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Abstract
Background Executive leadership boards in healthcare should be diverse, reflecting the populations they serve and the workforce serving in them. Worldwide, women constitute most of the healthcare workforce, yet the minority of leaders. Women experience barriers to progression to board-level positions at personal, workplace and wider systemic levels, including self-imposed barriers, prejudice and limited access to role models. Evidence to understand enablers to progression is limited.
This study addressed the following research questions:
What are the inspirations and/or enablers for women, especially those from under-represented backgrounds, in the pursuit of career progression?
What are the coping mechanisms employed to respond to barriers for those women?
Methods A qualitative interview study with ten women in board-level positions in National Health Service (NHS) organisations across South Yorkshire, with semistructured interviews carried out through 2022, and thematic analysis of data informed by an intersectionality lens.
Results Three key themes emerged: (1) identities and self-improvement were informed by a sense of self, motivating experiences and the expectations of others; (2) barriers to progression included disability, disadvantage, limiting self-belief, lack of support and prejudice and (3) senior women proactively adopted coping strategies, leading to bespoke, blended solutions including formal programmes alongside personal approaches, notably the development of comprehensive peer networks.
Conclusion The study highlights the need for NHS Systems and healthcare organisations to adopt facilitating enablers to respond to the challenges faced by under-represented staff, including coaching and mentoring, talent management programmes and peer networking, to enable diverse women leaders to successfully apply for board-level positions.
- career development
- coaching
- role modeling
- mentoring
- development
Data availability statement
No data are available.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Previous published literature focuses on barriers and enablers for women or other minority backgrounds, at personal, workplace and wider systemic levels.
WHAT THIS STUDY ADDS
This study focuses on senior leaders in healthcare, and notes the impact of early experiences and individuals’ intersecting identities, including working-class backgrounds and limited educational attainment in shaping women’s adult lives.
Several enablers were cited by all participants including building and exploiting peer networks which was an enabler not widely identified in published literature.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Many enablers to career progression for women had been widely adopted among the sample and could therefore be considered as good practice for both individuals and at a system level, including coaching, mentoring and talent management programmes.
The importance of professional networks in career development suggests that women’s staff networks could be adopted as policy, alongside other staff networks i.e. those that focus on race or disability.
Introduction
Women make up 80% of the front-line healthcare workforce worldwide, but men continue to hold more senior leadership positions: ‘women still deliver health systems led my men’. (Zeinali et al, Dhatt and Keeling pp.44).1 2 In 2016 in England, the National Health Service (NHS) employed 77% women, and set a target for all executive boards to reach 50:50 men: women representation by 2020.3 The overall change by 2020 was that 44.7% of NHS board directors were women, but this ranged from 15% to 78% across boards, recognising that many healthcare organisations have much to do.3
Why this is important
There is a strong values-based case for change, grounded in fairness, equity and transparency. A review of published literature suggests there is also a compelling business case for diversity in leadership. Studies show that the highest performing companies are the most diverse.4 Without the opportunity for women to progress to senior roles, workforce morale can fall and attrition rates among female nurses can increase.2 Diverse boards lead to better performance, expanding perspectives, improving relationships, fostering innovation and decreasing turnover in under-represented staff.4–8 Research conducted during the COVID-19 pandemic highlighted the skills of women of leading in a crisis and making more inclusive decisions, although this does not yet seem to have translated into inclusive recruitment or promotion practices.9
While people from under-represented groups may aspire to leadership in healthcare, a multitude of barriers prevent them from translating their goals into actions.10 There is a need to overcome both self-imposed and system barriers.11 In a culture with long-standing social inequalities, those that intersect across protected characteristics may feel they are not a good fit, may not express themselves or that they have to prove themselves.12–14
Low numbers of women in senior roles have resulted in a lack of role models for others.13–15 All workplaces hold norms, including gender role expectations. Implicit and traditional views that leaders should have male traits pervade. Men tend to employ men for senior management positions with many wishing to maintain a status quo.13 14 Men may idealise or protect women, assigning them less challenging roles.16 Furthermore, gender stereotypes can devalue women’s performance and prevent promotion as they receive less credit for achievements.17–19 Prejudices towards women exist through a double-bind of being perceived less favourably and having their behaviours evaluated less favourably.20
Societal expectations can further impact on women’s careers. Mothers can face disadvantages, including being seen as less committed: the motherhood penalty. Many women from minority backgrounds have additional pressures from their communities.21
Despite most of the healthcare workforce being women, research to investigate enablers and provide new solutions for career progression for women in healthcare leadership is limited.
