Entrepreneurial leadership, nurses’ proactive work behavior, and career adaptability: a structural equation model

Background Healthcare organizations with practitioners who exhibit proactive work behavior and career adaptability acquire a competitive advantage in the face of many adversities. Entrepreneurial leadership (EL) is a new leadership approach that has a huge impact on followers’ behavior, although research into its theory and empirical evidence is still in its infancy. Methods A non-probability convenience sample methodology (n = 450) was utilized to choose study participants, who were equally dispersed among the two private hospitals in Alexandria. A cross-sectional study was carried out in all departments of the hospitals, which were chosen at random using a simple random procedure. Three validated scales were used in this study to measure the study variables and establish a structural equation model. Results The result of this study revealed that nurses perceived moderate mean scores of all variables; entrepreneurial leadership (140.84 ± 11.94), proactive work behavior (46.02 ± 5.85), and career adaptability (85.55 ± 10.35). In addition, the structured equation model revealed a goodness fit index and presents that entrepreneurial leadership significantly affects nurses’ proactive work behavior with an estimated β of 0.555, coefficient of regression C.R. of 4.006, at P value < 0.001. Also, it significantly affects career adaptability with an estimated β of .834, a coefficient of regression C.R. of 3.491 at P value < 0.001. Conclusions The developed structural equation model confirmed the significant impact of entrepreneurial leadership (EL) on nurses’ proactive work behavior (PWB) and career adaptability (CA)”. Therefore, this study offers important implications for nurse managers, staff nurses, hospital human resources management practice, and academics.

fostering a positive public perception.By enacting a unique kind of leadership called entrepreneurial leadership (EL), which varies from traditional managerial leadership.This style highlights a leader's qualities and actions that may foster entrepreneurial behaviors.Those behaviors like spotting and seizing opportunities, encouraging proactive work habits, and encouraging career flexibility among nurses to achieve favorable career outcomes and organizational triumph in the healthcare industry [1][2][3][4].

Theoretical framework
The research paradigm is elucidated by Bandura's social cognitive theory (SCT), which offers a theoretical framework for grasping the effect of entrepreneurial leadership on nurses' proactive work practices and career adaptability.According to SCT, an individual's beliefs, deeds, and perceptions impact how they engage with behavior.Social structures and environmental influences often play a role in the development and change of human beliefs and cognitive capacities in this interaction between an individual and their surroundings.An individual's conduct influences the features of their environment, which in turn influences their behavior, constituting the ultimate interaction between the environment and behavior [5].The proposed conceptual framework in this study is built using this theoretical framework as a guideline (Fig. 1).

Entrepreneurial leadership (EL)
EL is the conduct of a leader who captivates followers with a compelling vision, gains their loyalty, and dedicates themselves to identifying and generating strategic value.EL combines the management of start-ups' leadership with their entrepreneurial drive, enabling new businesses to create the required diversity and navigate a complex, dynamic environment by identifying avenues for growth, taking calculated risks, pointing out directions, and putting ideas into action.By their distinctive offerings, leaders methodically and interpersonally lead, facilitate, and mobilize a group of followers toward achieving exceptional performance and fulfilling the corporate goal.Nurse Managers have the potential to invigorate work activities by formulating a novel vision that can profoundly impact nurses' capacity for career flexibility and proactive work habits [6][7][8].
EL comprises seven key components.Framing the challenge is the ability of entrepreneurial leaders to set extraordinarily lofty goals and standards for the competence of people and their work.Absorbing uncertainty refers to an entrepreneur's ability to take risks, foresee potential future developments, accept responsibility, form a vision, see the possibilities, and instill confidence in the staff.Underwriting is a way for an entrepreneurial leader to show their engagement in interpersonal negotiations and use their persuasive skills to persuade others to accept their ideas while also providing direction and support to followers [9,10].
Building commitment involves inspiring followers, fortifying the group's dedication to achievement, and fostering a sense of cohesion and collaboration among teammates.Defining gravity is the capacity to develop unity and cohesion via mutual understanding and consensus over the goals that need to be accomplished.Identifying and exploiting opportunities is defined as the entrepreneurial leader's capacity to assess the variables that influence the probability of success or failure and Fig. 1 Proposed researchers' study framework make informed decisions.Orientation towards learning is an attitude toward learning that emphasizes development programs, being current with developing trends, and having a sharp sense of where to find relevant information [9,10].
It has been shown through studies that EL enhances both individual and organizational performance.It acts as a catalyst to boost an organization's competitiveness by empowering it to successfully negotiate environmental and crisis-related challenges and achieve sustainable growth, holistic care, and preservation.Additionally, it had a major impact on the development of strategies and tactics that promote creativity and opportunity recognition as well as unrestricted behavior (proactive, inventive, and organizational citizenship behavior) by modifying, responding to, promoting, and utilizing opportunities in the workplace to improve enactment [6][7][8][9][10][11][12].

