The self-leadership concept has emerged from the self-management concept. This prompted researchers to explore the concept of empowerment as an alternative to a heroic leadership model [1]. In an organizational setting, self-managing work teams should behave in a manner that indicates self-leadership strategies in personal goal setting, self-reward and self-observation. However, this requires training interventions to improve performance and enhance job motivation [1].

Self-leadership is the act through which individuals express self-influence over their way of thinking and their practices at work [2]. Multiple studies indicate that employees develop self-leadership strategies to improve their attitude and workplace performance, giving them a sense of self-reward rather than external influence. A previous study tested the impact of the involvement of self-leadership on engagement in work, performance, and well-being of 195 healthcare employees from different organizations by proposing a hypothesis that the trained employees can influence autonomously their behavior and cognitions which will affect their engagement in work, apparent performance, and wellbeing [3]. The results showed that self-leadership training positively influences healthcare professionals' performance and work engagement without directly affecting general health. However, improved engagement in work was found to mediate the impact of training on health. Hence it was concluded that healthcare workers who are more engaged in their jobs have better performance and general health [3]. Self-leadership also involves using set strategies to manage one’s perceptions and behaviors in order to become more self-driven toward personal goals, identify needs, and work effectively [4]. Therefore, the development of self-leadership requires the acquisition of self-awareness, goal setting, and self-motivation, as well as the development of constructive thought patterns.

Self-leadership can be used in different fields and settings, such as businesses, governmental organizations, and the healthcare sector. In healthcare, self-leadership is vital for the development of self-motivation since the work within this field is often stressful, dissatisfying, and demanding, leading to high levels of absenteeism and early exit from the healthcare industry [5]. Self-leadership, therefore, allows individuals in the healthcare sector to take responsibility and initiative by using the available self-influencing strategies to improve self-motivation and well-being [5].

According to researchers, individuals with highly developed self-leadership skills are less reliant on situational management mechanisms and can independently establish what (guidelines and goals), why (direction), and how (methods) to do things [6]. True self-leadership is characterized by the ability to completely embrace one’s own actions and to act on the basis of higher-order considerations. It also requires behavioral and cognitive self-influencing methods (such as positive thinking and natural reward strategies) to maximize motivation, well-being, and performance [6]. A previous study showed that these strategies are a combination of behavioral and cognitive techniques that are designed to increase good feelings and self-motivation. The authors argued that it is possible to create more pleasant working environments to get natural rewards intentionally. In their view, by shifting the mental emphasis from painful components of one’s work to the pleasant, naturally rewarding ones, one may cognitively improve natural rewards as well [7].

Macro and micro levels of an organization are affected by self-leadership, as there is a direct correlation between self-leadership tactics used by staff and their work satisfaction [8]. The same is true for the health sector, where various characteristics and aspects of the work environment, the happiness of employees, and a company's success are interrelated [9]. The leaders are thus required to assist their subordinates in learning the skills needed for them to succeed in their positions and improve their leadership abilities. Self-leadership is instrumental in this process, as each leader and follower have an equal chance of acquiring power in this system [10]. Self-leadership is vital in the new kind of leadership to help organizations overcome the challenges of the 21st century.

A meta-analysis was performed to evaluate the role of self-leadership, and its principal strategies, including behaviour-focused, natural rewards and constructive idea approaches as interpreters of self-efficacy, job attitudes and job performance. The results of the study indicated that self-leadership was significantly related to conscientiousness, directness, extroversion, and transformational leadership [2]. It was suggested that encouraging self-leadership in employees might foster valuable cognition, feelings, and behaviours. Hence concluding that the training programs for self-leadership could affect particular approaches for coaching depending on the required outcomes [2]. As far as our knowledge, no systematic review has been conducted on self-leadership in Saudi healthcare.

