewhat Impacting (4)	Significantly Impacting (5)	No Response
External factors
Political climate	11 (4.0%)	33 (12.0%)	45 (16.3%)	61 (22.1%)	110 (39.9%)	16 (5.8%)
Budgetary constraints	5 (1.8%)	13 (4.7%)	54 (19.6%)	72 (26.1%)	117 (42.4%)	15 (5.4%)
Community expectations	7 (2.5%)	41 (14.9%)	61 (22.1%)	91 (33.0%)	63 (22.8%)	13 (4.7%)
Media influence	22 (8.0%)	53 (19.2%)	57 (20.7%)	83 (30.1%)	47 (17.0%)	14 (5.1%)

Support Strategies in Leadership

Participants identified several key policy changes necessary to enhance leadership support within their organizations, with protected time and skills development funding (n=184, 66.7%), resources and support for leadership training and development (n=173, 62.7%), and promoting leadership training and education for healthcare leaders (n=164, 59.4%) being the most highly rated, as highlighted in Table 9. Conversely, enforcing regulations on procedural practices (n=62, 22.5%) and developing policies to encourage engagement and collaboration (n=78, 28.3%) were rated as the least necessary changes.

Table 9.

Policy Changes Deemed Necessary to Enhance Leadership Support in Participants’ Organisations

What Policy Changes Do You Believe are Necessary to Enhance Leadership Support Within Your Organisation?
Policy Changes	N	%
Protected time and skills development funding for leaders.	184	66.7%
Providing resources and support for leadership training and development.	173	62.7%
Promoting leadership training and education for healthcare leaders.	164	59.4%
Establishing guidelines for transparent and inclusive decision-making processes.	125	45.3%
Introducing regulations for resource efficiency (waste reduction).	85	30.8%
Developing policies to encourage engagement and collaboration.	78	28.3%
Enforcing regulations on procedural practices.	62	22.5%
Not reported	17	6.2%

Note: Participants were able to select more than one option.

Additional legislative, system, policy, or organizational changes identified to support leaders in healthcare included equitable funding distribution between metropolitan, regional, rural, and remote health services, streamlining policies to reduce administrative burden, fostering better collaboration between primary, tertiary, and community health sectors, and adopting data-driven and evidence-based leadership strategies.

Participants highlighted a wide range of areas where they felt additional support was needed within open-ended questions. Many emphasized the need for greater support in people management and communication, such as when managing difficult conversations, addressing poor behavior, recruiting and retaining staff, managing performance, and fostering positive workplace culture. Leaders also sought support in strategic planning, influencing and implementing change management, and navigating complex healthcare governance systems. Further training was requested in managing budgets and finances, understanding business processes, project management, and resource allocation. Other identified areas for support included personal skills, such as time management, confidence building, resilience, and self-care.

Barriers and Opportunities in Leadership

Participants’ responses to open ended questions uncovered a myriad of barriers and opportunities in sustainable leadership. A significant number of participants reported the overwhelming burden of time constraints to be a major barrier to sustainable leadership. Leaders frequently cited an inability to balance their leadership responsibilities with clinical duties, administrative demands, and operational tasks. Resource and budget limitations were also significant barriers, as this hindered participants’ ability to secure adequate resources, staff, and support. These limitations led to difficulties in managing large workloads, often leading to burnout among leaders and their teams. Organizational culture was another significant challenge, particularly when there was a lack of clear vision, strategy, and clear communication from higher levels. Complex organizational structures posed additional challenges as slow and intricate decision-making processes hampered attempts to implement innovation. Communication and collaboration issues further exacerbated these problems, particularly when leaders were excluded from discussions or decisions directly impacted their teams. The lack of leadership development opportunities also emerged as a barrier, with participants reporting limited access to upskilling and further training, resulting in skill gaps. Career progression was particularly restricted for non-clinical staff and minority groups, with limited support for these emerging leaders.

Participants also identified several opportunities to promote effective leadership and management, emphasizing its critical role in improving organizational culture, employee wellbeing, and patient outcomes. They noted that fostering positive leadership could enhance teamwork, decision-making, succession planning, and create a more supportive workplace culture. Workplace wellbeing was seen as particularly important, with participants believing a strong, supportive leadership team could improve staff morale, reduce burnout, and increase role satisfaction. Participants highlighted the need for additional leadership training and development opportunities to continually upskill and stay updated with the latest evidence surrounding healthcare leadership. This, in turn, could retain high-performing individuals while empowering leaders. Opportunities for innovation were also noted, particularly in leveraging technology, encouraging cross-sector collaboration, and streamlining processes to build stronger, future-focused healthcare systems.