Proactive work behavior (PWB)
PWB entails anticipation, planning, and action to influence the future.It is also characterized as predictive, self-generated activities aimed at the future to improve the situation at hand or one's personal qualities.Furthermore, it was clarified that an individual's aspirational conduct, which is typified by a proactive strategy incorporating a proactive mentality, eagerness, and inventiveness, can initiate a shift in the current circumstances or generate new chances inside the workplace.PWB differs from a reactive and passive mindset that entails waiting for uncontrollable outside events to occur [13][14][15].
Four elements are integrated into PWB.Taking charge is an intentional, self-directed endeavor started by nurses who are actively working to bring about good change inside the enterprise.Voice is the intention of attaining a favorable result.Individual innovation is a practice that comprises creating and utilizing advantageous modern thoughts to support the organization's strategic durability and productive work.Problem prevention involves identifying the root of the issue and taking action to stop it from happening again soon.These proactive, independent preventative efforts are crucial to preventing workplace problems from recurring [16,17].
PWB is essential for fostering career adaptability (CA) and attaining positive adaption outcomes, such as task competency, individual inventiveness, lower turnover, improved performance, and enhanced productivity that benefits the business.It helps nurses deliberately become experts in their work environment, especially when faced with change and uncertainty.This can help them feel competent in their roles.To anticipate upcoming trends and chances for gaining a competitive edge, it also functions as issue-selling and proactive external milieu analysis [18,19]..

Career adaptability (CA)
CA is a psychosocial foundation and a concoction of attitudes, abilities, and behaviors that help people manage difficult situations in their line of work, such as disappointments, traumatic experiences, and upcoming or current job changes.It's a capacity to handle the predictable duties involved in getting ready for and doing a job, as well as the erratic alterations brought on by changes in the workplace and its surroundings.Additionally, it enables nurses to make career decisions and handle workplace difficulties by understanding both themselves and their occupation.As a result, nurses must be prepared to learn novel talents and adopt new working styles to deal with advances [20,21].
Concern, control, curiosity, and confidence are the four hallmarks that comprise career adaptability.The concern is a future-oriented dimension of CA and comprises the mental process of imagining prospective career paths and devising strategies to accomplish professional objectives.Control demonstrates how much nurses endorse self-control and accept responsibility for their future occupational success, establishing a feeling of autonomy and precision and facilitating an efficient performance of professional and developmental duties.Curiosity refers to the exploration of one's potential professions.It arises from a curious attitude toward future work opportunities as well as a willingness to investigate scenarios when faced with career changes.Confidence is described as feelings of self-confidence and nurses' belief in their capacities to pursue professional goals and aspirations in the face of threats [22].
CA improves career management and provides a better understanding of work-related concerns.It has a favorable impact on occupational and work outcomes, including job success, job performance, well-being, employability, entrepreneurial intentions, and professional fulfillment, as well as lower job stress and attrition [23,24].

