Challenges and successful approaches towards promoting women nurses into healthcare leadership, through the lens of implementation science

The healthcare workforce is predominantly nurses, with 90% being women. There is a clear trend towards greater professionalism, training, and hence costs acquired in attaining nursing qualifications, alongside greater postgraduate training and specialization. With increasing recognition of their vital role in healthcare provision, there is a need to increase the nursing workforce globally. However, for women in nursing, 25% want to leave their profession generating a nursing workforce crisis. This is due to poor job satisfaction, low pay rates, lack of career pathways and opportunities. A key issue is the notable under-representation of women nurses in healthcare leadership. Women in nursing face unique barriers to career progression due to cultural and societal perceptions of nursing, which is stereotyped as a caring, rather than leading profession, compounded by the intersection of gendered perceptions of caring rather than a leading role for women (Pincha Baduge, Garth, et al., 2023). Organizational and individual barriers also limit career advancement. Addressing these challenges is important. Having adequate representation of women nurse leaders reflects equity of individual opportunity and generates organizational and health system benefits, including a skilled workforce, role models, improved strategic planning, quality and process improvement, human resources, finance and intricate problem-solving (Harper & Benson, 2019; Pincha Baduge, Mousa, et al., 2023). Hence, it is a recognized priority to advance women nurses in healthcare leadership, to help address these issues. The analysis of leadership barriers unveils distinct challenges for women in health leadership globally, with nurses contending with unsupportive societal and organizational perceptions, roles and culture, and with the normalization of masculine leadership styles and roles and feminine caring and subservient roles (Pincha Baduge, Garth, et al., 2023; Pincha Baduge, Mousa, et al., 2023). Nurses confront other organizational barriers that influence ability and confidence, motivation and opportunity, including the absence of leadership training and mentoring programmes, ambiguous career pathways, a scarcity of mentorship and role models, gender bias, confidence issues and limited leadership opportunities. These are exacerbated in lower and middle income countries. Individual-level barriers encompass perceptions of leadership roles, confidence issues, a limited understanding of academic roles, and challenges with unbalanced parenting and home responsibilities. Organizational factors impeding the leadership potential of women nurses can also be categorized into factors that limit ability, motivation and opportunity (Figure 1) (Pincha Baduge, Garth, et al., 2023). Ability-limiting factors include insufficient leadership training and inadequate orientation to leadership roles, contributing to a dearth of effective guidance and skill building. Motivation-limiting factors include organizational barriers affecting the motivation of women nurses to assume leadership roles encompassing societal expectations, gender bias, hierarchical leadership structures, workplace policies, lack of mentors and networks, gender-related bias in leadership attainment and a lack of support for work–family integration. These factors underscore the impact of gender stereotypes, bias, and the recognition of issues on women's aspirations and progress in leadership roles. Opportunity-limiting factors extend to systemic challenges such as cost constraints, biases favouring full-time employment, and gender-related biases in leadership opportunities. The influence of part-time work, career breaks and age bias also limit leadership opportunities and hinder career progression for women nurses. Enabling factors linked to leadership advancement involve systematically attending to stereotyping and culture including respecting women nurses' professional and leadership ability, addressing gendered beliefs, attitudes and behaviours, and an equitable and supportive culture at every level within the organization—from the boardroom to the frontline, professional graduate degrees, leadership training, offering diverse experiences, a flexible supportive environment and policies, inbuilt opportunities for clinical women nurses, mentorship, sponsorship, networking, family support and career planning (Figure 1). These strategies when implemented at organizational and systems levels are proven to be effective across diverse levels and settings in advancing women including in nursing into healthcare leadership. Despite decades of research documenting the problem and the inequity and the barriers for women nurses in career advancement, women nurses continue to be underrepresented in healthcare leadership. The need to move beyond the individual, to organizational and systems change is recognized, emphasizing the need to establish a more inclusive and supportive environment conducive to the leadership aspirations of women in nursing. Effective strategies have been identified to enhance the ability, confidence, motivation and opportunity of working women nurses; however, these have not been implemented. Implementation science provides a mechanism to partner, and to tailor and drive evidence-based interventions for measurable impact at an organizational and system level. This requires working closely with stakeholders, applying proven methodical frameworks, identifying and addressing barriers in diverse contexts, and integrating evidence-based practices into