The aim of this study was to explore the enablers and coping strategies of women progressing to executive leadership (board-level) positions in the NHS.
Theoretical framework
The current evidence base is limiting as it predominantly focuses on the specific barriers that minority leaders face in relation to one aspect of diversity or another.22
Intersectionality provides a theoretical framework to enhance understanding of how all members of all groups are impacted. Multifaceted aspects of an individual’s character, gender, race, sexuality, etc, interrelate and shape individual experience.12
The sparsity of women leaders demands an intersectionality approach, striving for parity that is inclusive ‘of all identities and stratifiers’. (Zeinali et al pp.2).1
Methods
Design and sample
Qualitative research methods were employed to elicit in-depth insights into the experiences of women in leadership. The sampling strategy targeted a homogeneous subgroup of executives and board-level directors.23 The study setting was South Yorkshire, a diverse area of England, where at the time of the study, 45% of executives and board-level directors of NHS Trusts were female and 55% were male. Of the seven chief executive officers, four were female (57%). While this is representative of the South Yorkshire population, it is less representative of the regional health and care workforce where females make up 77% of employees.
Given the aims of the research and practical aspects of different approaches, interviews were considered the most appropriate data collection method. Participants were offered a choice of face-to-face or remote online interview. Face-to-face interviews were preferable, recognising that interviews are dependent on rapport and the interrelationship between interviewer and interviewee.24 COVID-19 restrictions had lifted by the time of the interviews so that these were possible. An interview guide was devised, informed by the aims of the research and with an intersectionality and life-history lens. Mitigations were in place to reduce risk to health or psychological harm to participants.
Data collection and analysis
The interviews began with participants completing a monitoring sheet to self-identify across certain characteristics—see figure 1.
Monitoring sheet used in participant interviews. NHS, National Health Service.
All interviews were audiorecorded and transcribed verbatim by the researcher (AJB). All transcriptions were checked for accuracy, pseudoanonymised and uploaded to NVivo data management software (V.2020) to support analysis.
Iterative analysis of the data began alongside data collection, with a continuous process of reflection and note-taking accompanying more formal analysis. Data were assigned codes, then grouped into patterned responses (themes). Informed by the work of Braun and Clarke on thematic analysis,25 a mid-range approach to coding was adopted, whereby coding did not attempt to fit a predetermined framework, but knowledge of the existing literature prompted identification of patterns across the data. Data analysis followed a process of familiarisation, generating codes, looking for themes, reviewing, defining, naming and developing themes then reporting them.25 A process of team discussion guarded against bias on the part of individual researchers.
Findings
Overview of participants
A total of ten women leaders in NHS organisations in South Yorkshire participated in interviews, conducted in April and May 2022. All had held executive-level positions through the COVID-19 pandemic that commenced in 2020. Of the ten participants, there was a variation in perceived characteristics, with many participants intersecting across several identities. One participant identified only as female. Of those with intersecting identities, one identified as a woman of colour, three had a disability, impairment or mental health need, and none were lesbian, bisexual or transgender. Nine participants identified themselves as ‘other’, describing themselves as ‘working class’ (n=5), ‘limited education’ (n=2), ‘young’ (n=1), ‘with a faith’ (n=1) or through parental status ie primary carer or not having children (n=4) (see table 1).
Summary of participants self-identities
Three closely linked themes were identified through qualitative analysis, as follows:
Theme 1: self-identification and self-improvement were informed by a sense of self, extending across character, motivating experiences and the expectations of others
Early life experiences, especially linked to class and education, were characterised as having shaped many of their characters and motivations to succeed.
