We know that the road to leadership for women is arduous and the pace is slower than anticipated, despite their increasing representation in the labour force. In Canadian health care, where women constitute over 80% of the workforce, their representation in leadership positions is low. In our project, Empowering Women Leaders in Health, we apply a gender lens to achieve transformative systemic gender equity change in these contexts through the increased participation, visibility, and advancement of women in leadership positions. In this paper, we provide an overview of the needs assessment we conducted, which forms the basis for the larger project. Across the health care, health sciences, and Indigenous health literatures, we know more about the barriers to than facilitators of women’s leadership. Where the literature describes an intervention, it is seldom evaluated. There is also a notable absence of information on how we can and need to engage men to be part of the solution and facilitate the inclusion of women leaders. The literature on women and Two Spirit leadership in Indigenous health is particularly sparse, which has produced an extensive knowledge gap in this sector.
KEY WORDS: women leaders, health care, health sciences, Indigenous health, Two Spirit, barriers, facilitators
Women hold a unique position in health care as they constitute over 80% of the health workforce, and their predominance in the field in Canada has been growing.1 Yet women attain disproportionately fewer leadership positions in hospitals and other health care organizations. In the prestigious teaching and research hospitals in Ontario, for example, only five of 23 CEOs are women.
Women’s leadership in health sciences is also critical to advancing scientific inquiry fostering the generation of new knowledge of unique interest to women. Here, too, women are less likely to be in academic leadership positions — deans, associate deans, and directors — and they are less likely to hold prestigious Canada research chairs.2 Beyond these leadership roles, women are less likely to receive competitive Canadian Institutes of Health Research (CIHR) funding, and when funded they receive significantly less.3,4 Women are also less likely to be first author, senior author, or authors of guest editorials in key medical journals,5,6 which affects the translation of knowledge that women scientists generate.
Indigenous women and Two Spirit leadership in health care and health science reveals a similar gap contrary to pre-contact leadership roles. (Note: Two Spirit is a term used by some Indigenous communities to describe people who identify as having both a feminine and masculine spirit.) Since confederation, gender inequity has been enshrined in the explicitly patriarchal elements of the Indian Act.7 We must design and support leadership programs for Indigenous women and Two Spirit to respond to the calls to action of the Truth and Reconciliation Commission8 to increase the complement of Indigenous health workers, who currently make up a mere 2.2% of the Canadian health workforce, in contrast to 4.9% according to the 2016 census. This increase will positively affect the provision of culturally competent and appropriate care to their communities and be a source of high-quality employment.
The overall goal of our project — Empowering Women Leaders in Health (EWoLiH) — is to achieve transformative systemic gender equity change in the health care, health sciences, and Indigenous health contexts through the increased participation, visibility, and advancement of women and Two Spirit leaders. We draw inspiration from the second recommendation of the United Nations High-Level Commission on Health Employment and Economic Growth,9 which stresses that we need to “maximize women’s economic participation and foster their empowerment through institutionalizing their leadership.”
EWoLiH aims to build and sustain their leadership capacity through two interrelated objectives:
Develop a strong and supportive network and community of practice among established and emerging women leaders, enhancing their capacity to make transformative systemic change
Develop and implement evidence-informed tools for transformative systemic change through our network
In this paper, we provide an overview of a knowledge gap analysis, which forms the foundational basis of the larger project.
Three key sources inform this gap analysis. The first was a targeted search and review of the published and grey literatures. The sources selected include 111 published articles and 48 grey literature sources. Although we take an intersectional approach in our project, focusing not only on women in general, but also Indigenous women, Two Spirit, women from visible minority backgrounds, and women with disabilities. The literature describing Indigenous women leaders, for example, is extremely limited; a review did not locate any articles specific to Canada and only three from outside Canada. One edited book, Living Indigenous Leadership,10 was reviewed; however, it was not specific to leadership in health. As well, we were unable to locate any literature relating to Two Spirit leadership in health care and health sciences. As such, most — if not all — of our findings refer to only non-Indigenous women, unless otherwise stated.
