Gender and healthcare leadership: Addressing critical knowledge gaps by explicitly considering the gendered concept of care

Abstract

This scoping review of gender and healthcare leadership synthesized the barriers and facilitators at multiple levels employing a framework that integrates a specific focus on the concept of care. The 71 sources identified focus predominantly on barriers to women’s leadership at the individual and team level and, to a lesser extent, at the organizational and system level. Facilitators tend to be presented as recommended actions than evaluated interventions. Healthcare leadership tends to ignore the gendered context of care elevating leaders who are least likely to provide such care. Where personal caregiving circumstances are considered, they are individualized, reflecting the literature in general. More critical analysis is needed to focus on women’s experiences and how their gender can predetermine their success in achieving and being in leadership positions. Healthcare leadership researchers are encouraged to include gender and care-focused analyses and interventions to address the under-representation of women in healthcare leadership.

Introduction

The literature on healthcare leadership is vast, but a focus on women and healthcare leadership is nascent. This is remarkable given the predominance of women in healthcare—making up over 70% of the global healthcare workforce^1,2—and their relative under-representation in leadership positions.³ Women’s role in healthcare leadership has far reaching implications for the knowledge and practices that reflect the entirety of our communities. Henrich and Viscoli,⁴ for example, found that the presence of a female medical dean made it more likely that the school’s curriculum would include topics taught on gender. Beyond considering gender as a factor by which to disaggregate leadership data, more critical analysis is needed to focus on women’s experiences and how their gender and all that entails can predetermine their success in achieving leadership positions.

Healthcare leadership, gender, and care

Studies of healthcare leadership range in focus from traits and characteristics of leaders to behaviours and processes involved in leadership approaches.^5-7 Turner,⁸ for example, identified nine approaches in the healthcare leadership literature, including generalist models,^9-12 transformational leadership,^13,14 servant leadership,¹⁵ ethical leadership,¹⁶ complexity leadership,¹⁷ authentic leadership,¹⁸ leadership models for improvement,¹⁹ and shared or distributed leadership.²⁰ More critical enquiries consider leadership as a process towards producing change and, in this way, have sought to understand how leadership promotes social change rather than defining leadership as a trait or capability.^21,22 Little of this literature focuses on the impact of gender.

In an initial rapid review of the healthcare leadership literature, we developed a framework that delineates four levels of barriers and facilitators to women’s leadership.²³ The most prominent focus was at the individual level with barriers ranging from leadership styles reflecting an internalized gender bias to facilitators encouraging the adoption of more assertive lean in attitudes. The team and organizational levels consider the barriers of unconscious gender bias to explicit sexism in recruitment and promotion, exclusion from influential social networks, and experiences of gender and sexual harassment. Facilitators to address barriers at these levels include gender-responsive mentoring and networking, gender-based targets or quotas, and gender-based policies recognizing caring responsibilities. Barriers at the system level reflect the broader patriarchal culture that privileges men’s participation in leadership which would need to be counteracted with gender transformative policies to foster a culture of equitable representation.

Intersecting this multi-layered framework is an explicit consideration of the gendered concept of care in positioning women’s leadership in healthcare. Women’s work in healthcare has been largely conceived of as care work and, to this end, much of feminist work has focused on categorizing, qualifying, and recognizing care work rather than defining or recognizing care in relation to leadership.^24,25 In Moral Boundaries: A Political Argument for an Ethic of Care, Tronto²⁵ describes care is not a disposition, but rather is a set of practices that take as their starting point the central role of caring in daily human life. This ethic of care recognizes that systems of power and privilege influences an individual social location and, in turn, their ability to lead.²⁶ A feminist ethic of care lens helps to identify opportunities for feminist iterations of healthcare leadership that builds upon feminist discussions of leadership as a process geared towards change.

Purpose

Guided by our initial orienting framework, this scoping review explicitly integrates how care as a set of practices is implicated in the development and success of not only women healthcare leaders but also our understandings of health leadership more broadly.

Methods

We followed the five-step methodological approach developed by Arksey and O’Malley²⁷ and updated by Levac, Colquhoun, and O’Brien²⁸ in conducting this scoping review (Table 1). This approach is guided by the principle that “the methods used throughout the different stages are conducted in a rigorous and transparent way.”²⁷

Table 1.

Overview of the 5 steps of the scoping review methodology.

