Exploring perceived barriers for advancement to leadership positions in healthcare: a thematic synthesis of women's experiences

Abstract

Purpose

This paper aims to explore the voices of women describing the perceived barriers for advancing to leadership positions in healthcare.

Design/methodology/approach

A systematic search was conducted through Elton B Stephans Company (EBSCO) host research platform using the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Medical Literature Analysis and Retrieval System Online (MEDLINE) Complete and American Psychological Association (APA) PsycInfo. Nine papers were selected for this review. Thomas and Harden's (2008) method of thematic synthesis was used drawing from eight qualitative papers and one mixed methods paper describing women's lived experiences in, or advancing to, leadership positions in the healthcare sector. Analysis was conducted using three steps of thematic synthesis: the inductive coding of the text, the development of descriptive themes and the generation of analytical themes.

Findings

Through the method of thematic synthesis, six descriptive themes (barriers) emerged: internalised feelings, work–life balance, lack of support, stereotypes, discriminatory behaviours and organisational culture. From these, three analytical themes were identified: personal, interpersonal and organisational.

Research limitations/implications

This review looked at nine papers and documented women's voices. However, the women were in disparate geographical areas across the world and did not consider the specific cultural context in which the women were located. The healthcare sector is very large, and therefore, whilst there are shared commonalities, the disparateness could be a limitation.

Practical implications

Barriers were categorised as either structural barriers or attitudinal barriers to determine the policy and practice.

Originality/value

This research is crucial to better understanding what remedies need to be implemented to address gender disparity in the sector.

Citation

Haines, A.C. and McKeown, E. (2023), "Exploring perceived barriers for advancement to leadership positions in healthcare: a thematic synthesis of women's experiences", Journal of Health Organization and Management, Vol. 37 No. 3, pp. 360-378. https://doi.org/10.1108/JHOM-02-2022-0053

Introduction

The World Health Organisation (2019) has described the healthcare sector as being delivered by women and led by men. Despite women forming about 70% of the global health and social workforce, there is still a significant gender gap whereby women hold fewer senior leadership roles. Although there has been some progress, gender disparity and underrepresentation of women in leadership positions persists – reaffirming that the glass ceiling has not been shattered but merely raised.

Reed et al. (2019, p. 1875) report a common definition for leadership: “influencing, motivating, enabling, or empowering others, often to achieve a specific goal”. As the health sector is ever-changing to provide safe and high-quality care, leadership in healthcare is about leading changes at all levels of the health system and revolves around the vision, ideas and inspiration whilst establishing the direction and driving others to achieve organisational goals (Ayeleke et al., 2018). Between the years 2011 and 2020, the proportion of women in senior leadership positions rose from 20% to 29% (Grant Thornton, 2020). This increase is attributed to the broken rung where there is a lack of gender parity at lower levels of leadership which slows down or prevents women from moving through the pipeline – halting the progress of gender parity (Grant Thornton, 2020).

Whilst women are the backbone of healthcare systems, they are not considered essential in decision-making processes. Men currently make the decisions, which women will then execute (World Health Organisation, 2019). Healthcare leadership refers to both clinical and non-clinical positions such as head nurse, team leader, or board member. Leadership is more than just Chief Executive Officer (CEO) status or making the final decisions at the top but is about inspiring and driving team members and setting direction towards visions and goals. Ideally, we would see gender parity at each level. Surawicz (2016) states that there is a regression of women in leadership positions through the leaky pipeline and glass ceiling leading us to believe that there are barriers at each level, rather than just at the most senior positions.

The glass ceiling and leaky pipeline are metaphors used to describe invisible barriers for women and minorities for advancement and the decreasingly level of representation of women at progressively higher levels of their career path (Surawicz, 2016). The glass ceiling still exists for women and research suggests there is a link to the role congruity theory (Koneck, 2006). Role congruity theory generally is the concept that bias, or prejudice, can occur from incongruency between the perception of qualities and characteristics of people in a group and the requirements of the social roles that the group should hold (Eagly and Karau, 2002). In this context, there is chauvinism and prejudice towards female leaders resulting from perceived contradictions between the typical requirements for leaders and stereotypical traits of women.

According to Eiser and Morahan (2006), healthcare systems have complicated organisational structures through which diverse leadership talent should be maximised and is essential to the success of the various delivery systems. However, it is widely recognised that this is not currently the case as most organisations still underrepresent women in all levels of leadership. Roth et al. (2016) reveal that organisations that have few or no women in leadership positions, are depriving themselves of an innovative and competitive advantage. Women bring deeper insights and better understandings of healthcare through their experiences and convey diverse perspectives with which stronger health systems will emerge. The most appropriate leadership styles for healthcare are transformational and collaborative – both of which rely on communication and are relationship-driven leadership styles (Al-Sawai, 2013). Merchant (2012) describes the difference between men and women's typical leadership styles – men being tasked-oriented and women being relationship-driven.

Men often exert take-charge leadership traits and exhibit more controlling and goal-oriented approaches – typically the behaviour that stands out and they are rewarded by being promoted quicker (Merchant, 2012). Women tend to focus on compassion, communication and connections and assume the care-taker role (Merchant, 2012). Eiser and Morahan (2006) question the typical skill set needed to be a leader and their research has concluded that the following five skills are most important for health organisation's success: (1) resourcefulness, (2) leading employees, (3) participative management, (4) building and mending relationships and (5) straightforwardness and composure – criteria of which women are fully qualified.

