Study: Why nurses are too often missing in health care leadership with major barriers to career advancement

New Monash University research has revealed the barriers women nurses face to advance into leadership roles. These findings will inform organizational interventions and strategies to improve the career opportunities for Australian nurses as part of an international initiative to advance women in health care leadership.

Through a comprehensive review spanning decades of research, researchers have for the first time identified, extracted and analyzed data to establish the collective sociocultural, professional, organizational, and individual barriers that hold women nurses back from being considered, applying for, or accepting leadership positions.

Published in the journal eClinicalMedicine, the international review reveals that health care systems and organizations generally limit women nurses in skill acquisition, motivation and opportunities in health care leadership, due to inequitable policies, practices and bias.

Gender stereotypes, cultural beliefs and real world scenarios in health care show health systems are generally led by men and delivered by women, who are perceived primarily as caregivers, and not as leaders. Nursing is considered women's work or a women's career, and is perceived as feminine.

Nearly 70% of the global health care workforce is women, and 89% are nurses yet only 25% of senior health care roles are filled by women.

This research also highlights gendered roles such as disproportionate childcare responsibilities and juggling family with part-time work, limiting leadership opportunities that are generally perceived as full time.

Researchers also showed that to break down these barriers, systems and organizational change are needed, and that change should not sit with the individual nurse. Evidence supports a need for implementing industry-wide measures, including leadership, culture change, policies and practices that should for example support women to work to their preferred capacity and incorporate part-time leadership roles.

Professor Helena Teede, Monash University Professor of Women's Health and Monash Centre for Health Research and Implementation Director, was senior author of this comprehensive research. It was part of a large-scale National Health and Medical Research Council-funded initiative to Advance Women in Health care Leadership (AWHL), also led by Professor Teede.

"The barriers identified show women nurses don't have the same opportunities for leadership as men, following a common theme throughout health care, a sector delivered by women and led by men," she said.

Co-author Professor Leanne Boyd, who is Chief Nursing and Midwifery Officer at Eastern Health and a Professor of Nursing, said, "Strengthening the nursing profession is key to workforce retention, equity and to providing cost-effective and accessible health care in Australia and globally."

First author Mihiri Pincha Baduge is a Ph.D. candidate with Monash University's AWHL international initiative and a critical care registered nurse. She was born and studied nursing in Sri Lanka, and shares her experiences as a woman, a nurse, a mother, a migrant and a person of color.

"I've noticed that health care leadership roles often overlook people like me," Pincha Baduge said. "When I returned to work after parental leave, I decided to shift from full-time to part-time nursing. Now my eligibility to apply for leadership roles is restricted because these leadership positions lack work-life flexibility and part-time options."

Pincha Baduge's work also explores barriers to leadership for nurses when gender intersects with other social identities such as culture and ethnicity. She faces many challenges as a nurse in Australia, which is reflected in her global research. "We've found that societal issues and organizational hurdles challenge women's individual credibility, capacity, and capability in nursing," Pincha Baduge said. "These barriers make it tough for women to feel confident pursuing leadership roles.

"It's like a double whammy—women nurses don't feel confident enough, and this is reinforced as qualified women get passed over for leadership roles. The workplace itself can be a battlefield, with unconscious bias and discrimination making it way harder for women, especially in nursing, which is seen primarily as a feminine caring role, to climb the leadership ladder."

Adjunct Professor Kylie Ward FACN, a co-author, and CEO of the Australian College of Nursing, a partner in the International AWHL Initiative, said, "Registered nurses are a highly trained, skilled and professional workforce, responsible for managing millions of occasions of service and guiding consumer experiences and outcomes, as well as delivering responsible stewardship of billions of taxpayer dollars.

"Yet nurses are still not respectfully recognized as essential to reform and governance at the highest levels of leadership in all health care settings.

"Effective nurse leadership will contribute to better access to quality health care for all Australians and better value for every health dollar invested by governments."

Professor Teede added, "These findings provide the foundation for research, codesign, and implementation of effective organizational and systems-level strategies as defined in our recent research. These are being tailored to the needs of women in nursing, alongside those in medicine and other disciplines, in the AWHL international research and impact initiative Advancing women in health care leadership."