Leaning in and speaking up? Students’ perceptions of female leadership in healthcare

2.1 Overview

Ethical approval for the study was granted by the Trinity College Dublin School of Medicine Research Ethics Committee. As the goal of this study was to identify and describe the students’ perceptions and experiences, a focus group was conducted and a qualitative descriptive approach to analysis was taken [17, 18]. The group dynamics of focus groups enable participants to voice opinions and generate new ideas, insights and perspectives that may not arise in individual interviews [19].

In line with qualitative descriptive design, participants with common characteristics were purposely recruited [17]. Students in the Faculty of Health Sciences in Trinity College Dublin were invited to participate in this study. A maximum variation sampling approach was taken as suggested for qualitative descriptive methodologies [17]. Therefore, students from any year of study in undergraduate or postgraduate health sciences courses were eligible to participate.

Potential participants were informed of the focus group in two ways. Administrators from the disciplines in the Faculty of Health Sciences were contacted and asked to forward information about this study via email to postgraduate and undergraduate students in their discipline. The administrators therefore acted as gatekeepers for the study. Recruitment posters were also put up in the Trinity Centre for Health Sciences to draw attention to the study. Administrators from the Departments of Physiotherapy, Department of Occupational Therapy, Department of Radiation Therapy, School of Pharmacy and School of Dentistry agreed to act as gatekeepers for the study.

The email invited female students to attend a focus group to discuss their experiences of leadership in healthcare. Students were informed that lunch would be provided as a small incentive to participate. Students who responded to the email to indicate their interest were sent the study information leaflet and consent form. The aim was to recruit 6–8 participants for the focus group as recommended by Gill et al.[20]. Nine students indicated their interest in the study, however, on the day of the focus group only seven were able to attend. The protocol for the focus group is detailed in Annex 1.

2.2 Data analysis

The focus group was transcribed verbatim by the first author. Before the data-set was finalised member checking was conducted; participants reviewed the transcript and were offered the opportunity to make amendments. To ensure confidentiality each participant was assigned a study code for the duration of the study and all identifying details were removed from the focus group transcript. The details of the data analysis are described in Annex 2.

The ‘Leader attributes’ theme encompassed the participants’ views and experiences of the behaviours, capabilities, skills or styles that leaders demonstrate or that they perceive to be important for leaders to demonstrate. Several of the participants spoke of communication skills. The participants recognised the importance of receiving feedback and encouragement from team leaders and the influence that this can have on their work.

Other attributes that were perceived to be important for leaders to demonstrate were confidence, people skills and understanding. Confidence was perceived as necessary to step forward into a leadership role or to perceive yourself to be a leader. People skills referred to being able to ‘read’ people and situations and adjust their behaviour and approach accordingly.

Being understanding of others and demonstrating empathy were valued. One participant spoke of the effectiveness of taking a transformational approach to leadership where team-members work towards shared goals because they want to achieve them rather than because they are directed to do so.

3.2 Gender differences

The ‘Gender differences’ theme encompassed the participants’ views of differences in the experiences of male and female healthcare professionals. These included parental responsibilities, maternity and paternity leave and gender stereotypes.

Within the subtheme, family responsibilities, the participants discussed how the burden of family responsibilities can often be predominantly borne by women. The participants commented on the disproportionate effect that parenthood can have on women’s careers with respect to those of their male colleagues. They discussed how women often assume more care-giving responsibilities than their partners and how this can have an impact on their working lives. However, the participants questioned whether things needed to be that way.

There were also comments specifically about maternity leave and how this extended absence from the workplace can affect women’s careers. Additionally, the students compared maternity leave entitlements in Ireland to other countries in Europe and the concept of shared parental leave where leave entitlements can be shared between parents.

The participants also discussed how gender stereotypes can mean that the same traits are perceived in a different way for men and women. The participants recognised that different words can be used to describe the same characteristics for men and women and how certain attributes, e.g. being ambitious, can be seen as a positive thing for men and negative for women.

The participants spoke about the gender profiles of their professions and there were references to how these are changing. The dental and pharmacy students reported that their professions were traditionally predominantly male but that the majority of students on their courses were now female.

3.3 Barriers to leadership

The third theme, ‘Barriers to leadership’, encompassed the barriers to demonstrating leadership that the students perceived female healthcare professionals to face. These barriers can be grouped into three types: intrinsic barriers, societal barriers and structural barriers. The intrinsic barriers included women’s perceptions of other women and a reluctance to lead. The participants shared their experiences of women judging other women harshly and how this judgement can consequently have an effect on women’s behaviour.

The participants recognised a reluctance to demonstrate leadership among some women and one of the participants commented that she didn’t want to be a leader.

The societal barriers were stereotypes and conscious and unconscious bias. One participant acknowledged that bias can impact on female health professionals’ employment and funding opportunities.

Gender stereotypes related to different expectations for men and women. These different expectations related to both work area, characteristics and behaviours.

The structural barriers included family responsibilities, finances and male-dominated environments. Family responsibilities included perceptions that certain healthcare roles are more difficult if you have a family, that having a family reduces your employment options, that mothers can experience guilt if they work and that supports aren’t currently in place to help mothers stay in the workforce. Related to family responsibilities was the financial strain that can go along with having children.