Despite recognising that women are undeniably suitable for leadership in healthcare and who best understand the sector through experience, gender disparity persists – even when the sector hosts a wealth of talented women to foster into leadership roles (Eiser and Morahan, 2006). It is time to change the narrative of men take charge, women take care by understanding and eliminating the barriers and circumstances that inhibit women from progressing in the leadership pipeline and taking on leadership roles across the healthcare sector (Prime et al., 2009, p. 30).

In this context, an increasing number of qualitative studies have reported on the perspectives of women reporting their experiences related to career advancement in healthcare settings. A single qualitative study typically focusses on a single sample of women in a specific context. The thematic synthesis approach (Thomas and Harden, 2008) was adopted to formalise the identification and development of themes from multiple studies and subsequently enables the development of a comprehensive understanding of the barriers and facilitators to advancement faced by women in leadership positions in healthcare. Adopting a thematic synthesis approach, the aim of this systematic review was to answer the following question: What are the perceived barriers for women advancing to leadership positions in healthcare?

Methods

Framework

The research question in this review was designed using the Sample, Phenomenon of Interest, Design, Evaluation and Research type (SPIDER) search strategy tool which is used to construct qualitative research questions (Cooke et al., 2012). This tool is an appropriate alternative to the more commonly applied Population, Intervention, Comparison and Outcome (PICO) search strategy tool as SPIDER adjusts PICO components to suit searching for qualitative research papers (Cooke et al., 2012). Table 1 shows the SPIDER framework.

Methodology

This systematic review aims to analyse and synthesise qualitative research to understand the voices of women describing the perceived barriers for advancement to leadership positions in healthcare. Hammarberg et al. (2016, p. 499) states that “qualitative methods are used to answer questions about experience, meaning and perspective, most often from the standpoint of the participant”. Therefore, as this review aims to understand the perceived barriers for women in healthcare leadership, only papers which contained evidence of qualitative research were reviewed. The method used to synthesise the data from these papers was Thomas and Harden's (2008) method of thematic synthesis.

Type of studies

The types of studies included in this review were journal papers which were qualitative or had a substantive qualitative component consisting of research methods such as: focus groups, semi-structured interviews, surveys, face-to-face interviews and in-depth interviews.

Search strategy

A comprehensive search strategy was performed in April 2021 using the Elton B Stephans Company (EBSCO) host research platform via the City, University of London library access where the search terms were run through Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Medical Literature Analysis and Retrieval System Online (MEDLINE) Complete and American Psychological Association (APA) PsycInfo. The table below shows the search terms used in the included databases and were developed from the SPIDER framework. Search terms were filtered to search titles only. Results were limited to English only, peer-reviewed and to publication within the last 15 years – papers published between the years 2006 and 2021 inclusive, were selected. Table 2 presents the search terms used in the SPIDER framework.

Study inclusion

1. Papers that have a focus on the healthcare sector are included;

2. Studies that have substantive qualitative research are included;

3. Studies included the voices of women talking about their experiences of leadership barriers in the healthcare sector;

4. Only English papers are included and

5. Papers published between, and inclusive of, 2006 and 2021 are included.

Study exclusion

1. No systematic reviews or meta-analyses are included;

2. Papers which are exclusively quantitative data are excluded;

3. Papers written in languages other than English are excluded;

4. Papers that focus on sectors other than healthcare are excluded and

5. Papers published prior to 2006 are excluded.

Study selection

A total of 844 studies were found from the selected databases of which there were no duplicates. The search was then filtered by methodology whereby qualitative methods were selected resulting in 66 papers chosen for screening. The studies were screened using their titles and abstracts and 13 were advanced for full-text reviews. Four of the studies did not contain elements of the women's voices and opinions. Nine studies were then selected as the final papers for this systematic review as shown in Figure 1 which displays the PRISMA (preferred reporting items for systematic reviews and meta-analyses) diagram for searches.

Quality appraisal

A quality appraisal was performed by the first author (AH) on each of the nine selected studies using the Critical Appraisal Skills Programme (CASP) Qualitative Research checklist (Critical Appraisal Skills Programme UK, 2021). This checklist comprises criteria to evaluate the study methods, approach to data analysis and interpretation of study findings. Eight of the studies were given a high-quality rating in terms of methodological rigour and one paper was given a medium quality rating, with the ratings discussed and agreed between both authors (AH and EMK).

Data extraction and synthesis

Data extraction and synthesis followed Thomas and Harden's (2008) thematic synthesis method. The first author (AH) conducted line-by-line coding of the findings presented in each of the included studies and identified key concepts. The data, drawn from the “results” or “findings” sections of the individual papers, were first coded individually generating 24 initial codes which formed the basis of the construct six descriptive themes shared across the papers. From these, three analytical themes were developed. Researcher triangulation was adopted to ensure that the coding process encapsulated all salient issues and reflected the data. The second author (EMK) independently reviewed the coding and proposed themes and agreed the overall emergent thematic framework with the first author (AH). Table 3 depicts the summary of included studies.

Results of the synthesis

The included studies (n = 9) focussed on the barriers that women experience whilst advancing or retaining leadership positions in healthcare and reflected the voices and views from those women directly – referring to their own past or present experiences and/or drawing on their colleagues' experiences they have witnessed. Six descriptive themes were generated: internalised feelings, work–life balance, lack of support, stereotypes, discriminatory behaviours and organisational culture. From these descriptive themes, three overarching analytical themes were produced: personal, interpersonal and organisational. Table 4 displays the themes identified within each of the studies

Personal barriers

Internalised feelings: personal feelings of doubt and lack of confidence towards leadership roles

One of the key themes emerging from across the papers in the synthesis was women talking about their own internalised thoughts and feelings of inadequacy and doubt in relation to their gender. These studies expressed women's perceived capability for leadership roles and their reluctance to seize leadership opportunities. This is exemplified in Bismark et al. (2015) where women described the “self-selecting process” and underestimated their capabilities, leading them to believe they were not suited towards such roles.