Significance of study
Nurses' performance has been influenced by many factors, including their usage of the internet, telecommunications, and highly revolutionary technology like artificial intelligence.Furthermore, because of the current COVID-19 outbreak, nurses have faced increased work pressures, a work-life imbalance, and a nursing shortage, according to the ICN study report 2023.The nurse shortage has increased dramatically from 30.6 million in 2019 when the epidemic began.Furthermore, COVID-19 has altered the dynamic structure of contemporary organizations, forcing both practitioners and scholars to focus on establishing work behaviors that are change-oriented, future-focused, self-starting, and career-adapted.These variables are reflected in scholars' findings and documented high levels of nurses' turnover intentions, low percentage of career adaptability, and proactive work behaviors among nurses [25][26][27][28][29][30].
Among several contextual factors, EL is an emerging leadership style that is still in its embryonic stages of empirical and theoretical development and has a considerable impact on the behaviors of followers [31].Despite previous research demonstrating the importance of entrepreneurial leadership, less is known about the influence of nurse managers' EL behaviors on nurses' PWB and CA.Therefore, this study addresses this empirical knowledge gap theoretically and empirically and gives further exploration of the importance of EL for nurse managers in improving PWB and the CA of nurses.

What is the relationship between EL, nurses' PWB, and CA?
Null H0: There is no significant relationship between EL, nurses' PWB, and CA.
Alternative H1: EL as an independent variable will significantly correlate with both nurses' PWB and CA.

The aim of the study
This study is directed at developing a structure equation model for testing the relationship between entrepreneurial leadership as an independent variable and nurses' proactive work behavior and career adaptability as a dependent variable.

Research design and setting
Based on the proposed framework, a cross-sectional and correlational study was done using three validated scales to measure the study variables.This study was conducted in all departments at two private hospitals in Alexandria that were selected randomly through a simple random method after conducting a sampling frame of all private hospital names that were similar in the types of service provided and slightly had the same bed capacity and number of nurses.

Participant
In this study, a non-probability convenience sampling technique of (n = 450) nurses was utilized to collect data, with an equal number from each selected hospital (n = 225).To be considered, participants had to meet the following criteria: (a) have more than 3 months of experience; and (b) willingly participate.

Instruments
Tool (I): entrepreneurial leadership questionnaire (ELQ) This tool was developed by Bagheri and Harrison (2020) and has strong internal consistency in previous studies to examine nurses' perceptions of their nurse managers' EL practices [10,32].It is made up of 40 items with high internal reliability (α =0.98) that are organized into seven dimensions: framing the challenge (5 items), underwriting (5 items), defining gravity (5 items), orientation towards learning (5 items), absorbing uncertainty (4 items), building commitment (6 items), and opportunity identification and exploitation (10 items).The replies were graded on a 5-point Likert scale, with 1 being strongly disagreeing and 5 being strongly agreeing.The overall mean score varied from 40 to 200, with a score of (40-93) indicating low nurses' perception of their nurse managers' EL practices, a score of (94 -less than 147) indicating moderate perception, and a score of (147-200) indicating high perception.

Tool (II): proactive work behavior scale (PWBS) Parker
and Collins (2010) constructed this tool, which has shown good internal consistency in earlier research to assess the frequency of nurses' PWB [33,34].The survey consists of 13 highly reliable questions (with a reliability score of α = 0.93) and is divided into four categories: taking responsibility (3 questions), voice (4 questions), individual innovation (3 questions), and problem prevention (3 questions).The responses were graded on a 5-point scale, ranging from (1) extremely infrequent to (5) very regular.The overall average score ranged from 13 to 65, with scores between 13 and 30 indicating a low frequency of perceived PWB (psychological well-being) among nurses, scores between 31 and less than 48 indicating moderate frequency, and scores between 48 and 65 indicating high frequency of perceived PWB among nurses.Porfeli and Savickas (2012) settled this scale and demonstrated excellent internal consistency in earlier research to assess nurses' perception of CA [22,35].It is made up of 24 elements with good internal dependability (α = 0.90).Concern (6 items), control (6 items), curiosity (6 items), and confidence (6 items) were the four dimensions.The replies were graded on a 5-point Likert scale, with 1 being strongly disagreeing and 5 being strongly agreeing.The total mean score varied from (24 to 120), with the score from (24 to less than 56) indicating a low level of CA, the score from (56 to less than 88) indicating a moderate level of CA, and the score from (88 to 120) indicating a high degree of CA.