Another structural barrier was the perception that certain environments or work areas are male-dominated. This meant that the participants viewed these environments or work areas as intimidating, difficult to integrate into or even directions that they were discouraged from pursuing.

Specific areas that were perceived to be male-dominated were sports and exercise medicine (SEM), maxillofacial surgery and orthopaedics.

There were also comments about there being a disproportionate number of male supervisors and male managers in the healthcare system.

3.4 Leadership facilitators

The final theme was ‘Leadership facilitators’. This theme encompassed perceived factors or strategies that may facilitate female healthcare professionals to demonstrate leadership. These included blinded applications, gender quotas and family experiences.

Family experiences referred to the influence that working parents can have on their children’s future career paths. The participants believed that seeing their mothers working and raising children impacted them and contributed to their professional ambitions.

The participants recognised the importance of context in facilitating female leadership. Having strong female leaders working in a specific area was seen as positive in inspiring other women to step forward into that area.

Two strategies for facilitating female leadership that were extensively discussed by the participants were leadership development and modelling. Overall, the participants had had very little leadership development through their university courses. Although, they had completed some leadership courses related to outside interests and also gained leadership experience through volunteering.

The participants were interested in completing leadership development, they viewed it as something that made people more effective leaders but as something that they would do later in their careers.

However, some of the participants also acknowledged that leadership abilities could be gained from experience and learning in the role.

The final strategy, modelling, encompassed the influence of role-models, the media and sports. Two participants spoke of how high-profile sports physiotherapists were most often male and the message that this sends.

A very prevalent subtheme within ‘Leadership facilitators’ was role models. There were many comments about the importance of female health professionals having leadership role-models.

There were examples given of specific female leaders that the participants thought of as role models. However, one participant reported that there was a lack of female role models for her in clinical practice.

3.5 Discussion

The views and experiences expressed by the participants in this study demonstrate how even at this early stage of their careers, these female students are very aware of the potential challenges facing female leaders in healthcare.

The first theme, ‘leader attributes’, encompassed the participants’ views of the attributes and characteristics that are important for effective leadership. The participants valued communication skills and the ability to interact well with others. The ability to give feedback and encouragement was perceived to be important and the participants reflected on their own experiences of this and the effect it can have on participation. Understanding others and demonstrating empathy were also viewed as ways to ensure that leaders were able to get the most from their team-members. Overall the value placed on these leader attributes suggests that these participants favoured a relational or transformational rather than directive or transactional style of leadership [21]. This is in keeping of other studies of leadership in healthcare. In a large systematic review investigating the effect of leadership styles on outcomes for the nursing workforce, Cummings et al. (2018) found that leadership styles focused on people and relationships were associated with higher nurse job satisfaction compared to leadership styles focused on tasks [22]. Additionally, this finding may have been influenced by the fact that all the participants were female. In a broad survey of the last 30 years of literature, Gipson et al. (2017) found that women were more likely to demonstrate a transformational leadership style and men were more likely to demonstrate a directive leadership style [23].

The second theme encompassed the differences that the participants perceived there to be between the experiences of men and women. The participants perceived women to be disproportionately affected in their careers by their family responsibilities. In particular, becoming a parent was viewed as having a bigger impact on female professionals than their male counterparts. These perceptions were in keeping with findings from a large study conducted by McKinsey and Company who surveyed 222 companies about their HR practices and over 70,000 employees about their experiences regarding gender, opportunity, career, and work-life issues [24]. In the study, women were found to do a disproportionately large proportion of housework, even when they are the primary earner in a household. Of concern, this may dampen women’s career aspirations as women who do the majority of the housework are less likely to aspire to be a top executive than women who share responsibilities equally with their partner [24].

In attempting to balance work and family obligations, women can be delayed from advancing through career ranks. Consequently, some women may feel they have to choose between having a family and progressing in their career [3]. Women are more likely than men to reduce their working hours or to take extended leave which can be detrimental to their careers, particularly in comparison to men who remain working full-time [3]. This was noted by the participants in this study who commented that women were more likely to work part-time than men and discussed how this may impact their careers.

While the participants in this study questioned whether family responsibilities should still disproportionately affect women over men, this may be a view held by some. In a study investigating the under-representation of women in medical leadership, Bismark et al. found that a small number of interviewees perceived gender disparities in leadership roles to be a ‘natural’ result of women’s responsibilities as mothers [5]. However, the experience of Scandinavian countries of introducing equitable parental leave suggests that ‘family reasons’ are, at least partially, a structural barrier to women re-joining the workforce, rather than an inherently biological one [25].

