Entrepreneurial intentions among medical doctors in a research-led hospital: The role of perceived organizational support for innovation and individual collaboration propensity

Entrepreneurship is widely recognized as a key driver of innovation and economic growth (e.g. Acs et al., 2008; Audretsch et al., 2024). In healthcare, entrepreneurial initiatives are increasingly viewed as mechanisms to improve service delivery and patient outcomes through the development and implementation of novel solutions (e.g. Lim et al., 2024; Schiavone and Vershinina, 2024).

Medical professionals, particularly medical doctors (MDs), with their unique blend of contextual knowledge and clinical experience, are well-positioned to identify unmet needs and address healthcare challenges (Kuratko et al., 2017; Schiavone and Vershinina, 2024). They are expected to engage in innovation-driven initiatives to find new solutions (Hoang and Perkmann, 2023; Toner and Tompkins, 2008; Yoda, 2016) as a result of the increasing attention that healthcare institutions pay to the commercialization of science (Wang et al., 2021) trying not to compromise organizational efficiency (Lim et al., 2024).

The necessity of balancing organizational efficiency and entrepreneurial initiatives represents one of the most complex challenges in healthcare today, which deserves academic attention and empirical investigations (Kimble and Massou, 2017). Despite growing scholarly interest, existing research offers limited insight into how individual-level factors and organizational conditions jointly shape entrepreneurial intentions (EIs) in highly institutionalized healthcare settings, leaving an important conceptual and empirical gap.

Traditionally, medical professionals have been seen as “custodians of clinical excellence”, and the transition from patient care centricity to entrepreneurship is considered far to be linear (Toner and Tompkins, 2008). Prior entrepreneurial behavior research has emphasized the role of individual differences (e.g. personality traits, beliefs, predispositions and motivations) (e.g. Covin et al., 2020) and organizational dimensions (Carlos and Hiatt, 2022) as antecedents of an individual's intentions to enterprise. However, little attention has been paid to how these factors interact in a setting such as healthcare, usually characterized by actors, activities, processes, concerns, expertise and goals different from those required for enterprising in other sectors (Glover et al., 2024; Guercini and Cova, 2018; Schiavone and Vershinina, 2024). This study now addresses precisely this gap, and it poses the following research question: How does entrepreneurial attitude (EA) among MDs translate into EIs in a research-led hospital, and what roles perceived organizational support for innovation (POSI) and individual collaboration propensity (CP) play in this process?

Building on the Theory of Planned Behavior (TPB), this study examines specific medical professionals, i.e. MDs, and the mechanisms through which their EA shape their EIs (e.g. Ajzen, 1991; Bird, 1988; Fishbein and Ajzen, 1975). The authors analyze these mechanisms in a privileged setting, such as that of the Gemelli-Science and Technology Park (G-STeP) initiative at the “Agostino Gemelli” research hospital in Rome (Italy) that exemplifies the convergence of research, clinical excellence and innovation infrastructure. The use of TPB is motivated by the need to capture evaluative components (EA), perceived social pressures (organizational support) and elements of perceived viability (collaborative propensity) in a context where entrepreneurial action does not coincide with founding an independent venture but rather with initiating change within the organization itself. This view, discussed by Miller and French (2016) advocates the “hybrid” logic where the role of research hospitals is to jointly pursue both the natural healthcare mandate related to improved patient care and the “business-like” mandate where the organization itself is a user of innovations developed by its own healthcare professionals. This is precisely the case of the G-STeP initiative, where the involvement of healthcare professionals and the support from the institution, i.e. the research hospital, should foster their entrepreneurial aspirations (Miller and French, 2016).

By integrating theoretical insights from the Corporate Entrepreneurship (CE) literature (Hornsby et al., 2002; Ireland et al., 2009; Kuratko, 2010) and the Social Capital (SC) theory, which highlights the importance of accessing to diverse resources, information and knowledge (e.g. Adler and Kwon, 2002; Burt, 1999, 2000; Nahapiet and Ghoshal, 1998), this paper also investigates the indirect (mediating) effect played by MDs' perception of organizational support for innovation (POSI), and the moderating effect played by MDs' individual propensity to collaborate (CP, high vs low).

In line with the theoretical predictions, the main findings reveal a strong link between EA and EI among MDs. Furthermore, results derived from the moderated mediation model suggest that the perception of the organization's commitment to sustaining innovation and the individual propensity to collaborate significantly enhance the translation of MDs' EAs into intentions and, in turn, into potential entrepreneurial initiatives (behaviors). In this setting, EIs refer to the willingness to initiate innovation within the organization rather than to create an independent venture. Clarifying this boundary condition allows, on one side, to reveal the role of organizational support as an important triggering social pressure element and, on the other side, to ensure alignment with the operational conditions of the MD's EA-EI nexus within the TPB framework in a structured environment (e.g. Ajzen, 1991). This framing also justifies the use of SC, which complements TPB and CE literature by explaining how individual CP shape the activation of MD's intrapreneurial intentions. SC, as a theoretical underpinning, highlights that entrepreneurial processes in healthcare are inherently relational and dependent on cross-disciplinary collaboration (e.g. Yoda, 2016) to leverage resources, information and opportunities. Its integration allows authors to theorize on how network-related behaviors, such as MDs' propensity to collaborate, condition the effect of perceived social pressure, such as organizational support, on EI.