Participant 003 ‘I've always been ambitious; I came from a working-class background, was the first in a large family to go to Uni, first not to go home and live near to the family, always wanted to achieve’
There appeared to be a relationship between upbringing, and the self-determination they relied on as adults. All referenced intrinsic elements of their character as important motivators. Early experiences, often in childhood, and the impact on their adult lives, were frequently described. Five interviewees referred to their working-class upbringing, and a further two to their limited education and how this had increased their determination to succeed, ultimately transforming hardship into leadership qualities.
Participant 006 ‘I think when you come from certain backgrounds, you almost have something to prove.’
Theme 2: barriers to progression included disability, disadvantage, limiting self-belief, lack of support and prejudice
There were similarities in the accounts of participants, including imposter syndrome and negative self-image. All cited inner drive supporting them into current positions and helping to overcome limiting self-belief. Participants provided examples where systemic factors that presented as barriers transpired to be enablers. Limited self-belief was an important barrier, cited by at least five participants. Through their careers, participants had noticed this in other women.
Participant 010 ‘I've got this massive hang up that I don't have a first degree. I was expected to go to Uni and didn't. It’s been an albatross that I feel that I'm not as clever as everybody else and you sit on Exec calls, and I feel as though everybody else has got 24 degrees each and they're all better than me.’
Women described building a credible reputation through experience. All participants referenced working hard and building their experience and reputation to enable progression, suggesting self-determination, inner drive and self-belief. This was a strong theme across the interviews for all participants.
Participant 003 ‘I've always worked, always worked full-time and always wanted to progress. Whenever new opportunities arose in my career, whether that was something more interesting or the next grade up or I was always finding myself putting my hand up for it.’
All women had experienced prejudice based on sexism, racism, ageism and/or classism through their careers. Some prejudice was demonstrated in subtle behaviours, for example, men starting conversations with other men relating to sport and leaving out the women, or suggestions for social activities. Some prejudice was more direct or observable, resulting in overtly discriminatory behaviour.
Participant 005 ‘I was asked to attend a meeting with IT directors [all men], and they turned around to me at one point and said ‘you can go now because this is for the big brains to decide’
Participants cited times their behaviours had been judged or certain behaviours had been expected. For example, Participant 003 was advised to ‘wear a broach’ while participant 009 discussed men’s behaviour being seen as assertive, whereas the same behaviour in women seen as ‘bitchy’.
Theme 3: women proactively adopted coping strategies and found solutions
Overall, participants were predominantly solution focused. Their unique sense of self, together with a unique set of challenges faced, resulted in the adoption of bespoke ‘toolkits’ of coping strategies. These often comprised a blend of established formal programmes (coaching, mentoring and sponsorship) alongside personal solutions (including building professional networks).
Coaching and/or mentoring had been adopted in all cases and was described by all as a positive experience. Benefits arose from formal practices of coaching and mentoring, often with an external agency. Participants had numerous suggestions about the potential value of systemic, whole-scale approaches such as talent management programmes.
Participant 001 ‘We need a structured approach to talent management such as deliberate conversations with people who have potential to do more so jobs designed around people. We did it in response to a crisis. We have massive workforce shortages and burn out of staff, so we have to do things differently.’
The power of female role models was mentioned by many, numerous times. Peer and family support were important, including seeking out a strong and extensive network of peers for bespoke and personal support at different times of their career. This was a compelling theme throughout the study. These networks would facilitate new connections, and increase the opportunity to find advice, information, build confidence and hear about opportunities.
Participant 010 ‘One of the important things is I just have this amazing phone book of contacts and that has stood me in good stead because I can call upon people, it’s amazing. And, you know, you can’t put a price on it really. And I just think the network in the NHS is amazing.’
The participants’ experiences told a story, not just of their individual career journeys but of central concepts of self-identification, prejudice and coping strategies determined from the data collated across the sample. These are summarised in figure 2.
Summary of key findings.
Discussion
The journeys of these successful women who intersect across many identities, can lead to better understanding of barriers faced and solutions that could be explored and adopted across the system for all under-represented staff.
Career journeys to these very senior roles are not easy for women, especially if they hold intersecting identities such as a disability. Even women in these senior roles can be conscious of how they are perceived. As the majority identified as ‘other’ in some way, this could have derailed their progress, but all participants had found ways to overcome their perceived disadvantages. However, only women who had succeeded in becoming senior leaders took part in this study, so such positive outcomes are not to be taken for granted across women generally. There are many women in the NHS workforce who have not managed to circumvent these obstacles.