Extraction of the key themes from the literature followed an initial framework that delineated the barriers and facilitators to women’s leadership. This was more fully fleshed out into the framework described below, with input from our three project leaders in the domains of health care (Dr. Gillian Kernaghan), health sciences (Dr. Nancy Edwards), and Indigenous health (Dr. Lisa Richardson) and our Interdisciplinary and Intersectoral Women’s Leadership Project Advisory Group, our second and third sources. We met with our three women leaders on three occasions during the fall and winter of the first year of our project (2017–2018) and with our advisory group twice since the inception of the project. We shared our findings from the scoping review of the literature and promising practices enhancing women’s leadership. Top
Emerging conceptual framework
The conceptual framework that informs our project delineates three levels of barriers and facilitators (Figure 1). The first, and most prominent in the women’s leadership literature, is at the individual level. Here, a number of barriers are noted: from one’s leadership style to a lower sense of control/self-esteem and internalized sexism/gender bias and colonialism. The typical facilitators discussed in the literature are for the individual to somehow develop resilience and resistance to these barriers and to adopt an assertive lean in attitude. This individual level, however, is not the primary focus of our conceptual framework.
Our project encourages a more organizational level approach. Here, the barriers include unconsciously gender and racially biased recruitment and promotion, sometimes conceptualized as a “glass ceiling.”11 Others include gender and racial discrimination, which can be overt. Women’s lack of mentors and their experience of exclusion from influential social networks is another barrier. Challenges with retention, sometimes as a result of sexual harassment or when women are only recruited to positions doomed to fail (i.e., a “glass cliff”) is another.12 The caring dilemmas13 that women experience when managing work and home life result in a disproportionately heavier load of care, which is another substantial barrier to leadership advancement.
Sex/gender-based policies that operate as targets or quotas are a facilitator at the organizational level. Another gender-responsive mentoring and networking programs is where women are matched within and across organizations, and time is made during work hours to allow for mentoring and networking activities. Such initiatives can level the playing field in terms of access and participation. Gender-focused leadership opportunities that explicitly encourage and foster women’s equal participation and promising gender-based organizational policies, such as setting meeting times around caring responsibilities and providing parental leave and childcare support (both maternal and paternal), are additional facilitators.
At the systems level, policies that do not consider sex/gender serve to obfuscate their differential impact on women, thus reflecting a broader patriarchal culture that privileges men’s leadership participation. To counteract these gender-blind policies, we are encouraged by a growing culture of representation and gender equity initiatives at the policy level. We applied this conceptual framework to a needs assessment of women and Two Spirit leaders in health care, health sciences, and Indigenous health. Top
Barriers to women’s leadership in health care roles
Women in health care face significant barriers when pursuing leadership positions. Bell14 argued that the hierarchical organization of health care also conforms to a gender hierarchy. Women’s predominant role has been that of a support worker to primary health care providers, such as nurses, dental hygienists, and dental assistants, although women are increasingly entering medicine and dentistry to the point that these professions are said to be feminizing.15-17
Women in typically female health professions and in the professions of medicine and dentistry are underrepresented at the top levels of both clinical leadership and the most prestigious subspecialties.15,17,18 Riska17 argued that the “persistence of gender segregation in the practice of medicine and the existence of a glass ceiling in the careers of women doctors” (p. 389) have become markers of gender inequality in the health care workforce. She further noted that women doctors were relatively well represented in specialities that confirm gender-essentialist notions of women’s work, such as pediatrics, psychiatry, geriatrics, and obstetrics and gynecology. Subsequently, women’s work in health care has been more typically positioned within the caring aspects rather than the curing aspects of health care, which has important implications for gender equity.