In a healthcare context such as that of the G-STeP project, individual MDs' collaborative orientation functions as a contingent viable element to exploit organizational support measures for innovation, thus potentially enabling their intrapreneurial actions. By integrating considerations on awareness and openness to networking, the paper enriches our understanding of how propensity towards interdisciplinary interactions, trust-building and reciprocal knowledge sharing (e.g. Davidson and Honig, 2003) may act as conduits for translating organizational innovative support measures into actionable innovative projects. The relevance of the interaction between organizational and individual elements that emerged in our research contributes to the current debate in the literature on entrepreneurship within healthcare institutions (Asoh et al., 2005; Glover et al., 2024; Lim et al., 2024; Schiavone and Vershinina, 2024). By offering insights into how MDs can enhance their entrepreneurial mindsets, ultimately cultivating the idea of efficiently driving innovation in patients' health and care services (Guercini and Cova, 2018; Wilden et al., 2018), this research provides recommendations for policymakers, managers and administrators seeking to foster a culture of CE within a healthcare research-led environment (Flores et al., 2024; Miller and French, 2016).

The growing demand for patient-centered care characterizes today's healthcare systems worldwide (Toni et al., 2024). This places innovation at the forefront to face efficiency complexity and address the pressing challenges on human and social issues (Audretsch et al., 2024; Kimble and Massou, 2017). Innovation in healthcare is “centered on advancing healthcare delivery, products, or services that inherently generate social good” (Lim et al., 2024, p. 2131). This makes MDs, nurses and other medical professionals crucial to finding new and better solutions for health-related problems as it connects economic, social and human values in their actions (Schiavone et al., 2021).

By considering the current scenario, innovation in healthcare should increasingly rely on the entrepreneurial engagement of MDs, who are in a privileged position to identify unmet clinical needs and develop novel solutions (Hoang and Perkmann, 2023). Physician-entrepreneurs leverage their clinical expertise to bridge the gap between patients' needs, medical science and market-driven innovation, particularly in areas such as digital health, medical devices and telemedicine (Pisano, 2006). Nowadays, MDs are increasingly required to think beyond the boundaries of clinical care, embracing a broader vision that includes systems design, strategic thinking and leadership (Avolio et al., 2014) and proactively act and drive organizational change, including the digital transformation led by artificial intelligence (AI) (e.g. Kraus et al., 2021; Sacre et al., 2024).

The physician-entrepreneur, thus, becomes a system innovator, who not only applies medical knowledge, but also contributes to the analysis of needs and the architecture of solutions that enhance care quality, contribute to better access and reach sustainable outcomes (Glover et al., 2024). This shift aligns with the growing demand for ‘hybrid’ professionals who combine clinical authority with entrepreneurial skills (Shukur et al., 2024).

By assuming such a role, MDs can act as internal agents for change, what Mintzberg called “intrapreneurs”, who generate innovation from within the institutions (Mintzberg, 2009), representing the next generation of entrepreneurs in an unconventional setting such as healthcare (Guercini and Cova, 2018), lately called “Doctopreneurs”.

It is important to remark that, in healthcare institutions, entrepreneurial behavior is expressed through an internal commitment to identify new solutions but requiring support in the process often occurring within the boundaries of the organization (Miller and French, 2016). The literature on intrapreneurship has long clarified that the antecedents of EIs are relevant not only for prospective founders, but also for individuals who act entrepreneurially inside established organisations (Ireland et al., 2009; Hornsby et al., 2002; Kuratko, 2010). In these settings, intentions are oriented toward improving services, promoting novel practices or contributing to organizational renewal rather than toward creating an autonomous enterprise. For MDs, this means that EIs are better understood as an inclination to mobilize clinical expertise, problem-solving capacity and knowledge to advance innovation and address unmet needs from within the research hospital (Miller and French, 2016).

However, the extent to which MDs engage in entrepreneurial activities is not clearly established in the literature and various factors can play a crucial role in fostering their EIs. In the following pages, the authors discuss the choice of the theoretical frameworks selected for this research, including the considerations on the role of the organization within which entrepreneurship might flourish (Bergman and McMullen, 2022) and other individual elements potentially paving the way towards MDs entrepreneurial initiatives (Asoh et al., 2005).

In behavioral and organizational psychology studies, the cognitive hierarchy model that explains how individuals progress from internal values to outward actions, i.e. the human behavior, is made of three core elements: orientation, attitude and intentions (Grammatikopoulou et al., 2021).

In the field of entrepreneurship, intentions are considered the most accurate indicator of entrepreneurial behavior (Bird, 1988), especially when the behavior is difficult to observe, or involves long-term planning (Krueger et al., 2000). EIs refer to a conscious state of mind that precedes and directs action toward the launch of a new business initiative (Prodan and Drnovsek, 2010; Liñán and Fayolle, 2015). In healthcare, as said earlier, EIs typically unfold within existing structures, supporting internal innovation rather than new venture creation (Miller and French, 2016).

As reported in van Gelderen and colleagues (2008, p. 541): “… two models dominate the literature explaining EI. The first is Ajzen's (1991) theory of planned behaviour (TPB), which explains intentions by means of attitudes, subjective norms, and perceived behavioural control ^[1]. The second model is proposed by Shapero and Sokol (1982), and explains EI on the basis of perceived desirability, perceived feasibility and the propensity to act. Although Krueger et al. (2000) regard these models as competing, they overlap to a large degree. Shapero's perceived desirability and perceived feasibility correspond to Ajzen's attitudes and perceived behavioural control, respectively. Both models have consistently received empirical support”.

Following van Gelderen et al. (2008), this paper relies on the well-established TPB as it is considered more detailed and consistent, and it has received the greatest deal of research advancing its use (Liñán and Fayolle, 2015).

Previous scholars employing TPB (e.g. Lüthje and Franke, 2003) acknowledge that attitudes toward entrepreneurship represent the most accurate predictor of intentions. EA is the degree to which an individual holds a favorable or unfavorable evaluation of being an entrepreneur (Bird, 1988), and it often stems from intrinsic motivations such as a desire for independence, personal achievement, financial success, or societal impact. Moreover, such an attitude is shaped by past experiences, exposure to entrepreneurial role models and cultural values that valorize entrepreneurial behavior. Empirical evidence indicates that individuals who exhibit a strong EI are more likely to report higher levels of EI (Liñán and Chen, 2009).

