Entrepreneurial Leadership and Sustainable Development Behavior: A Moderation–Mediation Model of Sustainable Leadership and Team Psychological Safety

Abstract

Introduction

Nursing leadership is pivotal for sustainable healthcare, yet the interplay of entrepreneurial leadership (EL), sustainable leadership (SL), team psychological safety (TPS), and sustainable development behavior (SDB) remained underexplored, particularly in resource-constrained hierarchical contexts such as Egyptian nursing.

Objectives

This study investigated how EL promoted SDB by examining the mediating role of TPS and the moderating effect of SL based on job demands-resources and social cognitive theories, in alignment with the United Nations Sustainable Development Goals (SDGs).

Methods

A quantitative cross-sectional design was employed, utilizing data collected from an administered survey. A convenience sample of 318 nurses from different university hospitals participated in the study. Descriptive statistics and inferential techniques, such as Pearson’s correlation, multiple regression, and moderation-mediation analyses, were used to analyze the data.

Results

Nurses exhibited strong positive associations among EL, SL, TPS, and SDB, collectively accounting for substantial variance in sustainable behaviors. TPS partially mediated the EL-SDB pathway, explaining a meaningful portion of the effect, while SL significantly moderated this relationship, amplifying EL’s influence under high sustainable leadership conditions.

Conclusions

By integrating entrepreneurial innovation with ethical sustainability and psychological safety, this model addresses critical gaps in the impact of relational leadership on workforce behavior, team resilience, and patient-centered outcomes in global health systems. Practically, nurse training programs should emphasize EL-SL synergies and TPS cultivation to embed SDG-aligned practices, such as eco-friendly care protocols and interdisciplinary collaboration.

Keywords

entrepreneurial leadership sustainable leadership sustainable development behavior team psychological safety nursing leadership sustainable development goals

Introduction

The global healthcare sector, particularly in resource-constrained settings such as Egypt, grappled with technological disruptions, workforce shortages, and growing environmental imperatives. These pressures demanded nursing leadership that fosters resilience and aligns with the United Nations’ Sustainable Development Goals (SDGs) (Assembly, 2015; Moustafa Saleh et al., 2024). In Egyptian nursing, where the cultural values of hierarchy and collectivism prevailed, these challenges manifested as high staff turnover, limited innovation, and unsustainable practices. These problems were especially salient in relation to SDGs 6 (clean water), 7 (affordable energy), 12 (responsible consumption), 13 (climate action), 14 (life below water), and 15 (life on land), which emphasize environmental stewardship in healthcare (Assembly, 2015; Federico et al., 2025; Moustafa Saleh et al., 2024).

Entrepreneurial Leadership (EL) was defined as a style in which leaders articulated compelling visions, motivated toward future goals, and generated value through systematic innovation and risk-taking (Awad et al., 2024; Taylor et al., 2025). This approach enabled proactive adaptation in dynamic environments (Ercantan et al., 2024; Saif et al., 2025). However, EL’s short-term focus required integration with Sustainable Leadership (SL) for ethical longevity (Wang et al., 2022). Team Psychological Safety (TPS) enabled collaborative risk-taking (Edmondson & Lei, 2014), ultimately driving Sustainable Development Behavior (SDB) proactive actions that balanced social, economic, and environmental needs (Mensah, 2019; Moustafa Saleh et al., 2024).

EL enhanced nursing creativity and adaptability (Bagheri & Harrison, 2020; Pu et al., 2022). The Integrating of entrepreneurial, digital, and visionary leadership improved collaboration, knowledge transfer, and care quality in healthcare (Awad et al., 2024; Moss et al., 2022). SL supported these goals by prioritizing staff well-being and ethical SDGs, such as green behaviors via transformational interventions (Moustafa Saleh et al., 2024; Gürgen Şimşek & Erkin, 2022), helped reduce fear in hierarchical teams and encouraged eco-initiatives, which improved team communication and collaboration (Cho et al., 2023; Ito et al., 2022; Montgomery et al., 2025; Ye & Li, 2024). In Egypt, a high power distance culture strengthened SL’s modeling role but limited TPS, highlighting the need for models that balance multiple leadership styles to address staff well-being and environmental sustainability (Salvage & White, 2020). Global frameworks including the World Health Organization’s (WHO) Global Strategic Directions for Nursing and Midwifery 2021–2025 and campaigns from the International Council of Nurses (ICN), emphasized empowering nurses for environmental and organizational sustainability through integrated leadership (ICN, 2017; World Health Organization, 2021)

