VOLUME 43, 2024 ISSN 1093-7099 EDITORS: BEVERLY J. IRBY, NAHED ABDELRAHMAN, BENJAMIN JANKENS, AND JULIA BALLENGER ASSISTANT EDITORS: JORDAN DONOP, KRISTINA HALL, & REBECCA PHILIPS 136 Advancing Women in Leadership Journal-Volume 43 Advancing Women in Leadership Vol. 43, 135-148, 2024 Available online at http://www.awlj.org/ ISSN 1093-7099 Full Length Research Paper “It takes a village to raise a leader”: Overcoming gender-specific barriers through individual, workplace, and organizational level facilitators Billie Jane Hermosura and Ivy Lynn Bourgeault Billie Jane Hermosura: Part-time Professor, University of Ottawa, bhermosu@uottawa.ca Ivy Lynn Bourgeault: Professor, University of Ottawa, ivy.bourgeault@uottawa.ca Accepted November 6, 2024 Women constitute most health workers, yet they hold proportionately fewer leadership positions. The literature is replete with normative advice to address gender specific barriers to women’s leadership; less attention is paid to the processes women undertake on their paths to leadership. We describe the leadership journeys of 23 women leaders in the health sector in Canada, guided by a multi-layered framework of barriers and enablers. A thematic analysis of 11 semi-structured interviews and 13 public presentations on leadership journeys was conducted, which applied a priori and emerging themes to segments of the transcripts using NVivo 12. Three key themes emerged: impetus for leadership journey, enablers to leadership development, and barriers to advancement. Women leaders reported a variety of reasons to embark on their leadership journey from their own desire to make a difference to being tapped on the shoulder by mentors and sponsors. Many of the barriers faced were specific to their intersectional identities where they often juggled the complex demands of gender role expectations, while maintaining personal and familial mental health and well-being. The multi-layered framework of important factors was validated and improved. Better understanding women’s leadership journeys needs to capture processual and structural dimensions. Keywords: Women Leaders, Leadership Journeys, Health Care, Health Sciences Women are uniquely positioned in health care given they constitute at least 70% of the health and social care workforce, but much less frequently in leadership positions which is closer to 25% on average (World Health Organization [WHO], 2021/2024). This gendered leadership pyramid (Women in Global Health, 2018) with women’s predominance at the bottom and absence at the top has attracted increasing global attention. A key recommendation from the United Nations High-Level Commission on Health Employment and Economic Growth stresses the importance of institutionalizing women’s leadership in health to “maximize women’s economic participation … and tackling gender concerns in health reform processes” (World Health Organization, 2016, p. 11). These calls have remained aspirational (Betron et al., 2019; WHO, 2021). The circumstances surrounding the COVID-19 pandemic have not interrupted these gendered trends. According to the WHO (2024), women provided much of the health care during the COVID-19 pandemic but did not have an equal say in decision-making at global or national levels. Women face a dual challenge in political participation: securing positions of power and gaining influence within them, necessitating a transformation of existing structures rather than merely adding women to them (Fuhrman & Rhodes, 2020). When women are present in leadership roles it has been shown to lead to more effective public health responses to the pandemic including more timely measures, contributing to lower death rates (Soares & Sidun, 2021). Increasing the number of women in leadership positions is essential for promoting gender equality and improving societal outcomes. The Empowering Women Leaders in Health project drew inspiration from global initiatives to achieve systemic gender transformative change in the health care and health science contexts through increased participation, visibility, and advancement of women. We concurred with arguments that to achieve meaningful change there is a need to move beyond an individual focus on fixing women (McGowan, 2018, p. 174), focusing instead on a more systemic approach that recognizes and addresses the effect of unconscious gender biases and gendered structural barriers. Additionally, drawing upon the foundational work of Kimberlé Crenshaw (2013), we took an explicit intersectional approach focusing not only on women leaders’ gender, including those who do not necessarily identify in gender binary terms, but also their racialized background, including Indigenous identity (Decady & Bourgeault, 2023; Soklaridis et al., 2022). Indeed, reflecting Advancing Women in Leadership Journal-Volume 43 137 the colonial Canadian context within which this project was situated, we also include a cross-cutting focus on Indigenous women and Two Spirit leaders in health care and health sciences. One strand of this gender transformative project was to better understand the journeys of women into leadership positions in healthcare and the health sciences (Bourgeault et al., 2018; Casad et al., 2021). The women’s leadership literature is replete with accounts of gender-specific barriers to advancement, with less attention is paid to the enablers women actively harness in support of their paths to leadership (James et al., 2024). Moreover, accounts of women’s leadership journeys rarely consider other intersecting influences beyond the gender-specific barriers to advancement that are experienced and how they can be counteracted by effective interventions to effect change. The purpose of this paper was two-fold: (a) to map the intersectional trajectories of women’s leadership journeys in health care and health science contexts in Canada, and (b) to frame the intersectional barriers and enablers women leaders face in their leadership journeys according to a multi-layered conceptual framework that moved beyond the individual focus to more systemic considerations Women’s Leadership in Health Contemporary literature on women and healthcare leadership has tended to be focused on women’s underrepresentation in key leadership positions (Bourgeault et al., 2019; Jacobs et al., 2023; James et al., 2024). Researchers have indicated that although women comprise most of the health and social care workforce, they remain underrepresented in senior leadership positions (Penfold, 2019; Wolfert, 2019). Despite paradoxically large proportions of women physicians, medicine has made relatively slow progress in achieving gender equity, particularly at the highest levels of executive leadership, academic promotion, and compensation (Gabster et al., 2020; Shillcutt, 2019; Silver, 2017). A persistent knowledge gap is how gender barriers intersect with race, other forms of gender identity, ability status, sexual orientation, and cultural backgrounds is a persistent knowledge gap (Ioannidou, 2019). Several barriers to women’s ability to obtain leadership roles have been identified in the literature. There is growing evidence that unconscious or implicit bias is a significant barrier to women’s advancement into crucial leadership roles (Gangwani, 2019; Moyer, 2019). Other barriers include gender stereotypes, societal expectations, assumptions, worldviews, and individual frames of reference, that continue to operate within a complex web of interrelated barriers and constraints (Andreas, 2021). Similarly, DeSimone (2021) identified external or structural barriers to women’s leadership, such as the lack of mentoring and sponsorship or exclusion from informal networks as well as internalized barriers, when women opt out of leadership opportunities due to caregiving responsibilities and other forms of work-life conflict. Evidence-based enablers that are invaluable to women’s success in leadership positions in health care and academic health sciences include formal leadership development programs that can significantly enhance women’s self- confidence and self-efficacy (Russel et al., 2023). Such programs offer structured learning, mentorship, and networking opportunities, which help women participants develop essential leadership skills and build supportive peer relationships; experiential learning and positive feedback further reinforce their confidence in their abilities (Russell et al., 2023). This growth can lead to greater representation of women in leadership roles, benefiting organizations by promoting diverse leadership teams (Mousa et al., 2021). Norander and Zenk (2023) highlighted how women seeking university leadership roles are consistently advised on tasks, such as strategizing, self-improvement, learning, and relationship-building demand individual time and resources. Supporting mentorship and sponsorship from leaders, more inclusive networks and more flexible work arrangements can also facilitate women’s career advancement (DeSimone, 2021; Mousa et al., 2021). Although incentivizing mentorship and implementing targeted recruitment to improve diverse leadership has been proposed, Moyer (2018) found that other strategies included senior women seeking junior women for mentorship and sponsorship and junior women pro-actively making their desire for leadership known. In the case of academic medicine and dentistry, the lack of appropriate role models and mentorship for the successful socialization of women faculty and the lack of peer support for women’s promotion through the academic ranks and their selection for executive administrative roles at equal rates as their male counterparts were notable challenges (Gangwani, 2019). Men are necessary supporters of diverse women’s leadership journeys. Some argue that men, who are more often in positions of power, are not always aware of how sexism, racism, ableism, and homophobia shape the experiences of their diverse women colleagues or are well-equipped to act as mentors or sponsors for their women colleagues (Bourgeault et al., 2022). An understanding of the role that power plays in both advancing and hindering male ally endeavors in supporting women’s leadership advancement (Shapiro et al., 2022). When men deliberately engage in gender inclusion programs, 96% of organizations see progress compared to only 30% of organizations where