The TPB should offer a structured framework to investigate the nascent phenomenon of healthcare entrepreneurship among MDs and to understand how EAs catalyze the formation of intentions, and thus their entrepreneurial behavior (Ajzen, 1991; Bird, 1988; Liñán and Chen, 2009). Furthermore, such a theory has proven particularly useful for identifying and modelling the cognitive and motivational process that underlie the entrepreneurial decision-making process (Lüthje and Franke, 2003). Several studies have applied TPB to explore how positive attitudes toward entrepreneurship influence intentions, further proving the validity of the theory, particularly when influenced by other contextual and psychological variables (Liñán and Fayolle, 2015; Vamvaka et al., 2020).

Contextual elements can influence EI and entrepreneur behaviour differently (González-Ramos et al., 2025). In this paper, the context is represented by the organization and its own healthcare professionals, namely MDs. This makes CE and intrapreneurship literature relevant for discussing the role of organizational support as an important triggering or hampering social pressure element in line with the TPB framework discussed above.

CE and intrapreneurship refer to a process where employees through the development and implementation of new and innovative ideas incrementally renew the organization (Hornsby et al., 2002). CE very much revolves around the ways the organization stimulates, facilitates and takes advantage of entrepreneurial activities and initiatives from employees (Ireland et al., 2009; Hornsby et al., 2002; Kuratko, 2010). In other words, to enable innovativeness, organizations must create a culture and structure for employees to facilitate innovation.

Previous healthcare literature acknowledges the role of organizational culture that, when it is oriented towards innovation, can be a key determinant of entrepreneurial actions by influencing how medical professionals perceive autonomy and risk, and by shaping EAs within their workplace (Miller and Fischer, 2016). Generally, a culture that fosters autonomy and promotes initiatives may serve as a critical enabler of entrepreneurial behavior especially when dealing with innovations (Ahmetoglu et al., 2018). When MDs operate in an environment that values innovation and intrapreneurship, they are more likely to translate their attitudes into concrete initiatives (Sabherwal et al., 2006).

Organizational culture is usually reflected in organizational measures or mechanisms to support entrepreneurial initiatives (see Shetty, 2004 for seminal research on this domain). Entrepreneurial support organizations (ESOs), such as incubators, science and technology parks, accelerators, and, more recently, many maker spaces and co-working spaces, are recognized as key in catalyzing entrepreneurial activity (Bergman and McMullen, 2022) and providing entrepreneurs with support and valuable resources. These organizational initiatives influence entrepreneurial behavior directly, but also indirectly by shaping perceptions of innovation support, that is, the degree to which medical professionals feel encouraged to develop and implement new ideas (Rosenbusch et al., 2011). Previous research suggests that organizations with a strong innovative culture are more likely to have policies and initiatives to stimulate entrepreneurship. This, in turn, produces positive perceptions on the supporting role of the organization (Burkholder and Hulsink, 2022).

The presence of ESOs (such as the science and technology park G-STeP, in our case) may act on the MDs perceived level of support regarding resources, training and structural measures to facilitate entrepreneurial actions (Karan et al., 2024). Coherently, recent studies exploring physician entrepreneurial behavior demonstrated that doctors-entrepreneurs are intrigued by the idea of altering their career plans, but often remain associated with the institution (e.g. NHS hospitals), recognizing the strong and crucial role of their organizations in supporting their entrepreneurial initiatives (Hoang and Perkmann, 2023; Miller and French, 2016).

Despite the positive, direct or indirect role of the perception of organizational support for innovation, its effect on MDs in fostering innovative entrepreneurial initiatives remains to be assessed (Burkholder and Hulsink, 2022).

Previous literature also acknowledges that EIs could also be influenced by individual characteristics, such as innovation tendency, openness to change and further personality traits (González-Ramos et al., 2025; Lüthje and Franke, 2003). Individual differences related to MDs' individual CP, for example, could drive the development of entrepreneurial solutions thanks to the possibility that MDs have to leverage on a wide network of professionals (Caprara et al., 2012). The latter refers to the well-known theory of SC.

“Social capital as the contextual complement to human capital” (Burt, 2000, p. 347) refers to the relationships created between individuals (Burt, 1997). While human capital refers to the quality of an individual, SC refers to a network of relationships between individuals and organizations that facilitate actions and create value (Adler and Kwon, 2002; Davidsson and Honig, 2003). These relationships can provide crucial channels for the acquisition of key resources and information that facilitate opportunity recognition and exploitation (Nahapiet and Ghoshal, 1998). They can assist aspirational entrepreneurs in establishing connections with professionals and other enterprises (Neves and Brito, 2020). In our research context, SC can help MDs to understand the entrepreneurial process and act as a “catalyst” to EIs (Bijedic et al., 2023; Yu and Zu, 2023).

Previous studies acknowledge that EIs derive from their specific research knowledge and EA (Fernandez-Perez et al., 2015). However, specific knowledge and EA could not be enough, and MDs, in our specific case, may need to compensate for their lack of managerial and commercial skills (Schiavone and Vershinina, 2024). While MDs may possess innovative competencies in their own fields of research, they are often less skilled at identifying the commercial opportunities that can arise (Lim et al., 2024). According to Shane (2004), opportunities often arise from academics and scientists' awareness of the importance of knowledge about markets, technologies and consumers being essential to create successful new initiatives. Social and professional network relationships play exactly that role of complementing knowledge for MDs with specific research knowledge.