Tool (III): career adaptability scale (CAS)
Furthermore, the study subject's demographic characteristics and work-related data sheet, which include questions on age, sex, marital status, educational background, and length of job experience.

Validity and reliability
Cronbach's alpha correlation coefficient was utilized to assess the internal consistency of the study instruments.The results confirmed that the three instruments were reliable.Five academics in the field evaluated the translation's fluency and content validity by translating tools into Arabic for Egyptian cultural relevance.As a result, several elements have been changed to improve clarity.Language experts then translated the tools back into English.The researchers and jury members assessed the back-translations to verify accuracy and reduce any threats to the research's validity.We also conducted a test run on 45 nurses (10%) who were not study participants to verify that the tools were clear and applicable, as well as to estimate the amount of time it would take to complete the questions.Considering the pilot research findings, no amendments have been made to the final tools.

Data collection
Having formal approval from the governing body for the designated environment enabled data collection to take place.Data was collected after the researchers described the purpose of the study and obtained subjects' consent by delivering questionnaires personally to study participants.Each nurse completed the questionnaires in around 30 minutes.Data was collected over 4 months, from February to May of 2023.During data collection, the researchers tried to overcome the common method biases by ensuring confidentiality and anonymity of replies as they notified the participants that the information they provide will be safely stored, combined, and utilized exclusively for the study.Additionally, the researchers used various response forms to gather the required data, create surveys with items arranged in a random sequence, and gather data at various intervals.

Statistical analysis
Cronbach's alpha was used to assess the tools' dependability.The participant's demographic data and study variables were analyzed using frequency and percent; the study variables were described using a mean score and standard deviation.Pearson's correlation was used to study the associations between EL, PWB, and CA.AMOS Ver.23 was utilized to investigate the impact of entrepreneurial leadership on nurses' proactive work behavior and career adaptability through structural equation modeling (SEM).The model fit indices included the evaluation of; χ2/df = Chi Square/degree of freedom, CFI = Comparative fit index; IFI = Incremental Fit Index; RMSEA = Root Mean Square Error of Approximation; NFI = Normed fit index; RFI = Radio Frequency Interference; NNFI (Non-Normed Fit Index); SRMR (Standardized Root Mean Square Residual); GFI (Goodness of Fit Index); AGFI (Adjusted Goodness of Fit); TLI (Tucker-Lewis Index).The model can be judged for its fitness based on Schermelleh et al., (2003) [36]

Background characteristics of the participants
The mean age of the staff nurses was 34.20 ± 7.72 years.
Half of them were in the age group of 30-40 years old.Most of them (92%) were female, and more than twothirds (66.7%) were married.Concerning educational qualifications, 43.5% of them had a bachelor's degree in nursing science.The mean years of experience were 9.12 ± 5.24 years, with 30.9% of them having 5 to less than 10 years of experience.Table 4 clarifies that there was a statistically significant positive moderate correlation between EL and PWB, EL and CA, and CA and PWB where (r = 0.449, p = 0.000**), (r = 0.359, p = 0.000**), (r = 0.319, p = 0.002**).
Table 5 and Fig. 2 Testing on construction models was done to confirm the suggested research hypothesis.According to the test results, the goodness of fit index is composed of the following values: CFI = 0.928; IFI = 0.930; RMSEA = 0.082; TLI = 0.910; RMR = 0.276; SRMR = 0.090; X 2 = 134.789;P = 0.000; df = 84 and χ2/df = 1.605.However, the values of NFI = 0.834; RFI = 0.793; GFI = 0.845; AGFI = 0.779; and NNFI = 0.7925 were slightly less than the acceptable level.It can be claimed that the structural the majority of model's parameters revealed a good fit index.So, it can be said that this model presents that EL has a significant effect on nurses' PWB with an estimated β of 0.785, coefficient of regression C.R. of 3.415, at P value < 0.001.Also, it significantly affects CA with an estimated β of 0.997, a coefficient of regression C.R. of 2.72 at P value < 0.001.
Table 6 Initial Model Values, Modified Model Values, and One Factor Model Values of EL, CA, and PWB demonstrate the validity and reliability of the study variables.Based on the test result of Confirmatory Factor Analysis (CFA) on the construct of EL, it is seen that the value of λ (loading factor) in every dimension is > 0.5.It means that all the indicators in the dimensions have been valid (first order).Likewise, the value of CR is ≥0.70, and VE is≥0.50.Thus, it can be concluded that all the indicators used in this study have good validity and reliability values.Considering CA, the value of λ (loading factor) in every dimension is > 0.5.It means that all the indicators in the dimensions have been valid (first order).Likewise, the value of CR is ≥0.70, and VE is ≥0.50.Thus, it can be concluded that all the indicators used in this study have good validity and reliability values.As regards PWB, the value of λ (loading factor) in every dimension is > 0.5.It means that all the indicators in the dimensions have been valid (first order).Likewise, the value of CR is ≥0.70, and VE is ≥0.50.Thus, it can be concluded that all the indicators used in this study have good validity and reliability values.