Despite these insights, a critical gap persisted: the interconnectedness of EL, SL, TPS, and SDB remains underexplored in nursing, particularly in hierarchical contexts such as Egypt (Ahmed et al., 2024; Atta et al., 2025). Prior research justified isolated effects, e.g., EL on innovation via entrepreneurial orientation (Awad et al., 2024), and SL on green creativity (Moustafa Saleh et al., 2024), and TPS on behaviors (Byeon et al., 2022), but lacks empirical tests of TPS mediation or SL moderation in integrated frameworks (O’Donovan & McAuliffe, 2020). This study filled this void with novelty: a culturally attuned moderation-mediation model grounded in JD-R and Social Cognitive Theories (Bandura, 1969; Montgomery et al., 2025). The model explained how EL translated to SDB via TPS, moderated by SL, to advance SDGs in Egyptian nursing. Contributions included theoretical extensions, e.g., cultural power dynamics, and practical training implications (Moustafa Saleh et al., 2024).

Review of Literature

EL integrates opportunity recognition, calculated risk-taking, and motivational vision to propel innovation and growth in complex environments (Taylor et al., 2025). Recent healthcare syntheses indicated that EL promoted nurse proactivity and creativity in the face of resource limitations, as entrepreneurial orientation maintained performance (Awad et al., 2024; Bagheri & Harrison, 2020; Pu et al., 2022; Saif et al., 2025). In nonprofit settings like Egyptian hospitals, EL drove market-oriented adaptability, yet its volatility necessitated ethical complements for SDB (Ercantan et al., 2024).

SDB entailed actions met current needs without depleting future resources, spanning social equity, economic efficiency, and environmental protection, e.g., SDGs 6, 7, 12, 13, 14, and 15 on water, energy, consumption, climate, oceans, and ecosystems (Assembly, 2015; Atobishi & Podruzsik, 2025; Federico et al., 2025; Mensah, 2019; Moustafa Saleh et al., 2024). Nurses operationalized SDB through eco-friendly stewardship and holistic care, amplified by WHO and ICN initiatives for sustainable systems that promoted practices to reduce waste, conserve resources, and enhance patient education on sustainability (Federico et al., 2025; ICN, 2017).

Florence Nightingale’s environmental theory stressed creating sustainable healing conditions via sanitation and resource stewardship (Gilbert, 2020). Sister Callista Roy’s adaptation model equipped nurses to facilitate systemic resilience against environmental changes (Vandemark, 2006). Jean Watson’s theory of human caring advocated ethical, compassionate practices aligning with SDG equity (Rosa et al., 2020; Watson, 2012) Recent evidence synthesized these theories: Green leadership interventions boosted SDB creativity in nursing (Moustafa Saleh et al., 2024), including organizational citizenship behaviors like eco-initiatives (Ye & Li, 2024). Nevertheless, environmental considerations remained detached from leadership dynamics.

SL emphasized long-term ethical vision, staff well-being, and organizational stability to counter nursing challenges like retention (Nehls, 2000; Wang et al., 2022; Gürgen Şimşek & Erkin, 2022). SL enhanced the adaptability of EL by ethically supporting innovations, as social entrepreneurship models showed hierarchical transformations toward SDGs (Alvord et al., 2004; Kuratko et al., 2017; Saebi et al., 2019). In Egyptian nursing, SL leveraged collectivism for role-modeling while addressing power imbalances (Salvage & White, 2020), fostering green behaviors (Moustafa Saleh et al., 2024).

TPS was defined as a shared belief that enabled interpersonal risks without negative repercussions, serving as a foundation for innovation (Edmondson & Lei, 2014). In healthcare, TPS was synthesized with JD-R theory to mediate leadership effects toward outcomes like error reduction and engagement (Byeon et al., 2022; Cho et al., 2023; Examiner & Graso, 2024; Ito et al., 2022; Liu et al., 2024; Montgomery et al., 2025; Paulus, 2023), including SDB via safe eco-collaboration (Ye & Li, 2024). Cultural hierarchies may constrain TPS, but supportive SL enhances it.

Theoretical Framework

Grounded in the Job Demands-Resources (JD-R) model, EL and SL acted as motivational resources that buffered job demands (e.g., resource scarcity), fostering TPS to enhance engagement and SDB; hypotheses derived from JD-R pathways that linked resources to outcomes via psychological mechanisms (Montgomery et al., 2025; van Zyl et al., 2025). EL and SL are linked to SDB, with EL leading innovation (Ercantan et al., 2024) and SL making sure that environmental ethics are followed (Moustafa Saleh et al., 2024; B. L. Wang et al., 2022), mediated by TPS for risk-tolerant actions (Ito et al., 2022).