In a healthcare setting, MDs may lack resources, skills and information which leads to a poor or no understanding of the market needs and of how to generate financial returns (Mérindol and Versailles, 2024). Indeed, professionals like MDs in complex settings often need complementary capabilities to advance entrepreneurial ideas (Hoang and Perkmann, 2023). Evidence from the healthcare sector shows MDs often have access to complementary expertise relying on their organizational and professional networks (Asoh et al., 2005; Fernandez-Perez et al., 2015; Glover et al., 2024; Yoda, 2016) or derived from their experience in working in interdisciplinary teams (Marsilio et al., 2017). This latter includes not only leveraging peer knowledge, but also collective problem-solving and shared risk-taking that could be brought to the table for new entrepreneurial initiatives (Ketchen et al., 2007). This could be particularly interesting where the “core” of the activities focuses on patient care rather than entrepreneurship. Research on opportunity exploitation suggests that individuals with lower collaborative tendencies often struggle to transform innovative ideas into actionable opportunities, as they lack the social reinforcement needed to navigate complex organizational and regulatory environments (Dacin et al., 2011). This is particularly relevant in healthcare, where entrepreneurial initiatives require multidisciplinary coordination, access to institutional networks and regulatory compliance (Wilden et al., 2018). Recent studies exploring MDs' EAs and behaviors clearly demonstrated that professional autonomy may decrease entrepreneurial actions (see Chudner et al., 2024). On the contrary, individuals' CP positively affects the success (vs the unsuccess) of such entrepreneurial efforts by leveraging a shift “from I to We” (Warhuus et al., 2017, p. 234).

In this section, working hypotheses are proposed based on the theoretical reasoning discussed in the previous pages. The TPB, as seen, should offer a robust framework for understanding the antecedents of EIs (Kautonen et al., 2015; Liñán and Chen, 2009). It has been widely validated across different domains, and it has become a central reference in entrepreneurship literature. TPB's core premise, that behavior is preceded by rational evaluation of beliefs, norms and control, makes it particularly suitable for examining EIs as a result of a planned and volitional act (Krueger et al., 2000). In other words, EA reflects an individual's behavioral beliefs – positive or negative – regarding entrepreneurial attributes and possible outcomes (e.g. Ajzen, 1991). Building on this theoretical foundation, the authors argue that EI among MDs could be “interpreted” as a reasoned outcome of their EA. Thus, it is hypothesized that.

In healthcare, and in this paper, EIs refer to the willingness to innovate within the organization, i.e. the research hospital. The development and implementation of new and innovative ideas is at the core of the CE and intrapreneurship literature which stresses the importance of organizational culture to promote measures and mechanisms for supporting entrepreneurial initiatives (e.g. Shetty, 2004). These organizational initiatives often make medical professionals feel encouraged to develop and implement new ideas (Rosenbusch et al., 2011).

In line with this stream of research, and coherently with the TPB that includes contextual and psychological variables to explain EI (Liñán and Fayolle, 2015), the authors hypothesize that the strength of the EA–EI relationship depends not only on the MD’s individual attitude, but also on the perception of organizational support for innovation (POSI). Previous studies in healthcare acknowledge the role of perceived organizational support measures as pivotal in a university medical school for strengthening researchers' commercialization endeavors (Burkholder and Hulsink, 2022).

Thus, this paper posits that the translation of EA into EI is mediated by POSI, reflecting the importance of the perceived social pressures embedded in the context of a research hospital that has promoted a support initiative such as G-STeP. This, in turn, should enable EIs among MDs. Thus, it is hypothesized that.

In professional contexts such as healthcare, where entrepreneurship is not a core component of the occupational identity, SC can be an essential element (e.g. Burt, 1997; Davidsson and Honig, 2003) to strengthen MD's EIs through social and professional networks providing information, advice and emotional support for entrepreneurial initiatives (Fernandez-Perez et al., 2015; Johannisson, 2000).

This paper aims at capturing the essence of the interaction between individual and organizational factors hypothesizing the function individual collaborative orientation (CP) plays as a contingent key element for exploiting the organizational support measures for innovation in place (POSI), thus enabling EIs among MDs in a healthcare setting.

Earlier in the paper, it was argued that EIs among MDs are affected by their perception of the support measures from the organization. Now the authors argue that, beside the MDs’ awareness of a favorable supportive environment, their propensity to collaborate captures the essence of networking for key complementary valuable resources and knowledge blocks, which in turn also help them to improve their entrepreneurial capabilities (Bijedic et al., 2023). In other words, the individual propensity to collaborate, which resembles the core concept of MDs' entrepreneurial readiness, is essential to fully exploit the organizational support measures for innovation that could lead to opportunity identification and exploitation (Shane, 2004). Thus, collaboration and the possibility for MDs to leverage on SC through interactions with a network of professionals (Caprara et al., 2012) should be strongly nurtured and encouraged in healthcare settings as it translates organizational innovative support measures into effective mechanisms to foster entrepreneurial initiatives among MDs. Thus, it is hypothesized that.

The conceptualization – shown in Figure 1 – includes organizational and individual factors to better capture the complexity of entrepreneurial behavior in a specific setting such as that of a research-led hospital (Schlaegel and Koenig, 2014) and it aims at showing how MDs' EIs emerge from a dynamic interaction between attitude, perceived innovation organization's support climate and individual's collaborative propensity.