men are not engaged (Johnson & Smith, 2018). Healthcare organizations and those who lead them can change the paradigm of gender inequity in organizations to face the challenges of leadership deficits and cultivate talented women for top administrative roles. Livingston (2018) demonstrated that with training, managers could become more aware of unconscious bias and call our behaviors that are not inclusive. A commitment to emphasize gender equality and diversity Advancing Women in Leadership Journal-Volume 43 138 competency, expansion of leadership training for current employees, identifying and developing women with promising leadership potential, and creating a network of coaching and mentorship to increase organizational bench strength (Shillingburg et al., 2019) is necessary. In sum, literature includes more barriers than enablers to women’s leadership journeys within studies in which researchers evaluate the effectiveness of interventions that foster women’s leadership (James et al., 2024). The outcomes of interest have focused on women’s numeric representation, an important issue, but fewer researchers have focused on the processes undertaken along women’s leadership pathways, the experiences of barriers along these journeys, and the ways in which women persisted. Researchers rarely take an intersectional lens that considers the impact of the power differentials of other identities. Gender is often considered as a binary. Recognizing these limitations, we developed a conceptual framework that helps inform the data presented in this paper on women’s leadership journeys in the health sector. Conceptual Framework The framework, based on our scoping review of the literature, informed our research and delineates five conceptual levels that influence women’s leadership development as either barriers or facilitators: societal, organizational, workplace, individual, and home (see Figure 1). Society can create barriers, like embedded sexism in seemingly gender-neutral policies, but fostering an inclusive culture can make it easier for women to pursue leadership roles. Organizational influences, including accountability for reaching gender-based targets or quotas and broader gender transformative policies, can address typical barriers at this level. Workplace culture, attitudes, beliefs, and behaviors that make up the atmosphere in a work environment can enable or prevent women from rising into leadership positions. Individual level factors, the focus of much of the literature, delineate knowledge, attitudes, and behaviors of women leaders, which can enhance or detract from their leadership development. Finally, and almost universally ignored in literature but crucial when fully considering the influence of gender, is the influence of home and care- giving factors, which can enable or create challenges along women’s leadership journeys. Drawing upon our multi- layered framework of factors influencing women’s leadership development in health, we map the process by which women cultivate essential leadership skills throughout their careers. Although our model portrays these structures as separate, in women’s narratives there are interconnections across all five levels. We recognize that the model does not visually capture individual leaders' process or leadership journey dimensions. Through our scoping review, we identified that the literature lacks research on how women develop their leadership throughout their careers. In this paper, we addressed this important gap to describe the journeys of women leaders in the health sector. Figure 1. Gender, Care, and Health Leadership Framework (James et al., 2024) Advancing Women in Leadership Journal-Volume 43 139 Drawing upon our multi-layered framework of factors influencing women’s leadership development in health, we map the process by which women cultivate essential leadership skills throughout their careers. Although our model portrays these structures as separate, in women’s narratives there are interconnections across all five levels. We recognize that the model does not visually capture individual leaders' process or leadership journey dimensions. Through our scoping review, we identified that the literature lacks research on how women develop their leadership throughout their careers. In this paper, we addressed this important gap to describe the journeys of women leaders in the health sector. Methods Our paper is part of a multi-phase project and reports specifically on a thematic analysis of the transcripts of 11 semi-structured interviews and 13 public presentations at events organized by our Empowering Women Leaders in Health project: eight learning lab presentations and five open house presentations. A total of 23 participants were included in this study. Participants were recruited to reflect a diversity of perspectives and experiences. Most participants held formal leadership positions in health care and health sciences, a few identified as emerging leaders, while another was a leader among patient partners. We did not systematically document the time frame of each individual’s leadership journey. The project was also committed to being inclusive