I suppose when I was thinking and talking about this role here, you know, I had to think, ‘Oh, can I do that?’ or, ‘Would I be able to do that?’ I wasn’t sure. (Bismark et al., 2015, p. 4)

Similarly, the experiences described by women in Gottenborg et al. (2021) reference battling the “imposter syndrome” and the unnecessary emotional energy spent on second-guessing themselves. The women interviewed in Tlaiss (2013) describe societal norms and the feelings of uneasiness and pressure arising from patriarchal standards that question their suitability – reinforcing their belief that they are not fit for leadership roles. Both Bismark et al. (2015) and Adams–Harmon and Greer–Williams (2020) suggest that from the women's feelings, there is a hesitancy and reluctance to self-promote and put themselves forward for leadership positions.

I had to have a couple people say to me, “Hey, are you gonna go for your boss’s role?” And I was like, “No way!” I mean, I was, I was my own worst enemy keeping myself back. And people were like, “Why not? You’re totally qualified, you could totally do it.” And I’m like, “Oh, no, no, no. (Adams–Harmon and Greer–Williams, 2020, p. 8)

Women in Roth et al. (2016) described each other as self-sacrificing and extremely sensitive to their colleagues' perceptions and feelings towards them. The idea of “stepping on toes” or offending their colleagues by pursuing opportunities for leadership roles, or the idea of being in charge or in control prevents women from putting themselves forward or self-promoting. The fear of rejection when self-identifying and self-promoting for leadership roles was a strong deterrent.

When asked if they saw themselves as leaders, one responded: “God no – I see myself as a collaborator, not telling people what to do. (Roth et al., 2016, p. 655)

Adams–Harmon and Greer–Williams (2020) explain success factors experienced by women who attained their leadership roles and key points arising were self-promotion and self-branding. Women who believe in their self-worth and strengths tend to have the confidence to promote themselves which has a massive impact on the successful and prosperous ascent to leadership positions.

Work-life balance: finding the right combination between family life and their job

The perceived capacity for women juggling career and parenthood was a shared concern amongst the papers. The women in Bismark et al. (2015) describe the ‘inherent incompatibility’ between motherhood and striving for advanced leadership –the continuous internal battle.

There may be people who can juggle and manage that, but I do think for a lot of people they go, ‘Oh, do I want to take that on and do all of that? (Bismark et al., 2015, p. 4)

The women in Roth et al. (2016) explained that they often take on a larger proportion of the home/family responsibilities compared to their male colleagues. These added responsibilities and their leadership ambition are in competition for time. Women are seen as the primary caretakers and automatically assume the role as such. The women in Soklaridis et al. (2017) and Gottenborg et al. (2021) express that the family responsibilities naturally fall onto them and it's their obligation to put the household above career.

The work life integration in particular because while in this day in age men do help, it is still overwhelmingly that the woman manages the home. Even though you delegate things to your husband, you still have to figure out what needs to be delegated. This is a challenge no matter how helpful your husband is. Generally speaking, women still manage the home. I can’t tell you how many times in my career early on I would joking say (but I half meant it) I wish I had a wife. (Gottenborg et al., 2021, p. 3)

Family responsibilities not only refer to children and the household chores, but also the responsibility of ageing parents (Adams–Harmon and Greer–Williams, 2020). The challenge of having to balance work and home life as well as make sacrifices is typically a woman's burden to bear (Kalaitzi et al., 2019).

I prioritize my job; … I chose not to raise a family. (Kalaitzi et al., 2019, p. 48)

I had to re-assess my work/life balance, my priorities, when my mother got sick. (Kalaitzi et al., 2019, p. 49)

Some women accept the view that family should be the centrality of their lives and accept full responsibility but reject the idea that it should impact their professional lives and career trajectory (Tlaiss, 2013).

As a woman, I accept the notion that women should care for their families and homes but reject the idea that it is the primary and only role for women. (Tlaiss, 2013, p. 27)

The women in Bismark et al. (2015), Soklaridis et al. (2017), Gottenborg et al. (2021) and Adams–Harmon and Greer–Williams (2020) all explicitly call for a more flexible and modernised work structure. Women express that currently the work practices are outdated and do not support or value work-life balance for women who want to “do it all” – build a successful leadership career and simultaneously run a household. Relocation/location flexibility is often a requirement in career advancement but women who are parents have more responsibilities that do not allow for spontaneity (Adams–Harmon and Greer–Williams, 2020). The lack of flexibility in scheduling and work hours makes it harder for women to aspire for leadership roles without feeling the overwhelming need to make sacrifices in their home lives – a notion men rarely encounter.

Which gets to the idea of honestly and truly if we want to make a difference in women in leadership, government, healthcare, whatever that is, there has to be a paradigm shift in the job and the job structure that doesn’t make it mutually exclusive, that you can really run up the career ladder and successfully run a family at the same time. (Soklaridis et al., 2017, p. 259)

Ultimately, for many women in the studies, the choice is between caring for family, or a strong career with leadership advancement – the sector is not currently designed for both

Interpersonal barriers

Lack of support: needing encouragement, mentorship and support for advancement

A lack of support for women leaders was one of the most prominent barriers for women emerging from these papers. This lack of support emanates from family, colleagues, a scarcity of female role models and inadequate communication of opportunities for advancement. In Magee and Penfold (2021), Gottenborg et al. (2021) and Kalaitzi et al. (2019), the “Queen Bee” phenomenon was introduced as a common issue in the healthcare setting. The “Queen Bee” phenomenon is experienced when a woman in a position of power reinforces the gender hierarchy by denying that women discrimination exists and is unsupportive of the fight against female equality. This generally arises from the women feeling overly protective of their role as exemplified by the women in Magee and Penfold (2021), who explained that some may feel that their position is threatened by other female colleagues. There is the shared perception that there is not enough room for more women in leadership roles. Not only is this a clear lack of support from other women but makes it harder for them to advance.