The Saudi healthcare system is already highly developed, but it is expected to advance further due to the health sector transformation program (HSTP) incorporated into the Saudi Vision 2030, launched to define responsibilities and commitments, set objectives, and support developmental and economic efforts. Specifically, it aims to restructure the Saudi health sector and boost its capabilities and status as a value-based, integrated, and effective ecosystem centered on patients’ health. Like many establishments, this program considers leadership essential in achieving its goals and sustainability [11]. Leaders help direct organizational resources to achieve goals and improve efficiency.

Through disease prevention and public health promotion, HSTP strives toward financial sustainability and transparency. This mission is realized through guidance and motivation from effective leaders who offer clarity of purpose. Consequently, the program facilitates access to insurance and free healthcare services for society, including visitors, residents, and citizens [12]. This modern healthcare model will require leadership skills in the distribution of resources to ensure healthcare quality improvement, digital solutions expansion, and comprehensive and fair geographical coverage. Effective leaders will ensure that HSTP improves traffic safety awareness among communities and implements global best and value-based practices, increasing beneficiary satisfaction levels [11].

Moreover, during the COVID-19 pandemic, leaders in Saudi Arabia were recognized for their contribution in response to social, economic, and health turmoil associated with the pandemic. The country was commended for handling this crisis better than most other countries as it overcame its challenges, emerging among the best-performing markets with a significant rise in value [13]. Similarly, the population experienced positive well-being and was ranked first among Arab countries in the World Happiness Report, which has provided opportunities for new wellness and health tourism packages and increased medical tourism [14]. In addition, in partnership with political leaders, the program leadership fulfilled its ambitious social and long-term plan of reducing dependency on crude oil. This achievement resulted in improved healthcare economic potential by facilitating access to emergency health services.

Considering leadership in the HSTP context is important since the program objective is identifying challenges experienced by government agencies, and the project requires institutional capacity to achieve its goals. Improving healthcare quality to the levels that meet expectations requires commitment from all employees, including administrators, health practitioners, and physicians [15]. Due to the increasing transformation, innovation, and adoption of digital technologies, leaders must educate workers on innovations and bring about change. Therefore, this research aims to systematically review extant studies focusing on the factors that exert both positive and negative influences on self-leadership in the Saudi Arabian health sector.

This systematic review followed the PICO (population, intervention, comparison, and outcome) research strategy and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) approach for reporting and presenting the gathered information. It aimed to provide evidence on the level of training on self-leadership that healthcare workers in Saudi Arabia receive by assessing, locating, and summarizing the available research findings. Its further objective was s to identify future directions for studies in this domain.

Nine papers fully met the inclusion criteria, as demonstrated by the PRISMA flow diagram presented below. The electronic database search produced 486 relevant articles, and a further 106 articles were identified via other search methods. These 592 potentially relevant articles included 93 duplicates, which were eliminated. The authors then reviewed the abstracts and titles of the remaining 499 articles to determine their potential relevance, which led to the exclusion of 346 articles due to irrelevance. The full text of the remaining 153 articles was thus reviewed, and 144 articles were further excluded based on limited information on the factors influencing self-leadership. Thus, only nine articles satisfied all the eligibility criteria and were included in the qualitative synthesis below.

Fig. (1). PRISMA flow diagram.

Fig. (2). Risk of bias summary (Joanna Briggs checklist).

This literature review offers critically synthesized information about the positive and negative factors influencing self-leadership in the Saudi Arabian health sector. As presented by Alshammari et al. [24], the level of emotional intelligence among nurses showed a positive relationship with the level of leadership. However, Baker and Alghamdi [18] found no link between job satisfaction, leadership, and support among nurses, indicating that nurse educators and nurse managers have the opportunity to choose leadership styles and orientation programs for new graduates. Their study suggests that nurse leaders in Saudi Arabia should remain consistent in developing and retaining competent nurses in the organization. Alaaddin et al. [23] similarly called for leadership and emotional intelligence training as prerequisites for the development of highly qualified personnel.