Discussion
Healthcare institutions are undergoing a fast transformation in response to a variety of difficulties, including enhancing public health, generating new health concerns, applying new information, and requiring cost-effective therapies.Entrepreneurial leaders are necessary for success in this globalized society.Considering technical advancement, the economic crisis, and a volatile marketplace, an entrepreneurial leader ought to steer the firm in an upward trajectory.Additionally, the entrepreneurial leader creates possibilities, gives individuals power, and upholds connections inside the company to enhance achievement [37,38].
The current study reported that nurses reported a moderate mean EL score in this regard.Possibly the nurse managers could empower nurses to    [47,48].This finding is consistent with the study's findings, and it may be attributed to the nurses' lack of initiative in thinking through, planning, and acting to address the problem as it exists.In addition, restrict their capacity to develop novel methods, look for root causes of issues, streamline processes, and communicate concepts.Additionally, it diminished their capacity to come up with novel solutions that stop issues from happening again.They were also unable to assume leadership roles in certain aspects of the job, including missions of the hospitals, standards for nursing, guidelines, and quality assurance.
This contrasts with Molin et al. 's (2019) findings, which show that nurses in management positions exhibit more proactive behavior.These nurses are accountable for leading or developing change proposals and coordinating teams to accomplish the suggested objectives.However, Frögéli (2019) discussed how avoiding PWB helps newly registered nurses cope with the symptoms of stressrelated illness and helps them transition to their new role in the workplace [49,50].The current study's findings regarding CA showed that nurses thought their level of adaptability was moderate.This outcome may be the result of the complicated and dynamic character of the healthcare industry, as well as the fact that high workloads have limited nurses' capacity to respond to stress related to current and future career growth and deal with unforeseen circumstances and job circumstances.[29,[51][52][53][54][55][56].
A structural equation model was created to test this research hypothesis.The model's results supported H1, which states that EL has a significant relationship with nurses' PWB and CA and shows a statistically significant positive correlation between the variables under study.This may be explained by the fact that ambitious nurse entrepreneurs are more likely to have a strong desire to adapt to their careers and impart these abilities to others who follow them.Additionally, given their propensity to recognize and seize professional possibilities as well as to design work settings that align with their interests, they are well-prepared for changes that may be pertinent to their line of work.
Furthermore, EL significantly affects an organization in several aspects, including growth, profitability, creativity, and innovation.Nurse Managers are encouraged by EL to be flexible in their adaptation to an unpredictable environment; this requires being creative and prepared to take chances to change one's behavior, create new values, and take advantage of opportunities.Improve their capacity to handle both the anticipated duties of getting ready for and performing the job as well as the unforeseen alterations brought on by shifting work and working environment. The

Conclusion
The results imply and support the statistically significant relationship between EL and the PWB and the CA of nurses.This study has multiple theoretical contributions based on the findings presented in the present study.First, this research adds to the literature on entrepreneurial leadership by developing and testing a new model through which entrepreneurial leadership promotes nurses' PWB and CA.Moreover, the findings of this research have wide-ranging implications for business leaders and entrepreneurs, both existing and emerging, who ought to encourage PWB and CA among their employees to maximize the growth and competitiveness of their organizations in the long term.