Some women may … think that there is not space for another / more women in their position / see other women as a threat to their position or think of other women as drawing attention to gender. (Magee and Penfold, 2021, p. 2)

Family and friends support were also voiced as essential in order to have some of the responsibility burden lifted from them so that they can find the time to transition to new roles (Bismark et al., 2015) (Kalaitzi et al., 2019). These personal networks outside of work are crucial for women to have the freedom to find the right balance between personal commitments and career aspirations. Some women have experienced a lack of support through being made to feel guilty for holding top positions and criticised by their communities for branching out beyond their expected roles and choosing career over family.

So being a woman, a doctor and occupying a top position, is strange, you know; there is so much unjustified jealousy and criticism. (Kalaitzi et al., 2019, p. 50)

Kalaitzi et al. (2019) further emphasise the lack of spousal support and the challenge that arises from spousal power balance. A lack of spousal support reinforces the view that women should not diverge from their expected responsibilities at home.

If you do not have spousal support, you can forget it. (Kalaitzi et al., 2019, p. 49)

My ex-husband was very competitive with me on both a professional and social level. Kalaitzi et al., 2019, p. 49)

The women in Roth et al. (2016) and Hopkins et al. (2006) call for more leadership support and transparency around evaluation criteria for certain leadership roles-many interviewees expressed that the expectations were unclear and they would welcome more information to self-assess their suitability. These women also expressed that if leadership opportunities were promoted and encouraged, more women would consider applying for them. These women also voiced the need for female mentors and role models to inspire others. Magee and Penfold (2021) interviewees voice the absence of females in leadership positions which feeds doubt and insecurity for women pursuing these roles.

It is difficult to imagine yourself fulfilling a leadership role if there is no visibility of female leaders. (Magee and Penfold, 2021, p. 2)

The women in Bismark et al. (2015) describe the need for more encouragement and support from female role models who have successfully entered leadership roles. Relatedly, women in Roth et al. (2016) and Hopkins et al. (2006) indicate a strong desire for more developmental support and training from their employers.

When asked: “What does your organization need to do to help you develop as a leader?” Answer: “Provide opportunities, resources and time to attend training courses.” (Hopkins et al., 2006, p. 258)

Women in Gottenborg et al. (2021) describe their perceived lack of support to acquire training and leadership exposure, whilst the women's experiences in Tlaiss (2013) talk about how they receive fewer opportunities for development than their male colleagues. Women in Bismark et al. (2015) talk about the significance of actively encouraging women to apply for upcoming leadership roles.

I probably wouldn’t have done any of these things without encouragement. I wouldn’t have had the sort of confidence I think to take on those roles unless somebody had asked me to do it. (Bismark et al., 2015, p. 5)

Tlaiss (2013) illustrates how mentorship, support and encouragement is crucial for women to advance in the healthcare sector.

Having a mentor is very important in the healthcare sector. However, since the majority of senior managers are males, females end up with no mentors, while males can pick and choose their mentors. (Tlaiss, 2013, p. 29)

Stereotypes: Preconceived ideas, bias and misconceptions about women communicated by colleagues and family

A common theme emerging from across the papers is the barrier arising from preconceived ideas about women and their purpose in the workplace. These stereotypes are experienced by countless women in healthcare in various forms such as the belief that women do not have suitable “leadership qualities” to be leaders – leading to the side-lining of women in the workplace and misconceptions about women's roles. In Bismark et al. (2015), the participants talk about their perceived credibility and how their traits are described as “too feminine”. Magee and Penfold (2021) further support this as the interviewees believe that they need to act a certain way to be perceived as having a personality consistent with the stereotypical leader.

Women may have had to exhibit stereotypically male behaviours to be accepted leadership roles. (Magee and Penfold, 2021, p. 2)

Women in Tlaiss (2013) and Soklaridis et al. (2017) reference the “think male, think manager” stereotype that led women to believe that they do not have the right qualities to handle or carry out leadership positions. Interviewees describe how society and patriarchal norms continue to question their appropriateness for decision-making roles (Tlaiss, 2013).

There is a common misconception that women are not able to be decisive because they are emotional and sensitive. (Tlaiss, 2013, p. 27)

Women work hard to prove their leadership suitability (Kalaitzi et al., 2019). Furthermore, they need to prove that they are better than their male counterparts to be considered leadership candidates. Gottenborg et al. (2021) refer to women who have deferred from their own leadership style and qualities into ones expected from a leader – feeling that they need to change and mould themselves into the normative stereotype of leadership to advance.

I have to be better than my male colleagues it would seem. (Hopkins et al., 2006, p. 265)

I may work harder than men just to receive the same recognition. (Kalaitzi et al., 2019, p. 50)

In Hopkins et al. (2006), participants were asked to describe the characteristics of a successful candidate advancing in the organisation. Some of the most shared responses include “ambitious”, “aggressive”, “workaholic” and “puts work before family”. These characteristics are described as typically masculine traits. “Puts work before family” is particularly difficult for women to do as previously explained in theme 2. The women in Adams–Harmon and Greer–Williams (2020) express their exhaustion from harmonising various characteristics. Women express that when attempting to be more assertive and aggressive to stand out or be perceived as a typical leader, they are regarded as forceful, rude and domineering. However, when they are kind and friendly, they are perceived as too weak to lead. The constant “balancing act” for women is tiresome.