Each participant’s distinguishable yet intersecting identities, such as class or educational attainment, had an impact on their perceived barriers faced. These barriers, in return, impacted their sense of self and identity by rendering a determination to find solutions, revealing a returning process. Women leaders had adopted a personal toolkit of solutions over time. While these toolkits are bespoke, the solutions could be adopted by others and offer genuine hope for other female staff.
An important enabler identified in the study, and one not widely appreciated in the published literature, was the impact of having a wide peer network to call on. As networking could be considered a communal behaviour, it is possible this has been undervalued in previous research and should be explored as we redefine how a leader behaves. It may be assumed this is ascribed to individual character and cannot be facilitated. Findings indicate that these extensive peer networks afford several benefits, including confidence-building, and sharing of experiences and information.
Strengths and limitations of the research
A methodological strength of this study was that participants could self-identify at the start of the interview. The option to self-identify as ‘other’ led to insights into a broader set of characteristics perceived to confer disadvantage, outside those protected by law. For instance, many cited their working-class background, often concomitant with educational attainment and imposter syndrome. This study recognised that characteristics, barriers and suggested solutions are all interconnected. Qualitative interviews led to rich and in-depth insights, however self-reporting is not always reliable—for instance, some participants may have exaggerated or withheld barriers.
This research focused on the experiences of senior women in NHS organisations in South Yorkshire. However, this study was limited in that just ten women were included, and all had progressed to very senior leadership positions. Future research is needed to establish how those women not reaching these very senior positions identify, whether these identities are considered barriers, and if so, how they have attempted to overcome them (or not). Limited diversity was represented through only one participant of colour, three with health conditions or disabilities and zero that identified as Lesbian Gay Bi-sexual & Transgender +. More research is needed to understand the particular challenges for those that intersect across these protected characteristics.
As experiences were unique and the sample small for such a complex topic, we must be careful not to conclude these are barriers that all women in NHS organisations face—one successful senior woman cannot represent her gender. A bigger sample could result in further identities being defined, which requires further and deeper consideration.
There are clearly factors that intersect that are not protected characteristics through law, but remain influential, such as limited education or class. Women do not necessarily talk about the impact of these intersections with gender, or may not be aware they exist, but it could be extremely relevant. Increased understanding of how race, sexuality and class intersect with gender, but also intersect with these other identities, is required.26
Comparison to published literature
All participants cited both internal and external barriers to their careers. Polarised views in the literature emphasise that we either need to ‘fix’ women, for instance, build their confidence, or fix the system, for instance, address the ‘leaky pipeline’—the loss of capable women. This research highlighted that both strategies need to be addressed, adopting a range of solutions tackling many barriers.
All participants reported facing prejudice, which they perceived to be the most significant barrier to their progression, as intimated in the published literature. The participants had adopted different methods to overcome it, sometimes challenging, sometimes relying on systemic solutions, and occasionally keeping their heads down. Responses may vary for participants over time, dependent on circumstance, as it is not always straightforward or pragmatic for women to challenge prejudice. Prejudice and discrimination can be both manifest and subtle, but both can be intensely impactful. There were instances of direct sexist behaviour, but everyday slights can be extremely exclusionary and need to be addressed alongside more blunt instances. As Thomas states, ‘We need to accept sexism, racism and hetero-sexism as the first step to removing them’ (Thomas pp.405).27
Inner drive and positive self-belief are key drivers, and some participants mentioned the need to harness this in others. Feldt’s concept of ‘intentioning’ was demonstrable through this sample, and further exploration could determine why some women successfully rewrite their life script, while some do not.11
This research confirmed some of the most impactful enablers were receiving coaching and/or mentoring. In addition, building reputation and widening experience through hard work was referenced by all participants supporting theories of building a track record and taking on stretch assignments, although this is not mentioned widely in the published literature.13 28 Workplaces are often depicted as places of meritocracy, with outcomes perceived as linked to merit not gender, but consideration could be given as to whether men have more faith in their innate abilities rather than their need to work hard.
Further comparisons could be made with the impact of enablers in other industries, such as use of networks for women in technology.
