Leading Change in Healthcare: A Systematic Review of Middle Management's Role

Background: Healthcare organizations are experiencing continuous transformation driven by digitalization, workforce challenges, quality improvement initiatives, and increasing service complexity. While strategic change is often initiated by senior leadership, its successful implementation largely depends on middle managers who operate at the intersection of strategy and frontline practice. Despite their pivotal role, the literature on middle management's leadership and sustainability of change in healthcare remains fragmented and underexplored. Aim: This systematic review aimed to critically synthesize empirical evidence on the role of middle managers in leading and implementing change within healthcare organizations. Method: A systematic review design was employed. A comprehensive literature search was conducted across selected electronic databases for peer-reviewed studies published between 2020 and 2025. Studies focusing on middle managers in healthcare settings and their involvement in change leadership were included. Following duplicate removal, title and abstract screening, and full-text assessment, ten primary studies met the inclusion criteria. Data were extracted systematically and synthesized using a narrative and thematic approach. Results: The findings revealed that middle managers played a central role in translating strategic directives into operational practice, facilitating communication, and supporting staff engagement during change processes. Key themes included change translation and implementation, leadership behaviors influencing workforce engagement, cultural and accountability leadership, digital transformation readiness, and constraints on leadership capacity. Transformational and supportive leadership styles were consistently associated with positive change outcomes, while resource limitations, workload pressures, and role ambiguity emerged as persistent barriers. Conclusion: The review demonstrated that middle managers are critical drivers of successful change in healthcare organizations. Strengthening leadership development, organizational support, and enabling conditions at the middle-management level is essential for achieving sustainable transformation and improving healthcare system performance.