Social cognitive theory (Bandura, 1969) and transformational leadership theory (Bass & Riggio, 2006), underpinned this framework: EL modeled adaptive SDB, amplified by SL’s inspiration (Sukhadeve & Tarar, 2024). Although isolated effects abounded—e.g., EL on performance (Rauch et al., 2009), SL on sustainability (Gürgen Şimşek & Erkin, 2022), and TPS on behaviors (Byeon et al., 2022)—empirical synthesis revealed a gap: no integrated moderation-mediation tests existed in nursing, especially for environmental SDGs in hierarchical contexts (Ahmed et al., 2024; Atta et al., 2025; Han & Roh, 2020; O’Donovan et al., 2020). This study advanced knowledge by modeling these pathways, informing Egyptian nursing for comprehensive sustainability (Moustafa Saleh et al., 2024).

Research Objectives

This integrative approach addressed a significant gap in healthcare leadership research by shifting focus from isolated constructs to a systemic framework that emphasizing innovation, ethical responsibility, and staff empowerment (Figure 1).

Figure 1.

Hypothetical model

Research Hypotheses

EL was positively correlated with SL and SDB in nursing contexts.

EL was positively correlated with TPS, which in turn was correlated with SDB.

EL, SL, and TPS jointly predicted SDB (incremental variance).

SL moderated the EL and SDB relationship, strengthening it under high SL.

TPS mediated the EL-SDB relationship.

Method

Design and Setting

This research adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and employed a multi-center cross-sectional observational design (Vandenbroucke et al., 2014). Data were collected using a self-administered survey at three university hospitals located in central, Zagazig, El-Fayoum, and Alexandria. The cross-sectional design precluded definitive causal inferences; however, the researchers tested a theoretically derived model consistent with causal pathways.

Ethical Considerations and Consent

The study obtained approval from the Zagazig University Faculty of nursing Ethics Committee (ID/Zu. Nur. REC#:0116, dated 20/8/2023). Authorization was obtained from the medical and nursing directors at participating hospitals (Zagazig, El-Fayoum, and Alexandria) and their respective department heads. Participants received a formal cover letter explaining the study aims, voluntary participation, and assurances of confidentiality. Questionnaire submission served as informed consent.

Participants and Sampling

The sample size was calculated using G*Power 3.1 for multiple linear regression with three predictors (EL, SL, TPS), assuming a medium effect size (f² = 0.15), α =.05, and 80% power, which yielded a minimum requirement of 77 participants. A convenience sample of 318 nurses was obtained from three university hospitals. To assess potential non-response bias, early and late respondents were compared on all study variables; no significant differences were found (all p>.05). The final sample size provided >99% power to detect medium effects, exceeding requirements for the planned analyses.

Inclusion Criteria

• ≥ 6 months of full-time registered nurse employment in clinical settings.

• Direct patient care responsibilities (TPS/SDB exposure).

• Voluntary participation with informed consent.

Exclusion Criteria

Prior participation in similar research (prevents carryover effects).

The Data Collection Tools Included Four Main Instruments

Tool I: Entrepreneurial Leadership Questionnaire

The data collection instrument comprised two parts. Part 1 collected demographic and job-related information, including gender, educational level, marital status, department, years of experience, and place of residence. Part 2 employed the Entrepreneurial Leadership Questionnaire Renko et al. (2015), to assess nurses’ perceptions of entrepreneurial leadership, consisting of eight items (e.g., “Often comes up with entirely new ideas for the nursing profession”) rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Previous studies have affirmed the tool’s validity and reliability (Bagheri & Harrison, 2020; Carpenter, 2018), reporting the original Cronbach’s α = 0.889.

Tool II: Sustainable Leadership Questionnaire (SLQ)

Sustainable leadership was measured with the 15-item (McCann & Holt, 2010). Nurses responded to statements such as “My leader balances social responsibility with practical goals” on a 1-5 scale. Research consistently validated this tool (α = 0.973), as shown by (Kullan et al., 2022).

Tool III: Sustainable Development Behavior Scale

Nurses reported their sustainable work behaviors using a 21-item scale adapted from (Dumitru, 2015; Temminck et al., 2015). Items were rated from 1 (not at all) to 5 (to a great extent). The scale showed solid reliability in previous research (α = 0.78).

Tool VI: Team Psychological Safety Scale

Nurses rated team psychological safety using a 7-item scale from Edmondson (1999). Sample item: “Team members can bring up problems and tough issues,” scored from 1 (strongly disagree) to 5 (strongly agree). The scale demonstrated good reliability in prior studies (α = 0.79).