Stereotypes about women often suggest that women are the primary caretakers of the family and that should be their main focus. This has led to the idea that women are preoccupied with raising a family and have no intention of pursuing leadership positions. The women interviewed in Magee and Penfold (2021) reference the barrier arising from the misconception about women's intended career path. Tlaiss (2013) emphasises this stereotype as women describe the expectation that they are more committed to raising a family than following their career-women with children feel overlooked as potential leaders (Bismark et al., 2015).

I’ve heard it said … ‘Oh no, she wouldn’t be interested. She’s got two young children. She wouldn’t be interested to be head of department.’ What? … Why not?” (Bismark et al., 2015, p. 5)

Women also describe their prime reproductive age as a biological barrier – organisations consider pregnancy a liability and do not want to “take the risk” (Kalaitzi et al., 2019). The “child-bearing” age coincides with significant career stages. The women in Roth et al. (2016) explain the desire to choose when they take on leadership roles as their priorities between work and home life change.

I would like to change the culture where you can say ‘no now, yes later, keep asking.” (Roth et al., 2016, p. 659)

As these studies have shown, there are many assumptions driving decisions whether to promote women into leadership positions, rather than focussing on their ambition and talent.

Organisational barriers

Discriminatory behaviours: unpleasant social interactions in the workplace based on gender

A noteworthy impediment conveyed by women from several studies was the gender bias and discriminatory comments emerging from their male colleagues. From these papers, the behaviour ranges from harsh comments comparable to bullying to innocuous commentaries in the form of microaggressions. Magee and Penfold (2021) clarify the consequences arising from seemingly innocent comments: unconscious bias that leads to deep-rooted sexism in the workplace by which women construct a negative mindset about work and their career path. Microaggressions can take many forms such as mistaking women for staff of less seniority or questioning/doubting of their abilities. This behaviour demonstrates the issue where women are not being taken seriously when rising to leadership roles and insinuates and instils a belief that women do not belong in such positions. An interviewee in Adams–Harmon and Greer–Williams (2020) shared her experience of feeling belittled by a male colleague who asked her who would be making the decisions in the team, insinuating that she was not capable.

When I was in a cross functional team, and I was attempting to solicit feedback and perspectives from the group. One male peer of mine inquired who would be the “Alpha Male” that will make the decision, which was really offensive to me.” (Adams–Harmon and Greer–Williams, 2020, p. 8)

The women in Gottenborg et al. (2021) described inappropriate behaviour and interactions they experienced whilst in a superior position to their male colleagues such as behaving in a very informal and casual manner or acting as if they were superior to her. This poor conduct undermines women's abilities and leadership authority and encourages others to participate in such a way.

Two men who were junior to me who made it pretty clear in lots of subtle ways that they were not so happy to have me as a leader. And that was … you know a learning journey for me, whether it was chewing gum during a meeting with me or other sort of casual behaviours that you normally wouldn’t exhibit in a meeting with a leader you know, to asking if the office meeting would be in his office or my office again typically one would assume the meeting would be in your leader’s office. (Gottenborg et al., 2021, p. 3)

Adams–Harmon and Greer–Williams (2020) participants reported mistreatment from their direct managers which hindered their ability, or desire, to advance into a position of leadership. Some stated that their direct manager made discriminatory remarks in front of their male colleagues. This encourages her colleagues to follow suit and mimic their boss' behaviour to fit in, or because they believe it to be customary – constructing an environment that tolerates microaggressions and bullying.

Sometimes on the surface it could be unintended bias at first you may find that there is not much there, but as you try to peel back the onion, you start to see there is something there and it’s not explicit, but people are pretty savvy on how to cover their tracks (Adams–Harmon and Greer–Williams, 2020, p. 9)

However, women are often afraid to call attention to these situations and report incidents since the instigator is in a greater position of power – women fear losing their job on the basis that no one believes their allegations, or simply just “brushes them off”.

Sexual harassment was also expressed as an issue experienced by women. The women interviewed in Kalaitzi et al. (2019) indicated that sexual harassment was a power move or proposition for career advancement, making women incredibly uncomfortable in their workplace and when pursuing leadership roles. Even when women ascend to leadership positions, they are still made to feel inferior, out of place and unwelcome.

Workplace culture: operating in a context which is heavily gendered and does not foster female advancement

The final theme that is identified is one concerning the organisation's demeanour towards women. The way women experience their workplace is essential to their level of interest and engagement with leadership roles. Women from these studies have described their experience with one of the more obvious discriminatory acts: unequal pay. Some of the women in Adams–Harmon and Greer–Williams (2020) explain that they discovered they were being underpaid for their role compared to their male colleagues and being paid less than their subordinates. Similarly, the women in Tlaiss (2013) reaffirm the gender pay gap but relate it to culture and society – men are believed to be the sole breadwinners and are rewarded as such. Kalaitzi et al. (2019) report the gender pay gap issue as being one of the less common barriers, but still raised by the interviewees as a problem they've encountered.

I am paid less than my male colleagues for, doing the same job … when I asked the top management for an explanation; they said that men are financially responsible for their families, while I am, as a woman, the financial responsibility of my husband. (Tlaiss, 2013, p. 28)

The women in Bismark et al. (2015) expressed the pressure they felt in senior leadership positions to act like their male colleagues and the heavily gendered environment which made women feel incredibly uncomfortable to be working around.