Discussion

Overall, study results provided insights on sustainable leadership in Australia’s health care system. Out of the 276 people who participated in the study, the majority were female who were from varying metropolitan regions and had diverse professional backgrounds that included allied health, nursing and medicine. Sustainable leadership was seen as the ability to manage current operational needs while also ensuring cognizance towards long-term strengthening of organisational culture to minimise burnout and boost morale. Training, in the form of workplace learning, mentoring, and formal education, was viewed as important for effective leadership, with mentoring being the most helpful. Some of the leadership challenges identified included managing performance, developing organisational culture, and workforce shortages. Participants stressed the importance of mentoring, peer networking, and even setting up training programs. Despite variation in organisational support, male respondents reported greater perceived support and well-being when compared to women. The political environment combined with budget restrictions were seen as external negative factors alongside systemic issues including the archaic style of leadership and insufficient time set aside for strategic planning. To find a solution to the issues, the participants recognized the necessity of innovativeness, psychological welfare, and the implementation of leadership strategies that are effective. These policies emphasized offering protected time, allocating sufficient resources, and providing focused leadership training as a means of defeating these challenges.

Importance of Sustainable Leadership in Balancing Operational and Long-Term Goals

This study suggests the potential of sustainable leadership in addressing both the immediate challenges of running healthcare operations and the broader goal of building long-term organisational resilience in Australia’s healthcare sector. Participants described sustainable leadership as striking a balance between managing day-to-day demands and fostering a workplace culture focused on resilience, inclusivity, and innovation. They also pointed to the critical role of ethical decision-making, transparency, and trust in boosting team morale and reducing burnout. These findings align with the perspectives of McCann and Holt²² and Choi²⁸ on fostering sustainable leadership, emphasising the importance of balancing the management of immediate operational demands with the pursuit of long-term objectives, where growth is driven by ethical, adaptable, and forward-thinking strategies.

The findings also highlight the influence of sustainable leadership in creating environments where talented healthcare professionals can thrive, contributing to higher-quality care. However, despite recognising its importance, participants lowly rated the sustainability of healthcare leadership. This points to a gap between the recognition of sustainable leadership principles and their practical implementation in the Australian healthcare system. As Gerard et al²⁹ suggest, leadership must go beyond achieving operational goals to nurture an inclusive and supportive culture that prioritises staff well-being, fosters innovation, and encourages professional development. This gap between theory and practice underscores the pressing need for strategies that make sustainable leadership a reality across healthcare organisations. Embedding these principles into daily leadership practices will not only address current challenges but also build a foundation for resilience and excellence in the future.

Importance of Training and Support in Enabling Sustainable Leadership

Effective training and support systems are essential for developing sustainable healthcare leaders. Participants in this study emphasised the value of mentoring, peer networking, and workplace training as the most effective methods for leadership development. In particular, hands-on programs, such as peers or managers led on-the-job training led and structured mentoring, were highly appreciated for helping leaders navigate the complexities of healthcare systems. These findings align with Shanafelt et al,¹⁰ who highlight the importance of leadership training tailored specifically to the unique challenges of the healthcare environment, especially for those without formal leadership education.

Interestingly, while fewer participants accessed formal education, such as postgraduate degrees, those who did found these programs highly beneficial. However, concerns about fairness arose, as access to these programs was uneven due to time constraints, financial barriers, and support from organisations to pursue further education. Male participants, for example, reported feeling more supported in their leadership roles when compared to females, highlighting systemic inequities that require attention. Addressing these perceived disparities is critical, as they can hinder diversity and inclusivity, which are vital for sustainable leadership. These findings resonate with Turato et al,⁶ who stress that effective leadership must not only address organisational challenges but also ensure equitable access to support and resources for all leaders, regardless of their demographics.

Participants also called for leadership development programs that go beyond basic management skills, advocating for training in areas such as resilience, adaptability, and psychological safety. These traits, described by Gerard et al²⁹ as central to sustainable leadership, are particularly relevant in healthcare settings where leaders often face resource constraints and high-pressure environments. Such programs should equip leaders with the skills to manage burnout, foster collaboration, and handle complex interprofessional dynamics. Tailored strategies that address the unique demands of healthcare are crucial for preparing leaders to excel in this ever-evolving and demanding field.