According to Alabdulbaqi et al. [17], as most nurses in the Saudi Arabian healthcare sector are non-Saudi and only have diplomas, more efforts are required in recruiting Saudi nurses as well as nurses with bachelor’s degrees. Albagawi et al. [26] further argued that lack of training on leadership skills in the healthcare settings in Saudi Arabia has led to nurse managers being solely responsible for decision-making which has resulted in hospital environments where nurses did not feel motivated and supported when performing tasks. Nurse leaders use the following leadership styles to lead other nurses: transformational leadership, transactional leadership, authentic leadership, situational leadership, classical leadership, and contemporary leadership.

In Saudi Arabia, leadership styles are the major factor affecting the attitudes and behaviors of nurses in healthcare settings. Despite the evidence that nurse managers have a direct and substantial effect on the healthcare environment, there is little research on the leadership styles nurse managers use in Saudi Arabia. According to Aboshaiqah [27], many issues nurses working in Saudi Arabia experience (such as shortages of staff, job satisfaction, and intention to leave the job) are caused by inadequate leadership. Research shows that the retention of nursing staff is an important factor for healthcare organizations in Saudi Arabia. Yet, according to Al-Yami et al. [25], little is known about the impact of leadership styles on outcomes in Saudi Arabia.

Research shows self-leadership is associated with positive work engagement through feedback and development opportunities. Therefore, training employees on self-leadership can be a valuable tool to help enhance the adaptive performance and job satisfaction during organizational crises. As presented by Alshahrani [19], the association between self-sacrificial leadership and work engagement is mediated by job satisfaction in the Kingdom of Saudi Arabia. The author further noted that the self-sacrificial leadership approach may outperform conventional leadership styles in multiple ways.

As presented by Al-Dossary [21], the differences in the leadership styles among nurse managers and nurses that result in issues in nursing management can be addressed by encouraging nurse managers to demonstrate transformational leadership to enhance the development of respect, competence, and mutual trust [20]. Algarni et al. [22] stated that there was a need for a clear security system for both leaders and employees in the healthcare sector to protect the rights of each person. Leaders helping employees, having moral criteria for employment, individualizing their motivation, and evaluating the employees’ mindset were some of the factors affecting leadership performance according to this study.

In summary, the most important factors of self-leadership that emerged from this review are emotional intelligence, education, job satisfaction, job engagement, and internalized moral skills [19, 20, 24, 27]. The self-leadership in Saudi Arabia was found to have a positive association with these factors. However, Baker and Alghamdi [18] reported no statistically significant relationship between experience and preceptors of self-leadership but rather noted that stress caused by the living situation, finances, relationships, etc., was the most important factor [23]. Most authors also identified the transformational approach as the most suitable for promoting self-leadership because it involves developing a unified vision for an organization and pushing the employees to work their best individually and collectively [2, 27-29]. The employees have intrinsic motivation as well as a high understanding of what they need to change so that they can evolve personally and professionally to achieve organizational goals. Further, due to the freedom of expressing one's thoughts and preferences, the lines of communication remain open under this type of leadership [28].

This systematic review provides insight into the factors affecting self-leadership in the health sector. Therefore, the outcomes of this study might impact the theoretical and practical clinical education offered to the healthcare personnel in Saudi Arabia, which is essential to prepare them mentally and encourage them when performing their daily tasks.

Moreover, self-leadership gives staff members the self-drive and motivation to achieve their goals and to respond effectively to challenges and changes, allowing them to increase their performance in the workplace. Healthcare leaders might encourage the employees to become more positive and help them develop self-leadership skills by using training interventions which would in turn, motivate them to enhance their knowledge and improve their performance.

The main strength of this review stems from its comprehensive search approach and deep data synthesis and analysis. However, as the review focused on self-leadership among nurses in Saudi Arabia, no generalization of findings to other settings is possible. This systematic review has implications for self-leadership in the Saudi Arabian health sector, as more research is required to develop more appropriate training aimed at healthcare workers. Further research on self-leadership in Saudi Arabia is needed to validate the findings and offer further insight into this phenomenon. It is presently unclear how different leadership styles affect the performance of nurses in Saudi Arabia, thus warranting additional studies.