It’s one thing for them to talk about cricket or something I don’t understand, but there’s times when they go into something which is probably … like it’s not sexually inappropriate, but it’s probably … if they actually thought about the fact that there was a young woman in the room, they probably wouldn’t say it. (Bismark et al., 2015, p. 5)

Soklaridis et al. (2017), Kalaitzi et al. (2019) and Adams–Harmon and Greer–Williams (2020) specifically reference the “Old Boys Club”/“Big Boys Club” as a barrier since the women feel that they don't belong and are excluded from their male colleague's domain. The “Old Boys Club” refers to the exclusivity of the male-dominated environment, where women feel left out of significant events such as sporting events. This is where informal networking occurs and where important decisions are made (Adams–Harmon and Greer–Williams, 2020). The women in Tlaiss (2013) describe the significance of nepotism, or “wasta”, on their leadership advancement – “who you know” has more value than qualifications and capabilities. Furthermore, some women described moments where they considered leaving leadership positions due to them feeling side-lined or out of place in their role (Adams–Harmon and Greer–Williams, 2020).

Our organization is male dominated; the rules of the game are quite male friendly and women unfriendly. (Kalaitzi et al., 2019, p. 50)

The women in Tlaiss (2013) explain how they felt excluded from both informal and formal networking events. Roth et al. (2016) express the observation that those who are visible and have built a rapport with their superiors are the ones who advance to leadership positions, rather than those who are most qualified. These women describe how the recruitment process is not transparent and roles are not clearly publicised.

I was always excluded from the networking activities at work. It was always about the men. (Tlaiss, 2013, p. 29)

An example of gendered structures being endorsed was explained by one of the women in Adams–Harmon and Greer–Williams (2020), where she experienced a meeting commenced by a male leader where he asked everyone to introduce themselves and share who their favourite football team was. This is possibly as dividing as a woman asking the team to share their favourite make-up brand.

Organisational culture shapes the way women view their workplace and often influences where women want to work. People generally desire a workplace that is welcoming, inclusive and respectful. Women still struggle to find space in leadership positions where they are appreciated and well received into the team. They no longer wish to tolerate the Old Boys Club but favour an environment that fosters inclusiveness and diversity.

Discussion

Research suggests that overall performance is higher for organisations with women in leadership positions compared to those without (Dixon-Fyle et al., 2020). Those without diverse leadership talent deny themselves of competitive advantage and innovative edge (Hunt et al., 2015). Women have proven to lead just as well as men and the assumption ought to be that both men and women are equally capable. However, organisations still underrepresent women in each leadership level despite the wealth of talent at their fingertips. Ideally, the aim is to increase women's leadership representation at every level to improve the leadership pipeline for sustainable advancement.

It is not accurate to believe appointing just one woman to a leadership team will be sufficient. Dynamic changes occur once there is a sense of diversity, inclusiveness and equality. At the top level, research has found that organisations with three or more women on the board of directors show a clear shift in dynamics which ultimately improves performance of organisations (Konrad et al., 2008). For instance, in C-suite (executive level), there are key shifts that happen between appointing one, two or three or more women on the board such as the following: (1) appointing only one female director means they are typically not taken seriously and are made to feel hyper visible and invisible simultaneously; (2) two female directors increases feelings of validation but share a concern for being seen as “conspirators”; (3) three or more female directors creates normalisation and a supportive environment that fosters collaboration and inclusiveness (Konrad et al., 2008). This model can be applied at lower levels of leadership to illustrate how affirmative action can play out within leadership teams.

Whilst studying the papers, several connections were established between the themes such as microaggressions fuelling the feelings of doubt, or stereotypes driving a lack of support. Thus, the barriers outlined are not necessarily experienced in isolation, but are all interconnected. There is also an underlying patriarchal attitude cutting across all the barriers, whether it is overt in microaggressions, or subtle from internalised feelings or organisational norms.

When developing remedies and reforms, barriers can be further considered as either structural or attitudinal. Structural barriers are a set of policies and procedures that perpetuate inequalities and affect a group disproportionately and are generally ingrained and embedded over time in organisational culture and norms. These are barriers that can potentially be eliminated through reforms and policies such as quotas and leadership training schemes. Attitudinal barriers are behaviours, perceptions and assumptions that discriminate against people of a certain group. These barriers are more challenging to correct than structural barriers as they are linked to internalised beliefs on the part of both women and others in the organisational and wider social context. Remedies and reforms for barriers for women advancing to leadership positions is not a straightforward fix, but rather complicated and multifaceted. They need to go beyond “fixing women” to suit the existing environment by telling them to speak up more, seek out mentors, or arrange their work and home lives (Bismark et al., 2015).

Research suggests that quota schemes, whilst facilitating advancement, can also have some negative outcomes in the short run where that women leaders appointed through such schemes are viewed as less qualified, leading women to devalue their position and capabilities – some even view it as an “unacceptable violation of merit” (Furtado et al., 2021). This can feed doubt and uncertainty about suitability for leadership roles. Although quotas may aid in correcting structural barriers by moving women into leadership positions, it does not necessarily consider the short-term effect on attitudinal barriers such as work-life balance, or internalised feelings. However, ensuring gender diversity at institutional level may be a useful strategy towards gender parity in all organisations in the long run, as more women will be able to act as role models, thus supporting women and working towards the attitudinal barriers, whilst driving forward structural changes. Moreover, increased women at the top mean more visibility of female leaders and an increased mentor base.