Barriers and Strategies for Sustainable Leadership

Barriers that pose challenges to achieving sustainable leadership in healthcare were also highlighted in the results of this study. Many of these barriers are rooted in systemic issues within the sector. Participants frequently reported the struggle to juggle their strategic responsibilities with the overwhelming demands of daily clinical and administrative tasks. Time constraints, limited resources, and the broader political climate were consistently flagged as major obstacles. These findings reflect the observations of William et al³ and Moy et al,² who highlighted how workforce shortages and mounting operational pressures further heighten leadership challenges in healthcare. Additionally, participants pointed out that outdated leadership models and rigid hierarchical decision-making often stifle innovation and adaptability, making it even harder for leaders to navigate modern healthcare complexities.

Despite these challenges, participants were optimistic about actionable solutions that could pave the way for more sustainable leadership. Participants suggested protected time specifically allocated for strategic planning, ensuring leaders have the space to think and act proactively rather than reactively. Participants also stressed the importance of increasing funding for leadership training and development, along with fostering workplace cultures that prioritise psychological safety, wellbeing and innovation. These suggestions align with Fridell et al¹ who advocate for creating resilient systems that can withstand and adapt to systemic stressors. Another key insight was the need to redefine how leadership effectiveness is measured. Participants urged a shift away from relying solely on financial metrics, advocating instead for qualitative measures like team satisfaction, workplace culture, and the ability to foster innovation. They also highlighted the importance of embracing technology and streamlining processes to make leadership roles more efficient and impactful. Cross-sector collaboration and data-driven decision-making were seen as essential for building stronger, more future-focused healthcare systems. Ultimately, participants envisioned a healthcare environment where leaders are equipped not just to handle immediate challenges, but also to create a foundation for long-term success. By adopting these strategies, organisations have the potential to empower their leaders and build a sustainable leadership model that thrives in both the present and the future.

Strengths and Limitations

The study has specific strengths. First, there were a total of 276 participants belonging to different professions which made the survey representative of healthcare leaders in Australia. Second, the survey covered a number of leadership issues ranging from training, challenges, and even support systems, hence painting a broader picture of sustainable leadership. Third, the use of both quantitative and thematic analyses added to the statistical breakdown captured from nuanced participant input. However, the study does have its drawbacks. Self-reporting can tend towards participants’ negative biases and socially acceptable answers while the cross-section nature of the study is not helpful in establishing causation or change tracking over time. It is also possible that potential participants with limited internet were not adequately represented in the data due to the online nature of recruitment which may have omitted these respondents. In addition, the lack of representation for certain populations like rural and remote healthcare professionals may make these findings difficult to generalize to this subgroup. This study used a convenience sampling approach, with participants self-selecting into the survey. No stratified or representative sampling was applied, which may limit the generalisability of findings. The results may reflect the views of health professionals with a particular interest in sustainable leadership, rather than the broader workforce. While appropriate for this exploratory study, future research should consider probability sampling to support broader generalisation and subgroup comparisons. These matters could be improved on in future studies by using more longitudinal methods and concentrating on more overlooked demographics. Further qualitative data beyond that which was collected in this survey also has potential to provide greater insights and enhance the results of this study. Future research should incorporate qualitative methods to explore the identified themes in more depth.

Conclusion

To foster sustainable leadership in Australian healthcare, organisations should focus on creating fair and inclusive support systems, addressing gender disparities, and ensuring equal access to resources and mentorship. Protected time for strategic planning and fostering a culture of innovation and well-being are also essential. Further healthcare leadership training should go beyond basic management skills, equipping leaders with resilience, adaptability, and strategies to promote psychological safety. Leaders also require support in navigating psychological challenges, addressing performance shortfalls constructively, and managing complex team dynamics and communication issues. Evaluating leadership effectiveness should include measures like team satisfaction and workplace culture, not just financial outcomes.

In conclusion, while sustainable leadership is widely acknowledged as important, systemic barriers like resource limitations and outdated structures hinder its practical implementation. By addressing these challenges and investing in inclusive and forward-thinking strategies, healthcare organisations can empower leaders to succeed, improve staff well-being, and create stronger, more innovative systems for the future.

Funding Statement

The authors have no sources of funding to declare.

Data Sharing Statement

Data is available upon reasonable request to the corresponding author.

Ethics Approval

Ethical approval was received by the Bond University Human Research Ethics Committee (ref #CH00253).

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors have no financial or non-financial competing interest to declare for this work.