Study Procedures

The English instruments were translated into Arabic using forward-backward translation methods to ensure linguistic equivalence. A committee of nine nursing experts (six assistant professors and three full professors) then evaluated the tools for face and content validity. Members used a 4-point Likert scale (1 = not relevant, 4 = highly relevant) to rate the clarity of the items, their relevance to nursing, and their cultural appropriateness. The content validity index (CVI) was 0.89, exceeding the 0.80 threshold. Minor wording revisions addressed committee feedback to eliminate ambiguity for Arabic-speaking nurses, ensuring that the revised items were clear and culturally appropriate for this demographic.

Pilot Study

A pilot test with 32 staff nurses from a university hospital (not involved in the main study) assessed feasibility, readability, and internal consistency. Participants were recruited via convenience sampling during staff meetings. Confirmatory factor analysis (CFA) of the main study data confirmed expected factor structures for all scales (CFI/TLI > .90, RMSEA < .08). Internal consistency proved strong (Cronbach’s α: EL = .88, SL = .78, SDB = .81, TPS = .78). Data collection spanned three months, from December 2023 to February 2024. Nursing staff received briefings on the study purpose through individual and group sessions.

Statistical Design

Data were analyzed using IBM SPSS v.29 and Hayes’ PROCESS macro v.4.2, designed to test integrated moderation-mediation (conditional process) models using bias-corrected bootstrapping, this robust approach that does not assume normality. Descriptive statistics and Pearson correlations summarized variables and tested bivariate relationships (H1, H2). Linearity and absence of outliers confirmed before the main analyses. Multiple linear regression tested H3, with SDB regressed on EL, SL, and TPS to examine predictive relationships. Moderation (H4) and mediation (H5) were analyzed separately using Hayes’ PROCESS macro: Model 1 examined SL moderation of the EL → SDB relationship, probing the EL × SL interaction at low, medium, and high SL levels via pick-a-point analysis. Model 4 assessed TPS mediation the EL → SDB path, employing 5,000 bias-corrected bootstrap samples to generate 95% confidence intervals for the indirect effect; mediation was considered significant if the CI excluded zero. All tests applied two-tailed α = .05, reporting effect sizes (β, B, ΔR²) with 95% CIs.

Common Method Bias (CMB) Assessment

Procedural remedies included respondent anonymity and scale separation. Statistically, Harman’s single-factor test revealed the first factor explained 32.7% variance (<50% threshold). A CFA comparing a single-factor model to our measurement model showed significantly worse fit (Δχ² significant, p<0.001), indicating CMB is not a primary concern.

Results

Table 1 presents the demographic and job-related information of the study participants. The sample consisted predominantly of female nurses (82.1%), held qualifications from a technical institute or bachelor’s degree (94.0%), worked in critical care units (69.8%), and had less than 10 years of experience (75.5%).

Table 1.

Demographic and Job-Related Information of the Study Participants (N = 318)

Socio-demographic data	N	%
Gender
Male	57	17.9
Female	261	82.1
Qualification^*
Diplomat	14	4.4
Technical institute	161	50.6
Bachelor’s degree	138	43.4
Post-graduate studies	5	1.6
Marital Status
Married	131	41.2
Unmarried	187	58.8
Department
Inpatient units	96	30.2
Critical care units	222	69.8
Years of experience
< 10 years	240	75.5
≥ 10 years	78	24.5
Residence
Rural	201	63.2
Urban	117	36.8

*Nursing technical institution (upper-intermediate education), nursing diploma (intermediate education), nursing bachelor’s degree (upper education), and nursing master’s degree (post-graduate education).

Table 2 presents descriptive statistics and Pearson correlations among study variables. EL showed strong positive correlations with SL (r = .713, p < .001) and SDB (r = .599, p < .001), supporting H1. SL also correlated strongly with SDB (r = .646, p < .001). TPS demonstrated a strong correlation with SDB (r = .591, p < .001) and a moderate correlation with EL (r = .408, p < .001), supporting H2. These large bivariate effects established a foundation for subsequent multivariate analyses, with discriminant validity confirmed through independent effects in regression models.

Table 2.

Descriptive Statistics and Pearson Correlations Among Study Variables (N = 318)

Study Variables	Range	Min	Max	M	SD		(1)	(2)	(3)	(4)	(5)
Age (1)	32	17	49	27.10	4.18	r	1
Entrepreneurial Leadership (2)	24	16	40	30.48	4.89	r	-0.124^*	1
Sustainable Leadership (3)	60	15	75	56.81	9.10	r	-0.177^**	0.713^***	1
Sustainable Development Behavior (4)	51	54	105	83.86	10.46	r	-0.143^*	0.599^***	0.646^***	1
Team Psychological Safety (5)	21	14	35	24.77	3.930	r	-0.101	0.408^***	0.536^***	0.591^***	1

Scores are mean (M) and Standard Deviation (SD) values, and r Pearson correlation.