In this study, the empirical analysis was conducted within G-STeP, the Gemelli Science and Technology Park of the Agostino Gemelli University Hospital in Rome, a research-intensive ecosystem comprising advanced laboratories, specialised core facilities and interdisciplinary research services (Link to the website). This setting provides a unique opportunity to observe entrepreneurial dynamics among MDs operating in a highly controlled and innovation-oriented environment. The Gemelli hospital is one of Italy's leading medical institutions, renowned for its comprehensive healthcare services and advanced medical research. Established in 1964 and affiliated with the Catholic University of the Sacred Heart, it is one of the largest university-led hospitals in Europe, offering specialized care in various medical fields, including oncology, cardiovascular health and neurology. Known for its cutting-edge technology and multidisciplinary approach, the Gemelli hospital also plays a key role in education and innovation, making it a natural pivotal healthcare hub in Italy and beyond. The case has been selected since useful and already validated as a setting related to research-led hospital activities (Schlaegel and Koenig, 2014).

In 2018, the Gemelli hospital committed to a specific support initiative called “Gemelli-Science and Technology Park” (G-STeP) that was aimed at building a research infrastructure inside the hospital, providing cutting-edge technological services through over 25 Core Facilities. The main aim was to support MDs in their scientific projects by offering advanced data analysis, AI solutions and innovation-driven research tools. Because the eligible population is intrinsically bounded (180 MDs, approximately), the resulting usable sample (69 MDs) reflects the actual structure of the field rather than a discretionary sampling restriction. Although limited in number, the respondents represent the full scope of professionals directly involved in innovation-related activities within the institution, allowing the investigation of EAs and intentions in a context where such behaviors are particularly salient.

This study employs a survey-based experimental research design to investigate how EAs (X) influence EIs (Y) among MDs, considering the mediating roles of the perceived support for innovation from the organization (Me), and the moderating role of MDs' CP (Mo). As anticipated, participants were MDs working in the research-led hospital “Agostino Gemelli” in Rome.

During the period from November 2024, to January 2025, the 180 MDs participating in the G-STeP project (the population) were asked to complete a questionnaire assessing their propensity to collaborate, entrepreneurial attitudes, POSI and EIs. The period is respectful of the typicalities of GSTeP, where MDs' involvement in innovation initiatives follows tightly scheduled research activities. In this controlled environment, attitudes, perceived support and intentions are relatively stable over short periods (e.g. Ajzen, 1991), making cross-sectional assessment appropriate without compromising construct validity. In total, 72 MDs completed the survey: In the sample 52% of MDs declared to be male, and 42% of them female, while the rest of the participants preferred not to declare their gender (5.8%). As for the age, the largest part of the sample was aged between 45 and 54 (34.8%), or 35–44 (30.1%); the rest of them declared to be aged more than 55 years (15.9%), or 25–34 (4.3%). As for their level of education, the widest part of the sample declared to held a Ph.D. (55.1%), or M.Sc. in Medicine & Surgery (nineteen participants; 27.5%), Specialization (0.8%), or a Master (I – II, level, Italian Education System standard; (2.8%).

Prior to assessing their EIs, participants responded to validated measures of their collaborative behavior, hypothesized as a moderator. The assessment of individuals' collaborative disposition was theoretically grounded in the personality-based tradition of prosociality developed by Caprara et colleagues (2012) which conceptualizes cooperation with others as a stable dispositional tendency rooted in traits, values and self-efficacy beliefs resulting in four items drawn and adapted from this seminal work (e.g. “I actively seek opportunities to collaborate with colleagues”, “Working in a team enhances my ability to innovate”, “I am inclined to seek collaboration with others when pursuing important goals”, “I feel comfortable engaging in shared decision-making and collective responsibility”). Then, it was asked to assess EA and perceived support for innovation from the organization, drawn from previous studies. In line with the TPB, two measurement items for EA are employed to account for the degree to which the individual holds a positive or negative personal evaluation or appraisal of the behavior in question” (Ajzen, 1991, p. 188), i.e. about being an entrepreneur. The first item (e.g. “I have a positive attitude toward starting new ventures”) was adapted from Liñán and Chen (2009). The second item (e.g. “I consider entrepreneurship as a viable career path”) was adapted from Vamvaka et al. (2020). Despite our first item is in the sense of founding an independent venture, the attitude expressed should be linked to EIs within the organizational setting, which align with forms of intrapreneurial or corporate entrepreneurial behaviour (Kuratko, 2010; Hornsby et al., 2002; Krueger et al., 2000; Ireland et al., 2009). Both measurement items account for affective (e.g. I like it, it is attractive) and evaluative considerations (e.g. it has advantages). The adequacy of the two measurement items employed was empirically verified through CFA.

The POSI has been measured by leveraging the construct of Perceived Organizational Support (POS) developed by Eisenberger et al. (1986). Precisely by using its four-items short version, as in Imran et al. (2020) and Zhou et al. (2023), dealing with similar research (e.g. “My organization provides adequate training for digital transformation”, “Adopting new technologies is a priority for my organization”, “My organization made continuous efforts for facilitating preparation for engagement in positive changes in routine activities”, “My workplace generally acted as a haven for relief from fear and anxiety through various new technologies”). After completing these sections, participants were asked to rate their EIs, measured using items from Ajzen and Fishbein (2000) (e.g. “I intend to develop new projects within my organization”, “I plan to take a leadership role in innovative initiatives”). All responses were collected using a 5-point Likert scale (1 = “Strongly Disagree” to 5 = “Strongly Agree”). The full list of items and the measurement scale is reported. Moreover, sociodemographic variables (e.g. age, gender, medical specialization, income level) were recorded to account for potential covariates in the analysis.

Before to proceed with the analysis, the authors successfully conducted the CFA also by confirming principal additional fit measures, e.g. CFI = 1 (acceptable because >0.9; Sun, 2005; Hair et al., 2017), TLI = 1.002 (acceptable because >0.8, Tucker and Lewis, 1973); NFI = 0.906 (acceptable, because >0.80; Bentler and Bonnet, 1980), together with PNFI = 0.659 and GFI = 0.912 (acceptable, because ≥0.90, by following Chau and Hu, 2001; Hair et al., 2017); see Table 1.