standard operating procedures in complex systems and organizations. It focuses on the adoption of evidence-based practices, rather than evaluation alone (Mousa et al., 2023). Advancing Women in Healthcare Leadership (AWHL) is an international initiative aiming to co-design, co-produce and implement evidence-based approaches at the organizational level, to augment ability, motivation and opportunity to enable women to advance into healthcare and health sciences leadership (Figure 2) (Marin-Garcia & Martinez, 2016; Mousa et al., 2023). The initiative is contextualized within the milieu of heightened sector-wide awareness, augmented political commitment and accelerated efforts directed towards achieving gender equity, including in healthcare and health sciences. To date, the project collaborates with 23 public and private partners to implement interventions that extend their impact on both a national and international scale. AWHL is co-funded by the Australian National Health and Medical Research Council (NHMRC), the Federal Government and project partners ($5M). Our partner organizations include healthcare organizations, professional colleges, not for profit, academic organizations and government agencies. Here, they are supported and facilitated with evidence-based interventions, processes, supportive and collective leadership to navigate diverse phases of planning, commitment, implementation and evaluation of transformative initiatives within this domain. AWHL deftly navigates this complexity by implementing interventions, developing benchmarking procedures and overseeing dispersed tailored implementations, at different phases of maturity (Mousa et al., 2023). The objective of AWHL was to address prevailing issues of gender inequity characterized by ad hoc, duplicative and ineffectual action within the domain. This is pursued through the implementation of systematic and organizational-level change, with the ultimate goal of generating sustainable impact on the acceleration of women in leadership within the healthcare and health sciences sector. Our efforts involve large-scale partnership, a shared vision, adequate skills and resources, synthesizing best-practice evidence, co-design and meticulously tailoring, implementing, evaluating and scaling evidence-based systemic changes. These initiatives aim to advance women into leadership roles and effectively contribute to achieving gender equity. Gender and professional diversity in healthcare leadership is crucial not only for individual opportunity and equity, but also for organizational and health system benefits including workforce retention and satisfaction, enhanced capabilities in strategic planning, quality and process improvement, human resources management, financial stewardship, and intricate problem-solving. Ongoing gender and professional disparity in healthcare leadership attainment is attributed to various barriers, including societal beliefs and stereotypes; discrimination and bias; lack of leadership training, mentoring and role models; limited organizational support; and lack of equity and support to navigate parenting and work–life balance. For women, there are additional and heightened barriers that affect ability, motivation and opportunity in career advancement. Understanding and addressing these barriers is essential for promoting gender equity in healthcare leadership—including for women from racially and ethnically marginalized backgrounds and other marginalized groups—and for improving career opportunities and vital healthcare system contribution for women. Effective organizational and system-level solutions are available and rise above fixing the individual to fixing the culture, organizations and systems in which they work. Vitally, these include addressing historical and organizational cultural issues that recognize women's professionalism and leadership ability. Beyond this, sustainable solutions are needed to implement effective organizational and systems change where women work. These include leadership training, mentoring, networking, role models, flexible and supportive policies and treaties to build motivation and opportunity. Implementation science offers the effective methods by which these evidence-based solutions can be embedded into healthcare. The AWHL initiative is a large-scale international implementation programme using validated implementation methods to drive evidence-based, sustainable solutions into practice and to scale them across the healthcare and health sciences sector, addressing known barriers and driving measurable change. Through widespread stakeholder partnership, understanding the barriers and using effective methods and evidence-based organizational and systems approaches with ongoing evaluation, the healthcare sector can work towards creating equitable opportunities for women nurses to advance their careers, addressing major barriers and priorities for high-quality healthcare. This work contributes to a competitively funded project by the Australian National Health and Medical Research Council (NHMRC), and is an international initiative, which aims to enable systems and organizational change to advance women into leadership in the healthcare and health medical sciences sector. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. This work was supported by the NHMRC Investigator fellowship for HJT and NHMRC Partnership Grant to the institution. We can confirm that there are no conflicts of interest with the funders. Research Training Program by the Australian Government Department of Education, Skills, and Employment, and Eastern Health, Melbourne, Australia provides funding for MSDSPB for her Ph.D. study.