Correlations are two-tailed. ***p < .001. **p < .01. p < .05.

Multiple regression analysis tested H3 (Table 3, Figure 2). The overall model significantly predicted SDB, explaining 53.7% of variance (R² = .537, F (3, 314) = 90.728, p < .001) a large effect size. Standardized coefficients revealed TPS as the strongest predictor (β = .334), followed by SL (β = .274) and EL (β = .265). All predictors demonstrated significant unique contributions, confirming H3.

Table 3.

Multiple Regression Analysis of Predictors of Sustainable Development Behavior

SDB
Model	Unstandardized coefficients		Standardized coefficients	t	P	95% CI for the difference
Model	B	Std. error	ß	t	P	Lower bound	Upper bound
(Constant)	28.612	4.365		6.554	<0.001	20.023	37.201
Age	-0.070	0.098	-0.028	-0.720	0.472	-0.263	0.122
EL	0.566	0.117	0.265	4.818	<0.001	0.335	0.797
SL	0.314	0.069	0.274	4.575	<0.001	0.179	0.450
TPS	0.890	0.121	0.334	7.328	<0.001	0.651	1.129

EL: Entrepreneurial Leadership, TPS: Team Psychological Safety, SL: Sustainable Leadership, SDB: Sustainable Development Behavior.

Demographic variables (gender, qualification, marital status, department, residence) were tested but removed from the final model as non-significant (p > .05) to enhance parsimony and reduce multicollinearity.

Significant difference compared to the reference category ≤0.001.

ß = standardized coefficient beta; t= Student t test for linear regression.

95% CI for difference 95% Confidence Interval for Difference.

R² = 0.537 (Adj R² = 0.531), F-change = 90.728, P≤0.001.

Dependent variable: Sustainable Development Behavior.

Figure 2.

Regression analysis of predictors for sustainable development behavior (SDB)

Table 4 illustrates the moderation analysis results, examining the role of SL in moderating the relationship between EL and SDB. The moderation analysis using PROCESS confirmed Hypothesis H4. The interaction term between EL and SL was statistically significant (B = 0.0305, p<.001), accounting for an additional 3.4% of the variance in SDB. Probing this interaction revealed a key insight: while EL had a positive effect on SDB at all levels of SL, this effect was significantly amplified under higher levels of sustainable leadership. At low levels of SL (16th percentile), EL had a positive but moderate effect on SDB (B= 0.397). At high levels of SL (84th percentile), this effect more than doubled in size to become very large (B= 0.885).

Table 4.

Moderation Analysis of Sustainable Leadership on the Relationship Between Entrepreneurial Leadership and Sustainable Development Behavior

Coefficients	B	SE	t	p	95% LLCI	95% ULCI
Constant	85.7505	11.1050	7.7218	< .001	63.9008	107.6002
EL	-1.0965	0.3894	-2.8159	0.0052	-1.8627	-0.3303
SL	-0.3913	0.2071	-1.8890	0.0598	-0.7988	0.0163
Interaction Term (EL x SL)	0.0305	0.0066	4.5990	0.0478	0.0174	0.0435

Conditional effects of EL at values of SL	SL percentile	Effect of EL on SDB	SE	t	p	95% LLCI	95% ULCI
Low (49.0)	16th	0.3974	0.1307	3.0402	0.0026	0.1402	0.6546
Medium (57.0)	50th	0.6413	0.1231	5.2086	< .001	0.3990	0.8835
High (65.0)	84th	0.8852	0.1373	6.4462	< .001	0.6150	1.1554

Model Summary: R²= 0.4909, F= 100.914, p(Model)= < .001Test of Interaction Effect: R² Change 0.0343, F (Interaction)= 21.1509, p (Interaction)= 0.0478.

EL stands for entrepreneurial Leadership, SL for sustainable Leadership, SDB for sustainable Development Behavior, B for unstandardized coefficients, SE for standard error, LLCI and ULCI for lower and Upper Limit Confidence Intervals. Conditional effects are reported at SL’s 16th, 50th, and 84th percentiles.

Table 5 and Figure 3 present the mediation analysis results, examining whether TPS mediated the relationship between EL and SDB. The analysis supported Hypothesis H5 by demonstrating a significant indirect effect of EL on SDB through TPS. The total effect of EL on SDB was significant (B = 1.2818, p < .001). When TPS was included as a mediator, the indirect effect remained significant (B = 0.3629, 95% CI [0.2394, 0.4991]), indicating partial mediation. The direct effect of EL on SDB remained significant (B = 0.9189, p < .001), suggesting that TPS accounted for part, but not all, of the effect of EL on SDB.