Moreover, Table 2 reports the results of the heterotrait-monotrait (HTMT) ratio and reliability analysis, assessing discriminant validity and internal consistency as well. All values fall within the recommended thresholds, confirming the robustness of the measurement model (see Table 2).

Then, to finally test our proposed conceptual framework, the analysis has been conducted by employing the moderated mediation model (Model 14) of the SPSS Macro Process (Hayes, 2018) to assess the relationships between attitudes toward entrepreneurship (EA) settled as the independent variable X, POSI acting as a mediator Me, MDs' CP acting as a moderator (mean-centered) Mo and EI, as the dependent variable Y, coherently with H1, H2 and H3.

Then, to test the proposed conceptual framework, the analysis was conducted by employing the moderated mediation model, namely Model 14 of the PROCESS macro for SPSS (Hayes, 2018). This model was used to assess the relationship between EA, set as the independent variable (X), POSI, included as the mediator (M), MDs' CP, included as the moderator (W) and EIs, set as the dependent variable (Y). Consistent with the conditional process logic adopted in the study, CP was mean-centered and modeled as moderating the relationship between POSI and EI.

Results in Table 3 indicate that EA has a positive and significant direct effect on EI among MDs (b = 0.539, SE = 0.132, t = 4.067, p < 0.001), thus supporting H1. Moreover, EA positively influences POSI (b = 0.362, SE = 0.176, t = 2.055, p = 0.043), suggesting that MDs with stronger EAs are also more likely to perceive their organization as supportive of innovation. In the outcome model, POSI shows a positive but non-significant direct effect on EI (b = 0.120, SE = 0.084, t = 1.429, p = 0.157), while CP also shows a positive but non-significant direct effect (b = 0.111, SE = 0.100, t = 1.103, p = 0.273). However, the interaction between POSI and CP is positive and statistically significant (b = 0.191, SE = 0.086, t = 2.211, p = 0.030), indicating that the effect of POSI on EIs depends on the level of MDs' CP.

The analysis of conditional effects further clarifies this interaction. At low levels of CP, the effect of POSI on EI is virtually null and non-significant (b = 0.001, SE = 0.108, t = 0.012, p = 0.990). At moderate levels of CP, the effect becomes positive but remains only marginally significant (b = 0.144, SE = 0.082, t = 1.756, p = 0.083). Finally, at high levels of CP, the effect becomes positive and statistically significant (b = 0.288, SE = 0.100, t = 2.864, p = 0.005). These results suggest that POSI translates into stronger EIs particularly when MDs display a higher propensity to collaborate.

Finally, the conditional indirect effects of EA on EI through POSI were examined at different levels of CP. The indirect effect was not significant at low levels of CP (effect = 0.000, BootSE = 0.044, BootLLCI = −0.106, BootULCI = 0.087), nor at moderate levels of CP (effect = 0.052, BootSE = 0.051, BootLLCI = −0.020, BootULCI = 0.177), nor at high levels of CP (effect = 0.104, BootSE = 0.086, BootLLCI = −0.024, BootULCI = 0.305), as the bootstrap confidence intervals include zero. Similarly, the index of moderated mediation was positive but not statistically significant (index = 0.069, BootSE = 0.060, BootLLCI = −0.017, BootULCI = 0.211). Therefore, while the findings support the direct relationship between EA and EI and confirm the moderating role of CP in strengthening the POSI–EI relationship, the evidence for the overall moderated mediation mechanism should be interpreted with caution. In substantive terms, the results indicate that organizational support for innovation becomes more effective in fostering EIs when MDs possess a stronger collaborative orientation.

Findings of our statistical analysis may extend the TPB by showing that the attitudinal pathway toward EIs is not “self-sufficient” in highly institutionalized contexts such as research hospitals. Rather, its translation into intentions depends on a dual mechanism in which POSI operates as a contextual enabler, whose effectiveness is contingent upon individual CP. Moreover, by integrating insights from CE and SC theory, the results suggest that CP acts as a relational catalyst that activates the value embedded in organizational support. Notably, the negative and non-significant effects observed at low levels of collaboration further indicate that, in the absence of relational openness, even supportive organizational environments may fail to generate entrepreneurial engagement.

To conclude, findings suggest that MDs with an entrepreneurial mindset are more likely to engage in entrepreneurial activities, especially when they perceive organizational support for innovation. However, this effect is stronger when MDs have a high propensity to collaborate, as collaboration enhances the positive impact of POSI on EIs. These findings have important theoretical and practical implications, particularly in research hospital environments where entrepreneurship is not part of the core mission, but CP emerged as a key enabling mechanism to induce EIs.

The authors employ the TPB to assess the direct relationship between EA and EIs among MDs’ working on a specific project, G-STeP, in the research-led hospital “Agostino Gemelli” in Rome. Findings align with previous studies (e.g. Lüthje and Franke, 2003), remarking the strong link between EA and EI in the context of a research-led hospital. EI, described as “a state of mind directing a person's attention (and therefore experience and action) toward a specific object (goal)” (Bird, 1988, p. 443), has been described as the most viable precursor of entrepreneurial behavior (Prodan and Drnovsek, 2010). In this study, however, this established relationship is extended to a highly professionalized and institutionally constrained setting, where patients and not entrepreneurship is at the core and entrepreneurial behavior unfolds as intrapreneurial action (Hornsby et al., 2002; Ireland et al., 2009; Miller and French, 2016).