Recommendations for future policy and practice
Based on this empirical research, there is a case for a coordinated response from organisations, such as redesigning recruitment, in light of prejudice or the tendency to recruit people we know and/or those that reflect us.7 13 A considered response is required to prejudice when identities intersect; a lesbian woman of colour could be affected by prejudice regarding all of her identities so organisations should guard against just addressing one to ensure the welfare of all. The leadership model should be transformed, redefining what a leader looks like. For instance, a revised leadership concept could value lived experience, authenticity or looking after others, all regarded as communal/feminine behaviours. When recruiting to senior roles, questions are often asked over women’s ‘credibility’, but recruitment policies should be revised giving further consideration to what behaviours are perceived as convincing as a leader.
While a difficult attribute to develop, there is a responsibility of all managers to build the confidence of those under-represented as part of their management practice, as this likely links to self-identity. Succession planning and developing the pipeline through deliberate talent management would be beneficial. Successful women should be encouraged to support and champion those more junior. Processes and environments need to be established to allow relationships to grow, with easy access to mentoring for all under-represented potential leaders. Steps need to be taken to make it easier for senior men to mentor more junior women for both sides to feel safe.
It is important that individuals that succeed in these very senior positions are not tokenistic: no individual represents their gender, race or class and therefore the concept of representation must be handled with care. Nevertheless, staff need to see themselves reflected in the most senior positions for their own self-belief, and diversity at board level is a key contribution to organisational equity.
Emerging NHS initiatives, such as NHS Confederation’s Health and Care Women leaders Network are a helpful contribution but like all initiatives require evaluation and understanding of their impact. While mindful of the limitations of the study, there are a number of recommendations that organisations could consider:
Tackle low self-belief/self-efficacy through targeted supervision and appraisal systems and targeted career conversations.
Encourage and resource successful women and minorities to support their junior colleagues to establish more role models.
Name, own and tackle both overt and the subtle prejudice head on through zero-tolerance policies and decisive managing through an intersectionality lens.
Be ambitious and proactive about securing significant increased diversity on NHS Boards by setting specific and clear objectives.
Develop talent management programmes to ensure pipeline of managers and give those at board –1/–2 level access to boards.
Introduce formal coaching, mentoring and sponsorship programmes to offer a structured response and help ensure access to these opportunities is fair and equitable.
Encourage all women to build wide peer networks and establish women’s network groups to facilitate connections.
Conclusion
This study provides evidence that could benefit NHS organisations in understanding the challenges and opportunities for women to achieve very senior positions. Amid leading healthcare organisations through a pandemic, personal battles, high demands and dysfunctional systems, all participants demonstrated strength in character. They did this through belief in themselves and their abilities, a resolute determination to persevere, and keeping sight of the bigger goals.
To improve diversity in leadership in the future, organisations are encouraged to adopt a programme of support such as the above suggestions, available and accessible to all, to prevent leaving it to those under-represented to find the solutions.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and this research dissertation was carried out during 2022 as part of a Master’s in Healthcare Leadership and Strategic Management course at the University of Sheffield, UK. Ethical approval was obtained from the University of Sheffield Research Ethics Committee (Ref 045175). All participants gave informed consent before taking part in this research.
Acknowledgments
The first author would like to thank their MSc dissertation supervisor, Professor Susanne Tietze, University of Sheffield, UK for all her support throughout the dissertation process.
Footnotes
Twitter @RealAliBishop
Contributors The submitting authors provide assurance that all authors included on this paper fulfil the criteria of authorship and that no one else who fulfils the criteria has been excluded as an author. AJB carried out data collection and drafted the paper. Data analysis was carried out by AJB, with input from SM. AJB drafted the paper, SM reviewed for intellectual content. Both reviewed and edited the paper. First author’s dissertation supervisor, Susanne Tietze reviewed and edited the original dissertation. The authors want to thank all of the participants of this research project from NHS organisations across South Yorkshire, who gave their time and shared their personal stories so candidly to make the thesis and this corresponding paper possible. The first author would like to thank their Master’s dissertation supervisor, Professor Susanne Tietze for all her support throughout the dissertation process. AJB acted as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.