Table 5.

Mediation Analysis of Team Psychological Safety in the Relationship Between Entrepreneurial Leadership and Sustainable Development Behavior

Path	Effect (B)	SE	t	p	95% LLCI	95% ULCI
Total Effect (EL → SDB)	1.2818	0.0963	13.3084	< .001	1.0923	1.4713
Direct Effect (EL → SDB)	0.9189	0.0930	9.8834	< .001	0.7360	1.1019
Indirect Effect (EL → TPS → SDB)	0.3629	0.0658	-	-	0.2394	0.4991
Effect of EL on TPS (a path)	0.3274	0.0413	7.9353	< .001	0.2462	0.4085
Effect of TPS on SDB (b path)	1.1084	0.1158	9.5740	< .001	0.8806	1.3362

EL: Entrepreneurial Leadership, TPS: Team Psychological Safety, SDB: Sustainable Development Behavior, B: Unstandardized coefficients, SE: Standard error, LLCI, and ULCI: Lower and Upper Limit Confidence Intervals, Conditional effects are reported at the 16^th, 50^th, and 84^th percentiles of SL.

Figure 3.

Integrated mediation and moderation model of entrepreneurial leadership’s effects on sustainable development behavior

The mediation analysis tested Hypothesis H5, which proposed that TPS explains the relationship between EL and SDB. The results, presented in Table 5 and Figure 3, supported a partial mediation model. The indirect effect of EL on SDB through TPS was significant (B = 0.3629, 95% CI [0.2394, 0.4991]), indicating that EL fostered sustainable behavior in part by creating a psychologically safe team environment. This pathway accounted for approximately 28% of the total effect of EL on SDB (0.3629/1.2818 = 0.283), underscoring the substantive role of climate-building as a leadership function. The direct effect remained significant (B = 0.9189, p < .001), suggesting that EL influenced SDB through mechanisms beyond TPS, such as direct motivation and support for sustainable practices, consistent with partial mediation.

Discussion

Healthcare institutions continually adapted to improve public health outcomes, address emerging health challenges, and manage rising costs. Entrepreneurial leaders were central to promoting sustainable practices in nursing by encouraging both innovation and flexibility. The literature emphasized the vital role of sustainable leadership, which integrated ethical decision-making with long-term objectives, in cultivating a work environment that supported team psychological safety. This safety fostered open communication and a willingness to take risks, which ultimately improved patient care and aligned with wider public health and environmental goals (Mehmood et al., 2021; Pauceanu et al., 2021). Therefore, this study examined the relationships among EL, SL, and SDB in nursing. In addition, the study examined how sustainable leadership moderates these relationships and how TPS mediates them.

Entrepreneurial and Sustainable Leadership

Consistent with the hypotheses, EL and SL exhibited a strong positive correlation, and SL showed a significant positive association with SDB. This high correlation indicates conceptual affinity, as both EL and SL emphasize visionary, innovative, and ethically grounded leadership (Gosling & Mintzberg, 2017). However, multivariate analyses confirmed their distinctiveness: each contributed unique variance to SDB in the regression model and demonstrated a significant interaction effect, indicating that EL and SL are complementary rather than redundant leadership dimensions that jointly influence sustainable outcomes. In nursing contexts, the synergy between EL and SL fosters collaboration, teamwork, and greater commitment to sustainable practices, which may help explain the observed results (Hendriks et al., 2020; Wang et al., 2018). Such leaders prioritized long-term sustainability, built positive relationships, and enhanced organizational resilience (Pauceanu et al., 2021). The current findings agree with Pauceanu et al. (2021), who reported that entrepreneurial leadership positively influenced organizational sustainable development performance. Di Fabio and Peiró (2018) reported that nursing leaders, managers, and educators enhanced their professional image by prioritizing dignity, fostering innovation, empowering frontline teams, and integrating sustainable procedures to advance community health and social equity.

Entrepreneurial Leadership, Sustainable Development Behavior, and Team Psychological Safety

The results also showed significant positive correlations between EL and TPS and between TPS and SDB. Look into how different leadership styles affect psychological safety and long-term behaviors to learn more and answer questions about cause and effect. This pattern showed that the environment was beneficial for long-term growth. In nursing, where mistakes can have serious consequences, entrepreneurial leaders foster an environment of trust and openness that enables team members to share their thoughts. By clearly defining their leadership roles, these leaders made the team safer and more creative, encouraging innovative ideas and improving overall team performance. The study’s findings are consistent with (Mehmood, Jian, Akram, Akram, et al., 2021), who examined EL and team creativity and highlighted the roles of team psychological safety and knowledge sharing. Likewise, Guo and Wang (2017) reported that leaders often maintain a dominant role within their teams, cultivating psychological safety among team members and, in turn, fostering team creativity.