1	Identifying the research questions	We began by identifying the following orienting research questions: • In what ways are gender and care reflected in healthcare leadership literature? • How does the gendered nature of care influence the barriers and facilitators for women in healthcare leadership?
2	Identifying relevant studies	Building on the rapid review, the project team updated our key search terms and search strategy and conducted additional searches to identify new sources that emerged since 2017 (Table 2). With the assistance of a research librarian, we searched relevant publications from Medline and CINAHL. We augmented these searches with targeted review of selected journals and identified additional sources promoted through social media
3	Selecting the research studies	We developed and employed an inclusion and exclusion criteria related to date, language of publication, document and study design, population, country, and content for consistency and relevancy to the research questions (Table 2). After the application of the key search terms and the inclusion criteria, the authors conducted a title and abstract review of the identified articles (n = 1,021) using Covidence software. The authors conducted a full review of the remaining eligible articles (n = 58) to confirm relevance and eligibility for this scoping review and all were included. The supplemental review of the grey literature uncovered an additional 28 sources and once duplicate articles were removed an additional 13 articles in the scoping review for a total of 71 articles
4	Extracting and collating the data	The initial data extraction involved the assignment of two reviewers per articles. We systematically extracted key pieces of information and themes through an excel-based Literature Extraction Tool (LET) informed by the initial orienting framework: citation (author/year), country, region (if Canada), health issue, work setting, aims/objectives/research questions, methods, intervention (details about design/development and process/implementation), if study was not intervention, details how it informs an intervention, number of participants, recruitment details, gender, any relevant details about gender, caregiving, any relevant details about caregiving, key findings, policy/program/intervention recommendations, limitations, research gaps and areas for future research identified, commentary, and grading. The reviewers met to calibrate their extractions and to further refine the LET
5	Synthesizing and reporting results	We synthesized and summarized the data extracted from the LET into the different sections of the results reported here

Table 2.

Key words and inclusion/exclusion criteria used in scoping review.

Key Words Searched	1. Women/
	2. wom*.mp.
	3. 1 or 2
	4. exp Health/
	5. exp “Delivery of Health Care”/
	6. health care.mp.
	7. healthcare.mp.
	8. health sciences.mp.
	9. exp Hospitals/
	10. exp Physicians/
	11. exp Nurses/
	12. Pharmacists/
	13. 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
	14. Leadership/
	15. leader*.mp.
	16. Mentors/
	17. Mentoring/
	18. mentorship.mp.
	19. leadership development.mp.
	20. 14 or 15 or 16 or 17 or 18 or 19
	21. indigenous.mp.
	22. aboriginal.mp.
	23. first nations.mp.
	24. metis.mp.
	25. Inuits/
	26. 21 or 22 or 23 or 24 or 25
	27. 3 and 13 and 20
	28. limit 27 to (English language and yr = “2008 - 2020”)
	29. 3 and 13 and 20 and 26
	30. limit 29 to (English language and yr = “2008 - 2020”)
	Inclusion Criteria	Exclusion Criteria
Date	- Published between 2009 and 2021 for all Canadian and international literature	- Published before 2008
Language	- Published in English or French	- Published in languages other than English or French
Document type	- Academic literature (empirical or review papers including systematic methodologies) and grey literature (publicly available reports, publications, and proceedings of meetings)	- Does not meet document type/study design criteria
Population	- Healthcare professionals; primary care; academic; private practice	- Other types of professionals
Country	- Canadian-based as well as a broader international literature	- No country will be excluded
Content	- Addresses gender, healthcare management, and/or leadership	- Does not meet content criteria

Findings

Our scoping review illuminates the depth of women’s exclusion across all facets of healthcare leadership quantifying their exclusion in general and in profession-specific disciplines and considers the barriers and facilitators to women’s leadership at the individual and team/work level and, to a lesser extent, at the organizational and societal or system level.

The quantification of women’s exclusion from health leadership

This literature is overwhelmingly focused on quantifying the exclusion of women from key healthcare leadership positions including in medical sub-specialities.^29-36 Skinner,³⁴ for example, assessed gender representation within surgical organizations in the United Kingdom showing that women are significantly under-represented in leadership roles with only 2 of 24 presidents and only 15.2% of all committee members being women. In Canada, Glauser²⁹ reported that women are under-represented in Canadian medical associations, including how the Canadian Medical Association’s Board consisted of 20 men and only 6 women.