In addition to the gender gap in clinical leadership, there is also a gender gap in leadership in health care management. Gumus and colleagues,19 for example, found that women health care managers are less likely to pursue professional development activities compared with their male counterparts, even when the outcome (i.e., obtaining professional certification) is associated with career advancement and salary increases. Simply offering professional development activities for men and women is not sufficient to address the gender gap in leadership. Facilitators are professional development opportunities that explicitly consider the implications of gender in their organization and implementation.
Whether in clinical and health care management roles, women are disproportionally burdened with unrecognized and unpaid care work in their professional and personal lives, sometimes to the detriment of their career advancement.20 In a qualitative study of male and female health care middle managers and executives, Boucher20 found that women described their office role as “unofficial counsellor” for both their peers and colleagues, and often experienced stress and burnout as a result. In this regard, facilitators include organizational awareness to ensure that women leaders are not being used as captive counsellors. Kuhlmann et al.21 also explored the gender gap in leadership and management positions in largely publicly funded academic health centres, taking four centres in European Union countries as case studies: Germany, Sweden, Austria, and the United Kingdom. They found that women were underrepresented in prestigious specialties and as senior doctors and full professors. Gender inequality was stronger in academic enterprises than in hospital organizations and stronger in middle management than at the top level. These novel findings reveal fissures in the glass ceiling effects at top-level management, while barriers for women shift to middle-level management and remain strong in academic positions. Kuhlmann et al.21 argued that setting gender-balance objectives exclusively for top-level decision-making may not promote a wider goal of gender equality.
Barriers to women’s leadership in health science roles
Women experience similar social and institutional barriers as they do in health care, which is reflected in numerical underrepresentation. In contrast to Kuhlmann et al.’s21 findings of greater female leadership in top than mid-level positions, academic medicine in Canada boasts a total of only five female deans ever; currently, there are only two.22 We know less about their numbers in the mid-level academic roles of associate and assistant deans and directors, as these data are not broken down by gender in Canada (nor by minority, disability, or Indigenous status). Reasons cited for underrepresentation of women in academic health sciences leadership positions are gendered stereotypes that define roles and expectations,23,24 differential responsibility for caregiving,25,26 lack of role models and mentors,27 and women’s dedication of more time to teaching and care of patients than research.28,29 A hostile organizational climate, isolation, bullying, harassment, and sexual harassment were all described as elements that influence a woman’s likelihood of achieving success in academic leadership.30-32 A number of these overlap with health care. Top
At an organizational level, measures of academic job performance privilege quantity over quality and research over other university functions, such as teaching, academic service, support, and broader community service. Unfortunately, as women continue to conduct more academic care work, their ability to advance into leadership positions continues to be hampered33-35; this workload is compounded for Indigenous and racialized faculty, who are often expected to sit on diversity committees and mentor and support Indigenous or racialized students in addition to other care work mentioned above.34,36
Research funding criteria also put women at a disadvantage. A recent analysis of the prestigious CIHR foundation grant program revealed that female applicants are 1.6 times less likely than male applicants to receive funding.3 Gender also influences authorship of research publications, another measure of impact. In leading United States medical journals, only 29% of first authors and 19% of senior authors were women, and women contributed only 11% of guest editorials.5 Women are also less likely to act as peer reviewers and editors at academic journals, which entails a scientific gatekeeping function.6
Barriers to Indigenous women and Two Spirit leaders in health care and health sciences
Indigenous women and Two Spirit leaders are significantly and negatively affected by systemic exclusion. Federal legislation purposefully undermines the roles of women and Two Spirit people, so as to advance nation building.7 The, Indian Act,37 for example, purposefully excluded women and Two Spirit leaders and replaced them with men, reinforcing patriarchal and colonial governance systems. Unfortunately, the Government of Canada has yet to demonstrate meaningful and systemic commitments to redress this significant loss of leadership. It is only through the resilience and resistance of Indigenous women and those who are Two Spirit that elements of their leadership in health have been maintained. Top
We learned from our project leaders and Indigenous members of our Advisory Group that the few women and Two Spirit leaders in health are actively engaged in their employment and community responsibilities. Many Indigenous leaders are often asked to take on leadership roles in early career, thus making them susceptible to overload and burnout. They are often unavailable to take on additional mentorship roles or the dissemination of leadership tools within their own professions or broader community. Further, their workload often far exceeds full time hours, so that they can properly engage with the communities they serve. As a result, there is simply not enough time and support to effectively engage with this vital community of leaders.