Limitations of the study
The limitations of the present research provide opportunities for further studies in the area.First, we concentrated on developing a structure equation model of EL, nurses' PWB, and CA, and the limitations of this study can be illustrated as follows; the data was collected from only two private hospitals thus the generalization of findings might be restricted.Second, even though this study employed the SEM approach, the cross-sectional study design makes it impossible to demonstrate causality, which limits the evaluation of the influence of study factors.Finally, the data was collected through selfreport measures that may be sensitive to subjectivity and response bias.To address these limitations, objective metrics will be required in the future through observational, longitudinal, qualitative, empirical, and multi-site research.

Implications
The research on the influence mechanism between EL and PWB and career adaptability has theoretically been enhanced and reinforced by this study.The practical ramifications of this study extend to staff nurses, nurse managers, and hospital human resources management practices.First, this study contributes to the body of knowledge on EL by creating and evaluating a novel model that explains how nurse managers' EL fosters PWB and CA in nurses while also illuminating the relationship between these factors.
Second, there aren't any studies evaluating the impact of EL on nurses' PWB and CA that we are aware of in entrepreneurship literature.Additionally, this study offers novel insight that shows how entrepreneurial leaders enable staff members to create successful outcomes for nurses.Leaders can also utilize the study's results to support EL as a means of fostering proactivity and CA.Thus, to enhance nurses' PWB and CA as a proactive strategy for upgrading career success and outstanding organizational objectives and staying on top of the rapidly evolving healthcare industry, it is necessary to continuously update job knowledge and skills through additional training and educational programs.
Furthermore, managers can utilize the study's results to support entrepreneurial leadership in fostering proactive environments that empower staff members to take initiative, feel self-assured, and develop their career flexibility.Also, these results inspire managers to create new healthcare business chances, and detecting market needs is a fundamental aspect of EL.Structuring a strategic, operational, and sustainable healthcare business plan that will be implemented by entrepreneurial leaders and proactive staff who are adaptable to their career opportunities.Additionally, hospital managers should recruit and retain top-talent staff to build EL with high-performing teams with enduring development opportunities.The research's conclusions can also be used by academics through studying entrepreneurship in more research methodologies to better comprehend the additional tasks and duties that contemporary and aspiring business leaders must fulfill as well as to assist them hone their entrepreneurial leadership competencies.
It also prevents them from making judgments in a clear and timely manner in reaction to changes and from quickly adjusting to the workplace atmosphere.Several studies by Dateling (2021), Chen & Zhang (2023), and Zhang et al. (2023) that found a moderate level of CA among nurses corroborated the findings of this study.Additionally, average CA perception among nurses was discovered by Kwak & Kwon (2017), Kim &
as follows;

Table 1
declared that nurses perceived a moderate mean score of overall EL (140.84 ± 11.94), which represented a moderate mean score of its related dimensions: framing the challenges (18.35 ± 1.77), absorbing

Table 1
Mean score and standard deviation of nurses' perceptions of EL of their nurse manager

Table 2
Mean score and standard deviation of nurses' perceptions of the frequency of their PWB

Table 3
Mean score and standard deviation of nurses' perceptions of their level of CA

Table 4
Correlation Matrix between EL, PWB, and CA

Table 5
Structure equation modeling of EL as an independent variable and its impact on nurses' PWB and CA χ2 Discrepancy Chi Square; χ2/df = Chi Square/degree of freedom, CFI Comparative fit index, IFI Incremental Fit Index, RMSEA Root Mean Square Error of Approximation, NFI Normed fit index, RFI Radio Frequency Interference, NNFI Non-Normed Fit Index, SRMR Standardized Root Mean Square Residual, GFI Goodness of Fit Index, AGFI Adjusted Goodness of Fit, TLI Tucker-Lewis Index

Table 6
Initial Model Values, Modified Model Values, and One Factor Model Values of EL, CA, and PWB MSV is the square of the highest correlation coefficient between latent constructs MSV Woo (2018), Lee & Lee (2019), and Jahani et al. (2022)