The studies reviewed emphasize the critical role of leadership in NICUs, highlighting both the complexity of leadership interventions and their impact on team performance and clinical outcomes. Loganathan’s pilot study, which compared teams with and without a dedicated leader, found no significant differences in terms of visual attention, behavioral skills, or self-reported workload. However, the team without a leader reported significantly higher physical demand and workload, suggesting that even in the absence of measurable improvements, the presence of a leader is essential for reducing team stress and improving dynamics [9].

The results reinforced the idea that leadership in NICUs goes beyond the individual leader. Kuntz and colleagues highlighted that shared understanding and vision between nurse-physician co-leaders, achieved through joint development programs, are crucial for fostering a safety climate and enhancing interprofessional cooperation [13]. This collaborative leadership model emphasizes teamwork and patient safety, a point echoed by other studies advocating for co-leadership and team training as means to improve communication and safety [19]. Transformational and self-leadership had a positive influence on job adaptivity [3].

Several studies demonstrated that structured teamwork training could significantly improve teamwork skills, leadership, communication, and mutual support within NICUs, enhancing team performance and patient safety [13, 15,16,17]. Leadership interventions such as simulation training, co-leadership models, and structured team training show promise in improving teamwork and clinical skills. However, the complexity of neonatal care necessitates continuous adaptation and evaluation of leadership strategies [10]. Future research should focus on assessing the long-term impacts of these interventions and exploring how leadership can be further integrated into training programs to address the unique challenges faced by NICU teams [20].

The findings of this systematic review fill a gap in the existing evidence and highlight the crucial role of leadership in NICUs. Previous research underscores that effective leadership enhances patient outcomes, improves staff morale, and fosters a culture of safety and collaboration [20]. Collaborative and inclusive leadership models reduce clinical errors and promote psychological safety within healthcare teams. These factors contribute to a supportive environment where healthcare professionals feel valued and empowered to voice concerns, a critical component in high-stress settings like NICUs.

In addition, Ngwenya’s study demonstrates that leadership focused on resource management and organizational strategies can have a substantial impact, especially in settings with limited resources [12]. However, Nishida’s cluster-randomized trial, which evaluated a comprehensive quality improvement program in NICUs across Japan, did not demonstrate significant improvements in clinical outcomes for very-low-birth-weight infants. Despite the extensive nature of the program, the lack of improvement may underscore the challenges of implementing large-scale interventions in the complex, high-risk environment of neonatal care [10].

This systematic review offers a thorough analysis of leadership interventions in diverse NICU settings, drawing from data across multiple countries and study designs. The inclusion of both observational and randomized studies strengthens the findings, providing a comprehensive view of how leadership impacts team performance and patient outcomes. The methodology employed, along with the broad search query, facilitated the retrieval of a wide range of relevant articles, ensuring a robust and inclusive collection of studies. These factors collectively enhance the reliability and generalizability of the review’s conclusions.

However, this review has some limitations. First, the heterogeneity of the included studies in terms of design, sample size, and intervention type may introduce variability that could affect the generalizability of the results. Second, while most studies reported statistically significant findings, a few did not, potentially indicating publication bias toward positive results. Additionally, differences in healthcare systems and cultural contexts across countries may influence the applicability of certain leadership models in different settings. Finally, the reliance on self-reported measures for evaluating leadership and teamwork performance in some studies may introduce response bias, limiting the objectivity of the findings.

Future research should focus on longitudinal studies to assess the long-term impact of leadership interventions in NICUs. Comparative studies across different healthcare systems could also provide valuable insights into contextual factors that influence leadership effectiveness. Moreover, exploring the role of co-leadership models and their impact on team dynamics and patient outcomes could offer practical solutions for managing “fluid teams”.