Facilitators of women’s leadership roles
Designing, adopting, and implementing gender-responsive organizational policies are important tools for women and Two Spirit leadership in health care, health sciences, and Indigenous health. Networks and mentorship among peers as well as senior colleagues are identified as facilitators for women’s career advancement. Interventions that focus on reducing isolation through networking, providing role models, and mentoring can support the advancement of women and Two Spirit people into leadership positions.24,30,34,35 Department-level bias-reducing workshops were shown to be effective in a post-intervention evaluation.38
By recognizing the on-going implications of the gendered hierarchy in health care, Bell,14 for example, recommended three steps for health care planners and policymakers to address inequity: reduce beliefs about general competence that privilege men over women; increase the number of women in leadership roles in medicine; and address the institutional connection of gender and medicine, which includes evaluating hiring practices, workloads, and educational requirements. Although these recommendations focus on leadership in medicine, they could be applied to increase women and Two Spirit leaders in other professions and in health care management as well.
To address the slow pace of institutional change in health sciences and across disciplines in the United Kingdom, the Athena SWAN Charter was adopted as a mandatory criterion for receiving federal funding for health science research.39 Currently, the Canadian Tri-Councils are undertaking a five-year pilot project to adapt the Athena SWAN program, and consultations are underway for a made-in-Canada Athena SWAN initiative.40 The initiative, by design, is to pay particular attention to the four protected groups — women, people with disabilities, Indigenous peoples, and people from visible minority groups — and how the intersections of these identities are considered in the Canadian context.
Another example is the ADVANCE program in the United States, which provides support to university-based organizational gender equity change initiatives.41 This program has supported the University of Michigan, for example, in creating resources, such as Creating a Positive Departmental Climate: Principles for Best Practices42 and Developing Anti-Harassment Programs in Academic Societies and Meetings: A Resource Guide43 to address gender inequity in their organization. Top
Our review of the literature, with input from project leaders and advisors, demonstrates that to advance women and Two Spirit leadership in health care, health sciences, and Indigenous health, we must address a number of critical gaps in our knowledge. From the health care, health sciences, and Indigenous health literatures, we know more about the barriers than facilitators or interventions that foster women’s leadership. Where the literature includes an intervention, it is most often only described and not evaluated. This is an important gap to address.
Because of the dearth of literature, a number of unknowns exist in the area of health leadership by Indigenous women and Two Spirt people. We do not know the specific facilitators and barriers that affect their participation in leadership roles in health; the mechanisms that facilitate knowledge transfer between established and emerging Indigenous and Two Spirt leaders; nor how non-Indigenous leaders in health care support and promote Indigenous women and Two Spirt leaders.
There is also a notable absence of information that describes how we can engage men to be part of the solution to facilitate the inclusion of women and Two Spirt leaders.
The next step of our project will be to gather key lessons learned into a tool kit of promising practices to support women and Two Spirt leaders.Top
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Yvonne James, MA, is a PhD candidate at the Institute of Feminist and Gender Studies, University of Ottawa, and a research associate at the Gender, Work and Health Research Lab at the Telfer School of Management.
Karen Lawford, PhD, RM, AM, is an assistant professor in the Department of Gender Studies at Queen’s University.
Jamie Lundine, MSc, is a PhD student at the Institute of Feminist and Gender Studies, University of Ottawa, and a research associate in the Gender, Work and Health Research Lab at the Telfer School of Management.