of perspectives from Black, Indigenous, and People of Color (BIPOC) women leaders: two women identified as Black, five women identified as Indigenous, five women identified as a person of color, and the remaining 11 women identified as White. Data Collection Semi-Structured Interviews The research team identified participants through purposive and snowball sampling. Prospective participants were invited to participate in an interview lasting up to 60 minutes. A total of 11 participated in the semi-structured interviews. The senior researcher conducted 9 of the 11 interviews, and another team member conducted the remaining two. The interviews were conducted in 2018 and 2019. Each interview was conducted on Zoom and recorded. Audio recordings were transcribed verbatim. To ensure a rich and nuanced understanding of participants’ experiences, the semi-structured format allowed for flexibility in exploring key themes while also permitting respondents to share their experiences with few interruptions. The researchers aimed to create a comfortable environment, encouraging participants to discuss their experiences candidly. This method enabled the interviewers to gather diverse insights and understand the complexities of the experiences and factors being studied. The transcripts were subsequently analyzed using thematic analysis to identify common patterns and themes within the participants’ narratives. Learning Lab Presentations As part of the project, learning labs were organized to build women's leadership capacity in health care and health sciences. Two learning labs were held: June 2018 (Ottawa, Ontario) and October 2018 (London, Ontario). Each learning lab was two- and-a-half days long. The learning labs were open to senior and emerging leaders as an opportunity to share evidence and tools to make changes in their organizations. Several women leaders in health care and health sciences were invited to deliver presentations, of which eight were included in this study. These presentations were recorded. The audio recordings were transcribed verbatim for analysis. Open House Presentations In March 2020, a public virtual open house forum was organized as a culminating dialogue to the learning labs. The event allowed five learning lab participants to share their experiences and insights over the past year with a broader audience. Like the learning lab presentations, the open house presentations were recorded, and the audio recordings were transcribed verbatim for analysis. Ethics The protocol for the semi-structured interviews was approved by the University of Ottawa Research Ethics Board, Application number 08-17-14. Data Analysis Our analytic challenge was to map the personal leadership journeys of participants to a standard or collective process. NVivo 12 computer software was used to facilitate the analysis of interview and learning lab transcripts, which resulted in the creation of a codebook; then, the four virtual open house transcripts were coded manually based on the codes. A priori themes related to the framework (Figure 1) were used at the outset but modified to reflect the unique gendered experiences of women leaders in the Canadian health context. Because our intention in analyzing interview and presentation transcripts was also to add a process dimension reflecting individual leadership journeys to the structural model developed from the literature review, emergent themes were also identified through the coding process. The analysis followed four steps: (a) the lead author analyzed four transcripts in NVivo, two interviews, and two Learning Lab presentations; these codes were reviewed and discussed with the senior author to develop a codebook; (b) the codebook was used to analyse the remaining interviews, learning lab presentations, and virtual open house presentations; the researchers discussed any new codes that emerged; (c) the codes were organized into categories and themes were developed; and (d) lastly, the finalized code book was applied to four open house presentations, where the researchers remained open to any additional emergent themes. Advancing Women in Leadership Journal-Volume 43 140 In addition to the key a priori themes, we added the impetus for career advancement and the management of mental health when managing women leaders’ multiple gender roles as emergent themes added for exploration in this paper. Women’s leadership journeys included detailed descriptions of their impetus for career advancement and barriers and facilitators to advancement. Across these themes, the participant quotes are presented anonymously. Findings The findings are categorized under three main themes: impetus for career advancement, barriers to advancing women’s leadership, and facilitators to advancing women’s leadership. Impetus for Career Advancement Our conversations about women’s leadership journeys often began with the impetus for their career advancement. In analyzing their responses, we tease apart more active, passive, or reactive reasons to take on a leadership position and embark on a leadership journey. We recognize that both are prominent across participants and present these reasons as