Another difference between the genders cited in this study related to gender stereotypes and differences in expectations between men and women. The participants recognised that certain traits or behaviours can be judged differently for men and women. Women face not only the challenge of doing their jobs well but also the need to overcome stereotypes that can impede perceptions of their leadership potential [3]. In a survey investigating the conditions for career advancement in healthcare management, LaPierre and Zimmerman (2012) found that one third of female healthcare managers reported perceived gender discrimination in the past five years compared to only 4% of their male counterparts [10]. In this study, the barriers cited by the participants were grouped into three categories: intrinsic, societal and structural. An intrinsic barrier was the perception that women can be reluctant to put themselves forwards to leadership positions. This echoes findings from a survey conducted by LaPierre and Zimmerman (2012) where female healthcare managers were less likely than their male colleagues to aspire to top leadership positions [10]. Similarly, Bismark et al. (2015) found that self-doubt, low self-confidence and underestimating personal leadership capabilities can lead some women to doubt that they are suited to leadership roles [5].

Societal barriers included biases, stereotypes and how societal perceptions and expectations can affect the way that women in the workplace are evaluated and treated. Implicit bias is the unconscious inflation or deflation of a groups’ perceived value as influenced by socially accepted depictions of those groups [26]. Gender stereotypes and conscious and unconscious biases play a role in impeding women’s attainment of senior and executive level positions [3, 27, 28].

Everyone has certain biases, however most people do not recognise or acknowledge them. As such people can be susceptible to unknowingly making biased choices and actions, even when these are contradictory to their explicitly held beliefs [29]. This is why men and women who do not perceive themselves to be biased can unknowingly more harshly judge a woman’s behaviour and performance. However, if individuals can recognise the existence and consequences of implicit bias and acknowledge their own potential for biases then they can address these shortcomings [29].

The structural barriers identified in this study were similar to the ‘perceived capacity’ barriers described by Bismark et al.[5] and included parenthood, inflexible working conditions, childcare responsibilities and challenges around work-life balance. Overall, Bismark et al. (2015) found that parenthood was the most commonly cited barrier to women assuming leadership roles in their interviews about female leadership in medicine [5]. In a gender comparative analysis of the career perspectives of physicians in Germany, Ziegler et al. found that female physicians with children are burdened and disadvantaged more often than their female colleagues who do not have children and male physicians in general [30].

Another structural barrier was the perception that certain environments or work areas are male-dominated and that this can make these areas intimidating for women. Being excluded from these “boys networks” disadvantages women as often they will miss out on decision-making and other opportunities to demonstrate their leadership capabilities [31]. Further, in these environments it is not uncommon for women’s suggestions or comments to be neglected or ignored until they are proposed by a man [31].

There were several potential facilitators of female leadership discussed by the participants including quotas, family experiences, role models and leadership development. Young women need to see other women in positions of leadership so that they can emulate the behaviours of women who hold positions to which they aspire [32]. The participants in this study also demonstrated how their own family experiences can influence their career paths and it was apparent that many viewed their mother as a role model. McDonagh et al. (2014) advocated that female leaders should take action to overcome the barriers women face in career advancement by acting as role models and mentors for other women [2].

While the participants in this study had completed little formal leadership training, they had experienced some leadership development through volunteering and work experiences beyond their university courses. Relative to men, women participate less in formal leadership training [3] and this lack of early leadership engagement can thwart their development of a leadership mentality [24, 33]. The participants in this study perceived leadership development to be something that they would pursue later in their careers. However, Sexton et al. advocated that women should seek out training early and if possible complete a residency or fellowship training programme to help prepare them for leadership roles [34].

3.6 Implications for practice strategies to improve gender equality

In the literature, many strategies have been suggested to improve gender equality in healthcare including the monitoring of gender equality, gender-sensitive appointment and promotion, provision of training opportunities, flexible working hours, support for parents, helping women to connect with female leaders and mentors, inclusion of gender issues in teaching curricula, advocating for gender equity in wider social policy debates and diversity training for all staff [5, 35]. However, no one approach will be a panacea and various initiatives will need to be adapted to meet the specific needs of a specific organisation [2]. It is through a combined approach of interventions that a cultural change can be promoted to support gender diversity in top roles.

To achieve meaningful change there is a need to move beyond ‘fixing the women’ to a systemic approach that recognises and addresses the effect of unconscious gender biases [36]. Chisholm-Burns et al. (2017) advocated that to mitigate the damage done to the careers of women, organisations need to directly confront and address issues of overt and implicit gender bias [3]. Similarly, Bekker et al. (2018) asserted that instead of placing the onus on individual women to ‘lean in’, the focus should be on dismantling the structural barriers faced by women [29]. Based on the results of their survey of healthcare executives in the USA, LaPierre and Zimmerman (2012) suggested that addressing issues at the intersection of work and family have the potential to be the most fruitful in promoting gender equity[10].

3.7 Limitations

This study has several limitations. First, while efforts were made to recruit students from across the range of health sciences courses in the University and four professions were represented, there were no nursing or medical students represented in the focus group. Additionally, all of the participants were studying in the same university. This may limit the generalisability of the results to other health sciences students. Another limitation was the risk that there may have been social desirability bias in the focus group as the participants may have wanted to give socially acceptable views, avoid criticism or gain approval from other group members[37]. Finally, due to time constraints only one focus group was conducted. The study would have been strengthened by conducting another focus group with a separate cohort of healthcare students and comparing the results. Therefore, while the study does provide useful information on the experiences and perceptions of a diverse sample of health sciences students, these limitations should be acknowledged when interpreting the results.