The study found a weak, negative, significant correlation between age and EL among nurses, suggesting that younger generation Z nurses may be more open to change, represent diverse entrants to the workforce, and value adaptive courage, and yet still perceive their leaders’ entrepreneurial behaviors at moderate levels, possibly due to high demands, staffing shortages, and limited control. In contrast, a study conducted in Egypt by Akeel et al. (2023), titled “Entrepreneurial leadership and work engagement among nurse managers,” identified a positive statistically significant relationship between entrepreneurial leadership and age among nurse managers.

The study revealed that EL, SL, and TPS were significant predictors of nurses’ SDB. These factors played a vital role in enhancing team effectiveness within healthcare organizations. Similarly, research conducted in Egypt by Mahfouz et al. (2024) found a significant positive correlation between nursing managers’ sustainable leadership knowledge and practice scores and their SDB and organizational attractiveness scores. Taken together, these findings suggest that EL, SL, and TPS are critical to promoting sustainable practices in nursing settings.

In the Egyptian healthcare system, leadership and sustainable nursing practices are shaped by cultural values that promote hierarchy, respect for authority, loyalty, and collectivism (Sukhadeve & Tarar, 2024; Ye & Li, 2024). This cultural framework enhances the ethical dimension of SL, positioning leaders as role models (Salvage & White, 2020). However, it may also constrain TPS by preventing questioning of authority unless leaders intentionally cultivate supportive and trusting environments, which can limit innovation and adaptability in nursing practices (Salvage & White, 2020). SDB thrives on teamwork and stewardship but may prioritize consensus over rapid EL-driven change. Developing culturally responsive leadership programs that integrate the flexibility of EL with the ethical focus of SL could enhance TPS and SDB among Egyptian nurses, thereby fostering respectful dialogue and progress toward the SDGs in ways that fit local contexts (Hughes, 2017; Salvage & White, 2020).

SL as a Moderator

The study revealed that SL moderated the relationship between EL and SDB. These findings enriched the leadership and sustainability literature and offered actionable implications for healthcare organizations seeking to move from isolated green initiatives to embedded, system-level sustainability practices. The moderation effect of SL underscored its pivotal role in guiding entrepreneurial initiatives toward sustainability. While EL promoted creativity, innovation, and calculated risk-taking essential for addressing complex healthcare challenges these behaviors might have lacked alignment with long-term ethical and environmental goals without SL. SL ensured that entrepreneurial efforts were grounded in sustainability principles, emphasizing responsible resource use, ethical decision-making and organizational resilience. This finding extended prior work on green transformational leadership (GTL), which fostered intrinsic motivation and environmental engagement by demonstrating that sustainability-oriented leadership strengthened the conversion of entrepreneurial intent into measurable sustainable behaviors (Deng et al., 2022; Farrukh et al., 2022; Li et al., 2020).

TPS as a Mediator

The mediating role of TPS clarifies how EL led to SDB. EL typically encouraged idea-sharing, experimentation, and constructive risk-taking. Nevertheless, staff might have hesitated to voice ideas without TPS, fearing criticism or failure. TPS created a climate in which individuals felt comfortable contributing and challenging assumptions, thereby enabling co-created solutions. TPS was the mechanism linking EL to sustainable clinical practices, allowing leaders’ encouragement to become daily behaviors that foster a supportive environment for staff to share ideas and collaborate effectively. These findings align with prior evidence that leadership and climate jointly promote creativity and innovation, and they suggest that TPS is a key mechanism through which EL translates into everyday sustainability practices (Fu et al., 2022). Similarly, Younis and Hussain (2023) found that green transformational leadership mediated the relationship between human resource practices and perceptions of a sustainable work environment through a green psychological climate, emphasizing the value of psychological factors in sustainability initiatives. In the context of radiography, managers who prioritize green strategies can substantially reduce the environmental impact of radiology departments by implementing practices such as energy-efficient imaging technologies and waste-reduction initiatives. A systematic review also stressed that investing in leadership development and encouraging collaboration between clinical and technical teams are important for making healthcare systems more environmentally friendly (Federico et al., 2025).

In the model, EL drove innovation, SL ensured ethical and long-term alignment, and TPS enabled open idea-sharing and sustained adoption. Together, these factors explain why leadership development and collaboration powerfully enable sustainability across clinical departments. The results further clarify this relationship: GTL training enhanced green creativity and ecological behavior among nurse managers and staff (Moustafa Saleh et al., 2024). Taken together, it becomes clear that leadership capabilities can be trained. When training is paired with a clear sustainability orientation, SL, and climate enablers such as TPS, organizations can accelerate the translation of innovative ideas into sustained green practices.