Personal

Attitudinal: internalised feelings

Addressing the barrier of internalised feelings is a tricky task. The way women perceive themselves and how they feel about roles is not necessarily something we can change directly through a reform. However, as structural barriers are eliminated, feelings of self-doubt and inadequacy should fade and become less prominent as women see more representation and equal opportunity for leadership roles and are encouraged and supported. As mentioned previously, visibility of women leaders makes those roles less unattainable, or taboo.

Structural: work-life balance

Women are more likely to take on the primary caretaker role, but the potentially rigid work structures and set hours inhibit women from balancing work and home life (Kalaitzi et al., 2019). More health organisations could offer flexible and family-friendly working hours and allow for job sharing or part time roles to broaden and diversify their talent base (Roth et al., 2016). Regarding relocation requirements, we have found through the Covid-19 pandemic that we can do so much using technology – eliminating the requirement for leaders to be available for relocation or extended travel. Therefore, flexible working should be an option where possible, whereby employees can work from home or take office half days – allowing mothers to be at home after their children come home from school. Healthcare work hours can be unusual compared to the work hours of a standard business so it is necessary to recognise that work-life balance can be particularly tricky in the health sector (Kalaitzi et al., 2017).

Equal or shared parental leave after childbirth would spread the weight of responsibility between both parents rather than just on the women. This would prevent women from being viewed as “risky” when of biological reproductive age as the commitment of children is spread equally. In addition, organisations should modernise the way they design the leadership ladder. Instead of traditional, linear leadership trajectories, organisations can create an “M-shaped” trajectory whereby women can enter or re-enter leadership roles later in their careers. This means women will not feel worried about missing out on opportunities to advance to leadership positions when deciding to have children. In-house childcare centres could allow women to return to work quicker knowing they are not far from their children and can quickly check-in.

Interpersonal

Attitudinal: stereotypes

United Nations Educational, Scientific and Cultural Organisation (UNESCO) (2021) recognises that there are attitudinal barriers that are trickier to eliminate. An ideal method to break down stereotypes and bias is to ensure that future generations do not have any to start with-however, recognising that is not a straightforward undertaking. One example is UNESCO tackling gender bias from an early age by shaping educational systems to reflect equal opportunity and leadership empowerment (UNESCO, 2021). It is important to educate young girls about all career possibilities-particularly male dominated industries such as careers in Science, Technology, Engineering and Mathematics (STEM) - as adolescents construct ideas and opinions early on about what they believe to be appropriate and the norm.

As support for women in leadership grows and more females are being represented in leadership roles, women should begin to feel more confident and have a more positive outlook about applying for available positions. The concept of female leaders will feel less taboo and women's reluctance and self-doubt (internalised feelings) should be reduced.

Structural: lack of support

Women feeling that they do not have support from family, colleagues and organisations was expressed as a major deterrent to leadership roles (Kalaitzi et al., 2019). Support and encouragement for women, from other female role models and mentors, was described as essential for women to advance in the healthcare sector (Magee and Penfold, 2021). Organisations would do well to establish mentorship programmes, developmental training and regular networking opportunities (Hopkins et al., 2006). This would allow for the support, guidance and encouragement they need to feel confident to self-promote for new roles and opportunities and should boost women's confidence and reduce self-doubt and imposter's syndrome. Organisations could also assist women by directly introducing them to female mentors and leaders to create and foster female leadership groups which will cultivate support systems.

Organisational

Attitudinal: discriminatory behaviours

Discriminatory behaviours cause unnecessary angst for females in the workplace and are said to be unlikely to report it for fear of being brushed off or regarded as too sensitive. It is important to improve reporting of gender-related issues at all levels to instil accountability and reduce cases of sexual harassment or microaggressions – a guaranteed zero-tolerance for sexual harassment policy. Large organisations could also implement counselling/advisors (both male and female) with whom employees can share concerns and seek advice from. This can create a safe space which may help women feel heard and supported whereby they can make informed decisions rather than step away from leadership roles or be anxious in the workplace.

Structural: organisational culture

Policy makers and organisations should certify that expectations are clearly outlined and recruitment process is transparent and gender neutral to eliminate discrimination/bias (Roth et al., 2016). Nepotism has been reported as an issue in the healthcare sector (Tlaiss, 2013). Women are still witnessing organisations rely heavily on informal networks and favourited candidates to be “shoulder tapped” for roles rather than through the formal appointment process (Tlaiss, 2013). This concern can also be ceased through policymakers' efforts to make promotions transparent and explicit throughout the entire recruitment process.

Succession planning is another factor that organisations should consider as it has been established that the leaky pipeline is one of the main drivers of gender disparity. Women need to be represented at all levels so that women do not gradually fade out of the leadership ladder. If organisations find themselves in positions where the only potential successors are males, they should urgently reconsider and restructure their leadership pipeline.

Practical implications

Implications for policy and practice

Flexible and remote working opportunities (where possible) are a favourable remedy for women who have family responsibilities. Family-friendly/flexible hours and job-sharing would also help women in clinical roles to be able to have a little more flexibility and control over their work-life balance. It was also noted that women and men should be given equal or shared parental leave so that the “burden” does not automatically fall on the women. An in-house childcare centre for young children is a great option for parents to be able to check in on their children whilst at work.

Mentorship programmes should be established, as well as developmental training and regular networking opportunities so that women feel supported. Having mentors guide you through the leadership journey will help women feel less daunted and nervous when it comes to putting themselves forward for leadership roles. These role models can also be in-house “champions” to ensure short-to long-term goals for representation are being met. Furthermore, the educational system is a perfect place to start eliminating gender bias and fostering equality, rather than being a space where bias is created. Educating new generations on opportunities, whilst breaking down bias and eliminating gender roles by exposing children to both male and female role models and correcting stereotypes.