Based on our results, MDs' attitude toward entrepreneurship positively influences their intentions to initiate innovative entrepreneurial activities. Consistent with the TPB, EA is conceptualized here as an individual-level evaluative judgment toward engaging in entrepreneurial behavior (Ajzen, 1991). Distinguishing this construct from perceived desirability and feasibility (e.g. Shapero and Sokol, 1982; Krueger et al., 2000), and organizational-level entrepreneurial orientation (Covin and Slevin, 1989; Lumpkin and Dess, 1996) ensures conceptual clarity and alignment with the study's level of analysis.

By leveraging CE literature and SC theory, this study also examines the indirect role of POSI and the conditional role of individual CP in shaping the relationship between EA and EI among MDs. Findings supported the proposed hypotheses and highlighted the interdependence of individual, organizational and relational drivers of entrepreneurship within the unconventional context under investigation. Specifically, a direct relationship between EA and EI emerges mediated by the role of POSI. However, such a mediation effect is contingent upon the level of MDs' CP, which emerges as a key mechanism for explaining EI in a research-led hospital. Organizational support for innovation is therefore perceived as a relevant and potentially enabling factor, but its effectiveness depends on individuals' willingness and ability to mobilize relational resources. In this sense, entrepreneurial support provided by the research hospital is not perceived as sufficient on its own to foster entrepreneurial actions. Rather, MDs' propensity to engage in professional collaboration functions as the condition through which organizational support measures for innovation can be perceived and eventually transformed into effective drivers of EIs and, ultimately, entrepreneurial actions within the organization.

The complexity of a research-led hospital (Miller and French, 2016; Schlaegel and Koenig, 2014) makes this setting very interesting to investigate the entrepreneurial behavior of a group of individuals in a working environment that focuses primarily on patients' care rather than on business (Guercini and Cova, 2018). This study advances existing research by positioning MDs' CP as an enabling mechanism rather than a background characteristic (Yoda, 2016). Although MDs are routinely engaged in teamwork, collective problem-solving and shared responsibility (Dacin et al., 2011; Ketchen et al., 2007; Caprara et al., 2012), our results show that variation in openness to professional collaboration could meaningfully shape entrepreneurial outcomes. Even in contexts where clinical excellence and patient care remain the dominant priorities, EIs depend on individuals' awareness that innovation is inherently relational and cannot be pursued in isolation (Trivedi, 2017). In this sense, MDs' CP represents a key individual-level capability that allows MDs to mobilize organizational support and relational resources, thereby enabling entrepreneurial actions within the boundaries of the research-led hospital.

Based on the above, a diagnostic model is proposed that illustrates the managerial actions at different levels of CP and EIs (see Figure 2 below).

Figure 2 shows that in cases of high EIs but low CP, MDs may experience frustration and disengagement, as their innovative drive lacks relational grounding. Here, managers must prioritize interpersonal trust-building and team cohesion to unlock latent potential. Conversely, when both EIs and collaboration are high, the setting represents an ideal zone for innovative initiatives. In this case, leadership should focus on empowerment, resourcing and scaling through team-driven support. Figure 2 presents valid solutions to enhance the effectiveness of managerial support measures aimed at guiding potential EIs by promoting collaboration initiatives among MDs in a specific setting, such as that of a research-led hospital.

Healthcare entrepreneurship is a nascent field of study (Lim et al., 2024; Schiavone and Vershinina, 2024; Wilden et al., 2018) increasingly characterized by the new technologies that are changing the offerings of modern healthcare services (Kraus et al., 2021; Lim et al., 2024; Sestino and D'Angelo, 2023). Healthcare professionals are eager to adopt new technologies and provide better-quality services, whereas healthcare organizations are facing efficiency pressures from governments and political institutions, and patients are requiring affordable prices. Entrepreneurship among medical professionals may be the answer to these complex challenges balancing the business concepts of scarcity and efficiency, and the business model logic to disrupt traditional services through entrepreneurial initiatives. Medical professionals could integrate clinical knowledge and expertise with the right entrepreneurial spirit to enhance new ideas, new technological applications, and new healthcare delivery at lower costs (e.g. Toner and Tompkins, 2008). This is a unique opportunity, as healthcare institutions are increasingly recognizing the need to foster innovation and intrapreneurship with supportive environments where medical professionals, who usually work to save lives, could also explore new ideas and new solutions that address pressing healthcare challenges (Kimble and Massou, 2017). However, entrepreneurship in non-traditional settings (Guercini and Cova, 2018; Schiavone and Vershinina, 2024), such as healthcare (Asoh et al., 2005; Burkholder and Hulsink, 2022; Kuratko et al., 2017), will continue to evolve and this represents an exciting challenge not only for academics but also for policymakers and healthcare managers.

By integrating the TPB with insights from CE and SC theory, this study develops a multi-level explanation of EIs formation within a highly institutionalized healthcare context (Guercini and Cova, 2018; Kuratko et al., 2017; Wilden et al., 2018).

Investigating the role of POSI and individual CP among MDs, this study contributes to the entrepreneurship literature by addressing the recent plea by Lim et colleagues (2024) who called for empirical research to better understand factors and drivers influencing entrepreneurship from those committed to social good. More specifically, the study responds to this call by showing that entrepreneurial engagement in healthcare depends not only on favorable attitudes or supportive organizational environments, but on the alignment between organizational support mechanisms and individual relational orientations.

The findings demonstrate that EA alone is insufficient to generate EIs among MDs. Instead, EIs emerge from the alignment between individual attitudes, perceived organizational support and CP. Coherently, from a theoretical perspective, this result refines TPB-based explanations by demonstrating that POSI (conceptualized as a form of contextual social pressure) exert heterogeneous effects depending on individual relational orientations.