The literature also details how women leaders are excluded from senior author positions and journal editorial boards, a means by which to shape a field and future research within it. Silver³⁴ examined the gender profile in the four highest-impact general paediatric journals identifying women’s under-representation as first authors. Litvack³⁰ reported on the absence of women in high-profile otolaryngology journals and Silva³³ identified the exclusion of women in academic neurological surgery. Penfold³¹ discussed the recurrent issue of “manels,” a term to describe an all-male panel of expert participants at healthcare conferences. A cross-sectional analysis in the United States and Canada demonstrated that the mean proportion of female speakers across 181 medical conferences was 34.1%.³² The absence of women from expert panels or as invited speakers is important because panels are purported to ensure a “diversity of opinions and perspectives are brought to issues affecting health and social care.”³¹

Barriers to women’s healthcare leadership

Barriers to women’s leadership in healthcare were the next most prominent theme in the literature.

Individual level

An individual level was the most common lens which focused on care-related concerns of work/life balance and familial responsibilities as barriers to women’s healthcare leadership.^29,37-41 Kalaitzi et al.³⁷ identified lack work/life balance and spousal support as a barrier to Greek women’s advancement into healthcare leadership positions. In the context of global health leadership, Moyer⁴⁰ reported that regardless of age, country or origin, or career stage, challenges surrounding domestic care work and balancing work and family responsibilities were among the leading barriers to women’s leadership in this sector. Glauser²⁹ and Sepulveda⁴¹ both attributed the exclusion of women from leadership roles in Canadian medicine and academic radiology, respectively, to the incompatibility of these roles with family and parental responsibilities. The influence of care, therefore, figures prominently.

Team level

Barriers to women’s leadership in healthcare also emerged at the team level. Thompson-Burdine⁴² reported on a qualitative analysis of interviews with women in medicine, where it was found that relational barriers surrounding gender-based interactions (i.e., the role of gender stereotypes in workplace interactions) constituted major barriers to advancement for women in healthcare leadership. In a review of academic advancement in medicine and dentistry, Gangwani and Kolokythas⁴³ identified the absence of appropriate role models for female faculty, lack of peer support, and implicit bias and negative stereotypes surrounding women in medicine and dentistry.

Organizational level

The most prevalent barrier to women’s leadership at the organizational level is institutional bias.^34,44 Shillingburg et al.⁴⁴ conducted a study on perceptions of women’s leadership among oncology pharmacists and, despite the leadership gender gap in the profession, found that women’s leadership was not a policy priority for its professional association members. Silver³⁴ attributed the exclusion of women first authors in high impact paediatric journals to “a flawed process at the journal level related to institutional bias.” She goes on to state, “as organizations are made up of individuals, it is important to consider how people’s unconscious bias may inadvertently contribute to institutional bias.” Berry et al.⁴⁵ examined the number of National Institute of Health (NIH) grants awarded to Black and Asian American women-surgeon scientists over the past two decades revealing a notable disparity in organizational and institutional funding for these surgeons hampering women’s leadership opportunities in these areas.

System level

Barriers at the system and societal level were noted in a few articles. Kalaitzi et al.,³⁸ for example, identified prevailing barriers to women’s advancement and participation in healthcare leadership, including culture, negative stereotypes, gender bias, lack of social support, and the absence of a theoretical model to consider gender and healthcare leadership. Ioannidou⁴⁶ and Thompson-Burdine⁴² identified the gender pay gap and salary inequities within and between cadres of workers as a central concern and barrier to women leaders in medicine, science, and dentistry workforces.

Facilitators of women healthcare leadership

Facilitators of women’s leadership in healthcare were the least prominent theme, much of which focused on recommended actions that were not systematically evaluated.

Individual level

The most common facilitator focused on improving women’s leadership capacity through formal individualized training.^39,47 Wolfert,⁴⁷ for example, examined the under-representation of women in neurosurgery in Europe and suggested that women neurosurgeons should adopt strategies like cognitive behavioural programs to breakdown perceived gender bias in this field. Mathad³⁹ examined data-driven interventions to increase women’s leadership in global health, which included individual and gender-specific leadership training to empower women leaders.

Team level

A recommendation laden literature revealed allyship as the most prevalent facilitator at the team level.⁴⁸ To address manels, for example, Penfold et al.³¹ said that “men in the field can be allies and seek to intentionally be more inclusive and aware of the gender disparity at these conferences, diversifying representation of both women and men. In the context of global health leadership, Moyer⁴⁰ discussed the critical role of financial and nonfinancial support from men, other women, and institutions.