Implications for Nursing Practice

The findings of this study have important implications for nursing practice, particularly for nurse managers and frontline nurses involved in implementing sustainable healthcare practices: Nurse managers should receive targeted training in EL and SL to balance innovation with ethical, long-term sustainability goals in clinical practice. Creating a psychologically safe environment is essential for nurses to share ideas without fear of criticism, enabling creativity and sustainable care innovations. Because nurses are at the forefront of patient care and resource utilization. Leadership that prioritizes sustainability can encourage the adoption of eco-friendly protocols, waste reduction, and more efficient resource use. In addition, nursing leaders should strengthen interdisciplinary collaboration with professionals in radiology, pharmacy, and administration to integrate sustainability into patient care pathways better. Sustainability principles should also be embedded in nursing curricula and hospital policies to prepare nurses to lead and advocate for green healthcare practices.

Strengths and Limitations

Strengths of the study introduce a unique model linking of EL, SL, and TPS to predict SDB among nurses, enhancing both theoretical and practical implications. A multicenter approach with a sample size of 318 adds credibility and applicability in the Egyptian healthcare context. Practical Relevance: Findings provide actionable insights for nurse managers and nursing teams, offering strategies to embed sustainability into everyday clinical practice. Integration with Current Evidence: The study aligns with and extends prior research on GTL and sustainability in healthcare, reinforcing its theoretical robustness. Highlighting TPS as a mediator adds depth to understanding how leadership behaviors translate into sustainable actions among nurses.

Several limitations should be noted. The cross-sectional design limited causal inference. Although procedural and statistical controls were used, common method bias cannot be fully excluded because the data were self-reported. The convenience sample from three university hospitals may also limit generalizability. In addition, the hierarchical Egyptian healthcare context may represent a boundary condition for interpreting the findings in other settings.

Conclusion

EL and SL synergistically promote SDB in nursing, amplified by TPS, offering novel insights into leadership mechanisms for sustainability. It contributes to nursing leadership research by integrating entrepreneurial and sustainable approaches, addressing gaps in relational styles’ impact on workforce behaviors and patient outcomes, and providing a roadmap for nursing leaders to drive change. Nurse managers who combine entrepreneurial agility with sustainability principles and create psychologically safe environments can empower nursing teams to innovate and adopt green practices. These efforts not only reduce environmental impact but also enhance patient care quality and organizational resilience, positioning nurses as key agents in building a sustainable healthcare future.

Footnotes

Acknowledgements

We would like to acknowledge the support of Prince Sattam bin Abdulaziz University for funding this research under project number PSAU/2024/R/1445. We express our heartfelt gratitude to everyone who participated in the study.

ORCID iDs

Mohamed Hussein Ramadan Atta

Asmaa Kamal Ahmed

Ethical considerations

The study received approval from the Ethics Committee of the Faculty of Nursing, xxx University (ID/Zu. Nur. REC#:0116 on 20/8/2023). Following an explanation of the study’s objectives, the medical and nursing directors of the hospitals and the head nurses of various departments also granted permission to conduct the study. Participants were informed of their voluntary participation in the research, and the cover letter ensured confidentiality. Consent was obtained through questionnaire completion. The study adhered to the ethical principles outlined in the Declaration of Helsinki and received approval from the Ethics Committee of the Faculty of Nursing, Zagazig University (ID/Zu. Nur. REC#: 0116 on 20/8/2023). Before data collection, approval was obtained from the medical and nursing directors of the hospitals, as well as from the head nurses of the respective departments. All participants were informed about the study objectives, procedures, and the voluntary nature of their participation.

Consent to participate

Participants provided informed consent by completing the study questionnaire, in accordance with the approved protocol. The cover letter accompanying the questionnaire stated that all responses would remain confidential and that personal information would be protected. Completion of the questionnaire indicated participants’ consent to take part in the study.

Author contributions

Alia Ibrahim Mohamed: conceptualization, methodology, investigation, writing the original draft, and project administration. Mohamed Hussein Ramadan Atta: Investigation, validation, writing, review, editing, and supervision. Ahmed Hashem El-Monshed: formal analysis, resources, methodology, writing – review & editing. Asmaa Kamal Ahmed: data curation, writing review & editing, and project administration. All authors contributed to the final manuscript, approved the submitted version, and agree to be accountable for all aspects of the work. Every author has read and approved the final article, which includes important intellectual content.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

“Data are available on request from the corresponding author.”*

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