Entrepreneurship, not only in a healthcare setting, often requires interdisciplinary collaboration and cooperation, involving professionals from diverse fields (e.g. Yoda, 2016). Indeed, previous studies show that a collaborative environment facilitates knowledge exchange, reduces barriers to entry and enhances the scalability of innovations (Lim et al., 2024). This study confirms the importance of organizational support and highlights the role that individual collaborative propensity plays in exploiting organizational support measures that, in turn, may lead to new entrepreneurial initiatives among MDs. Rather than treating organizational support as inherently enabling, the findings qualify its role by showing that individual MDs' CP explains heterogeneity in intrapreneurial responses under similar organizational conditions.

Leveraging on CE and SC literature, this research highlights the contingent and relational nature of intrapreneurial intentions formation in healthcare, demonstrating that organizational conditions and individual capabilities jointly shape entrepreneurial engagement (Asoh et al., 2005; Glover et al., 2024; Schiavone and Vershinina, 2024).

Furthermore, this study advances the understanding of intrapreneurial mechanisms in healthcare environments and calls for analytical frameworks capable of integrating individual-level cognition with the structural and relational characteristics of research-led institutions.

Many healthcare centers around the world are seeking new mechanisms to devise initiatives to enable innovation that generates both economic value and societal impact while avoiding the policies and bureaucratic burdens (Flores et al., 2024). Like other sectors, healthcare requires financing to sustain services and pursue innovation-driven solutions (Lim et al., 2024). Financing entrepreneurial initiatives in research-led hospitals often represents an obstacle for managers, given the priority for patient care and financial efficiency targets.

However, healthcare institutions and managers could benefit from the establishment of ESO and promote open innovation initiatives that work as an incentive pushing experienced entrepreneurs, large companies and investors into the healthcare industry supporting the raise of an environment that facilitates collaboration orientation and, thus, entrepreneurial activities among “Doctorpreneurs”. This could probably be a preferable solution rather than top-down resource allocation strategies (see Mérindol and Versailles, 2024). Unlike other industries, where access to funding, technology and training may directly enhance entrepreneurial outcomes, this paper shows that in a healthcare research-led institution the role of organizational support (even if just perceived!) is enhanced by the individual MDs' CP. MDs with a low propensity to collaboration may not fully perceive the potentiality of the innovative resources provided by the organization, whereas those who have a high propensity to collaborate are more likely to perceive and potentially leverage organizational support for new initiatives. To enhance intrapreneurship, hospitals and research institutions' managers should facilitate cross-functional interactions between MDs, healthcare professionals, technology experts and other professionals in other fields, e.g. as for initiatives like innovation teams, joint problem-solving workshops, mentorship networks and those one who could create a collaborative ecosystem where entrepreneurial ideas can emerge and be sustained over time. Figure 2, proposed earlier in this paper, could be used as an initial guide to hospitals and research institutions' managers in this endeavor.

Besides insights and actionable solutions for hospitals' managers and policymakers in understanding the dynamics that are essential for enhancing entrepreneurship in a research-led hospital, this research is not exempt from limitations that could represent possible avenues for future research. Since the data collection has been conducted by leveraging on MDs' participating at the G-STeP project at the research-led “Agostino Gemelli” hospital in Rome, the sample size is relatively small, with data usable from only 72 MDs (on a population of 180 MDs, approximately). Despite the sample size is numerically limited, it is fully representative of the specific context under examination (one-third of the entire population of MDs participating in the G-STeP project), ensuring a high degree of contextual validity. Nevertheless, the relatively small number of observations may constrain the external generalizability of the findings. This study focuses on Italian MDs, and future research may extend the analysis through cross-country comparisons. However, it opens to future collaborations to expand the sample size considering other similar research settings in Italy but including the aspect of acculturation as well as collecting data from other countries given the relevance of cultures, not only at the country level, but also at the hospital/organizational level, on entrepreneurial behavior. Another possible limitation of this paper may be the relatively short data-collection window (November 2024, up to January 2025). While consistent with cross-sectional intentions research, longer periods would be better to capture how antecedents evolve into intentions, suggesting the value of future longitudinal designs.

Finally, future research could employ alternative models and instruments designed for studying the propensity to act, such as those proposed by Soleimanof et al. (2021) considering perceived desirability and feasibility.

The absence of data on nationality and acculturation is acknowledged as a limitation of the study, as well.

In the current healthcare landscape, shaped by rapid technological advancements and the emergence of patient-centric care models, MDs are increasingly called to embrace the role of “Doctopreneurs” to find solutions to improve service delivery, patients' outcomes and organizational efficiency (Glover et al., 202; Lim et al., 2024). Such a term should reflect a growing expectation for physicians not only to deliver clinical expertise, but also to engage in entrepreneurial activities that lead innovation-driven initiatives and bring systemic social improvement. With new tools such as AI, wearable technologies and telemedicine transforming the doctor–patient relationship, physicians are uniquely positioned to identify inefficiencies, co-develop scalable solutions and lead interdisciplinary ventures (Asoh et al., 2005). As such, the modern doctor is no longer just a caregiver but could be a proactive system innovator solving social issues by shaping the future of health and care delivery (e.g. George et al., 2016; De Silva et al., 2021).

Healthcare institutions and managers need to play their part in establishing organizational initiatives and measures to create supportive environments where medical professionals could express their natural inclination to collaborate (e.g. Carlos and Hiatt, 2022; Hoang and Perkmann, 2023; Toner and Tompkins, 2008). When this is not in place, healthcare institutions and managers should promote initiatives for incentivizing collaborations that may give birth to entrepreneurial initiatives (i.e. commercialization of the research) without compromising the top interests in health and care, and the managerial goals for operational and financial efficiency.

Alfredo D’Angelo wishes to express his gratitude to the living memory of Prof. Giovanni Scambia who welcomed and favoured this research.