A zero tolerance for discriminatory behaviour and sexual harassment is essential in any organisation. Some organisations employ counsellors, both male and female, to be a guiding light for women who face difficult situations in the workplace and feel too anxious to speak up about it. There needs to be a safe space for women to go to when they feel they are experiencing microaggressions or sexual harassments. Mandatory and statutory training for roles should include high-quality unconscious bias training for all employees.

In addition, more equality, diversity and inclusion (EDI) roles should exist in organisations. These roles can also ensure that succession planning is considered so that they do not fall victim to the leaky pipeline. Governments, and/or individual organisations, should set targets for female representation in organisations to analyse progress against target statistics. These organisations should be transparent with their data and be held accountable if targets are not adequately met. Ultimately, by understanding what these barriers are, we can identify ways in which to remedy them. Further study can be done to analyse each of the barriers in different contexts to identify what remedies are impactful or not and the progress which we are making.

Limitations and future research

This study drew on published papers enabling the identification of key aspects of women's experiences related to the overall aim of the review. The review does have some limitations. Only English language studies were included in the synthesis. The synthesis also relied on the authors' own interpretations in the published studies and it is not possible to know how representative these are beyond the contexts in which they were conducted. The studies were conducted in a range of cultural contexts and healthcare settings, where this heterogeneity could be a barrier to definitive conclusions.

Sufficient research has been conducted to determine that leadership barriers for women in healthcare appear to be a shared perspective in women across the globe. In the UK, as an example, there are a few policies around trying to address the issue of gender disparity. Therefore, future research should look at how successful these initiatives affect cultural change in relation to gender and advancement - “women in leadership” type training courses may not be as effective for breaking down barriers as one would hope. Future research could focus on specific contexts such as the National Health Service (NHS) in the United Kingdom to analyse the effectiveness of the reforms put in place to advance women over longer periods of time. The findings from that could then inform international evidence to foster long term success.

Conclusion

Unless action is taken, the healthcare sector will continue to lose talent and the glass ceiling will prevail. The effective implementation of remedies will assist women in shattering this glass ceiling and repairing the leaky pipeline. Institutions, organisations and individual women will all benefit from women becoming more prominent and fully contributing to leadership positions at all levels.

Figures

Figure 1

Prisma diagram for searches

Table 1

SPIDER framework

Sample	Phenomenon of interest	Design	Evaluation	Research type
Women	Leadership positions in healthcare	Semi-structured interviews, surveys, in-depth interviews, focus groups and face-to-face interviews	Perceived barriers from lived experiences	Qualitative

Source(s): Authors' work

Table 2

Search terms used in SPIDER tool

SPIDER	Search term
S – Sample	“women”
PI – Phenomenon of Interest	“leadership” OR “leaders” AND “healthcare”
D – Design	contains elements of the women's voice within study
E − Evaluation	“barriers” OR “underrepresentation”
R – Research Type	“qualitative”

Source(s): Authors' work

Table 3

Summary of included studies

Authors	Title	Year of publication	Country	Design	Data collection
Magee and Penfold (2021)	Game of snakes and ladders: barriers and enablers for aspiring women leaders in healthcare	2021	United Kingdom	Qualitative	Focus groups or semi-structured interviews (n = 11)
Bismark et al. (2015)	Reasons and remedies for under-representation of women in medical leadership roles	2015	Australia	Qualitative	Semi-structured interviews (n = 30)
Roth et al. (2016)	Women physicians as healthcare leaders: a qualitative study	2016	Canada	Qualitative	Focus Groups (n = 35)
Hopkins, O'Neil and Bilimoria (2006)	Effective leadership and successful career advancement: perspectives from women in health care	2006	United States of America	Qualitative and Quantitative	Surveys (n = 140)
Soklaridis et al. (2017)	Gender bias in hospital leadership: a qualitative study on the experiences of women CEOs	2017	Canada	Qualitative	In-depth interviews (n = 12)
Gottenborg et al. (2021)	The Experience of Women in Hospital Medicine Leadership: A Qualitative Study	2017	United States of America	Qualitative	Semi-structured interviews (n = 10)
Kalaitzi et al. (2019)	Women, healthcare leadership and societal culture: a qualitative study	2019	Greece and Malta	Qualitative	In-depth interviews (n = 36)
Tlaiss (2013)	Women in Healthcare: Barriers and Enablers from a Developing Country Perspective	2013	Lebanon	Qualitative	In-depth interviews, semi-structured interviews, and face-to-face interviews (n = 10)
Adams–Harmon and Greer–Williams (2020)	Successful ascent of female leaders in the pharmaceutical industry: a qualitative, transcendental, and phenomenological study	2020	United States of America	Qualitative	Face-to-face interviews (n = 12)

Source(s): Authors' work

Table 4

Themes identified within the studies

	Personal		Interpersonal		Organisational
	Internalised feelings	Work-life balance	Lack of support	Stereotypes	Discriminatory behaviours	Organisational culture
Magee and Penfold (2021)			X	X	X
Bismark et al. (2015)	X	X	X	X		X
Roth et al. (2016)	X	X	X	X		X
Hopkin et al. (2006)			X	X
Soklaridis et al. (2017)		X				X
Gottenborg et al. (2021)	X	X	X	X	X
Kalaitzi et al. (2019)		X	X	X	X	X
Tlaiss (2013)	X	X	X	X		X
Adams–Harmon and Greer–Williams (2020)	X	X			X	X

Source(s): Authors' work