Organizational and system level

Less literature speaks to the facilitators of women’s leadership in healthcare at the system or organizational level. Mathad et al.³⁹ identified several organizational facilitators to women’s leadership in global health, including the ongoing public promotion of gender equality within an organization; institutional and formal policies on gender discrimination and harassment with clear reporting methods independent of committees to review and address complaints; and policies to support flexible working arrangements to support familial responsibilities. Both Sepulveda⁴¹ and Woods and Sharkey⁴⁹ discussed the possible advantages for promoting greater gender diversity at the organizational level by making diversity a departmental priority.

Enhanced conceptual framework: Care in context

By integrating an explicit focus on the cross-cutting influence of care across these different levels of analysis, we embellished our initial conceptual framework. Our enhanced conceptual framework (Figure 1) explicitly includes the level of home as a site of care and distinct influential factor on women’s healthcare leadership and encourages the explicit integration of care amongst the other individual, team, organization, and system levels. When we relegate care only to the home and individual level, as either a barrier or facilitator, we risk reinforcing a care binary that further stigmatizes the kind of care work (e.g., bringing children to school, moving an ageing parent into your home, and supporting a friend through gender transition) that is essential to daily human life outside of as well as within healthcare organizations.

Figure 1.

Framework of factors influencing women’s leadership in health integrating the concept of care.

Discussion

At present, gender and healthcare leadership scholars continue to focus on where women are missing from in formalized leadership positions rather than critically reflecting on how that happens. The quantification of women’s absence from healthcare leadership positions is important but leaves little room for qualifying women’s presence in these areas or imagining a shared experience of exclusion across other equity-deserving groups. Delineating the barriers and facilitators to leadership itself does not interrogate how each of these implicates the gendered concept of care in relation to women’s healthcare leadership.

While it remains vitally important to continue to collect demographic data to determine how and where women from all backgrounds are included amongst our health leaders, as well as individuals from other equity-deserving groups, we must go beyond a simple roll call. Indeed, increased representation is not the only solution to gender and other forms of inequity in healthcare leadership. We know that the “add women and stir” method, for example, has not guaranteed a road to gender equity. Indeed, the increasing number of women in previously male dominated professions like medicine and dentistry has not necessarily translated into gender equity within these domains nor in healthcare leadership as whole.³

Adopting a theoretical lens of care²⁵ helps to explain why the most prevalent barriers to women’s leadership in the literature focused on the influence of the home on individual leaders. Accounting for the gendered concept of care recognizes that women, regardless of whether they are parents, perform the bulk of the care work in the home; this invisible load of care work coupled with gender bias negatively impacts women’s leadership journeys in healthcare.^34,40,47 Taken together, current configurations of healthcare leadership in the literature are built outside of care as an orientating concept of leadership success. Indeed, it tends to elevate leaders who are least likely to provide unpaid care (e.g., as a parent or caregiver to an ageing parent) or need care (e.g., as a birthing person or person who is chronically ill). Moreover, recommended actions often suggest eschewing these care work activities both at home and at work in support of women’s leadership journeys.⁵⁰ Integrating rather than eschewing care work can support not only women’s leadership but also gender inclusive leadership more broadly.

Working towards transformative change in health systems requires critical reflection on how traditional models of healthcare leadership have produced the current system that is clearly segregated by gender. In so doing, it is imperative that we conceptualize care beyond the levels of the individual and their home so that our systems are built with care as a central component to all leaders’ success. Indeed, the absence of the broader consideration of care in a system predicated on and structured around the delivery of care is, quite frankly, ironic.

Limitations

This study is limited in that scoping reviews do not assess the quality of the data collected in the found studies; rather, they seek to map out the landscape of the extant research on a topic.²⁷ We also chose to only include articles and grey literature in English and French. It is possible that more extant literature is available in other languages. We did not explicitly focus here on barriers and facilitators to broader equity-deserving populations but have considered these elsewhere.⁵¹ There is a need for further research to explore these areas and ensure a more inclusive understanding of leadership dynamics in healthcare.

Conclusions

The literature available on gender and healthcare leadership is focused predominately on women’s quantitative under-representation in key leadership positions. A nascent focus on facilitators to women’s healthcare leadership has emerged where facilitators are presented in the form of recommended actions rather than evaluated interventions. We encourage future research to integrate a more explicit focus on the context of care in supporting women leaders to advance gender equity in healthcare leadership.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Status of Women Canada.

Ethical approval

Institutional Review Board approval was not required.

ORCID iDs

Billie Jane Hermosura

Ruth Decady

Ivy L. Bourgeault

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