sub-themes below. Active Approaches to Leadership Positions We begin with the internal motivation or personal drive of the women leaders we interviewed or had present at our events. In some cases, leadership was pursued for leadership's sake, recognizing one’s potential to make positive contributions while also seeking opportunities for personal growth. In other cases, leadership roles were pursued out of frustration with a situation being experienced. A common thread throughout the conversations around career advancement is the desire to address a particular challenge, whether for quality improvement or to achieve more significant equity in an organization. Participants actively positioned themselves into crucial leadership roles to lead change initiatives. Recognition of One’s Own Leadership Potential Recognizing one’s leadership potential was demonstrated as an impetus for pursuing career advancement, and this came at different points in their careers. Participants reported that when they could self-actualize their leadership potential, it was often coupled with an opportunity for growth and self-confidence. One participant described her transformative experience before becoming CEO: It was the first time a woman had been a CEO in that organization in [city]. That was exciting for me, but the morale in the organization was horrible, and people said, “Why would you even bother to take that?” I said, “Because you can only go up,” and I was going home where my family still was. I learned a ton while I was in [another province]... I learned about really being innovative. It was a different way of being, and I was just a different person when I returned to [city]. (KII #4). Some discovered early, and others later in their careers, that being in leadership positions was a way to facilitate a change they wanted to see. For example, one participant described her first managerial position as the role in which she was able to improve the work environment: In my first managerial position as a nurse manager ... I realized that I was much better suited to creating environments for people to work in... and I enjoyed the work much more. … That was the beginning of my journey, and it allowed me to reach where I am today. (KII #1). Frustration with Current Situation Several participants shared stories that began with frustration with a current situation at their workplace or with a particular organization. Striving to improve these situations, participants actively took steps towards leadership roles to drive change or "doing what I needed to do to change the situation... and hopefully make it better” (LL #4). For example, one participant shared: One of the reasons I wanted to be a leader was that I understood that those leading needed to be smarter. I brought things they did not bring, and I could change things if I were a leader (KII #5). In many cases, the steps taken by some leaders to improve a situation by “pushing the boundaries as women, as marginalized women, as scholars...” (OH #1) led to positive outcomes. The ability to contribute to an organizational change and “make the system feel and be different” (KII #5) was gratifying for several participants. One presenter in the virtual open house said, “I feel that even though there was a lot of learning on the job and not having a formalized structure for learning, I have been able to move the needle in meaningful ways” (OH #3). Inequities as the Impetus for Leaders from a Diverse Background Participants who self-identified as Indigenous or racialized described inequitable situations that were the impetus for seeking leadership roles. Many said, “If I do not do it, no one is going to do it” (OH #1). KII #10 associated this sentiment with “bravery.” She said: That bravery comes from experiences you have had in other places or challenges you have seen. I think many times I have heard Indigenous women leaders— and I think in my experience as well—I feel like if I do not do it, it will not happen. I am terrified most of the time. People tell me I make it look straightforward, but most times, I think I will go for it because if I do not do this, it will not happen. I think, particularly in places … where there are very few Indigenous leaders, you sometimes have to take a leap of faith. Advancing Women in Leadership Journal-Volume 43 141 Another participant described a situation with a student and made a comment related to providing medical treatment for Black people or people of color: My earlier motivation in clinical practice was when a patient told me that the student would start an IV on her. They tried a couple of times, but it did not work. The student just kept trying, and when the patient complained, the student said, " Oh, you know, it is well known that Black people have tough skin. That is why it is so hard” (LL #4). From this experience, LL #4 felt driven to address this misconception among others she had experienced as a nurse educator and researcher. Although many BIPOC women described situations when they were proactive and willing to contribute to changing organizational culture, at times, it can lead to an imbalance of work or tokenism. As one White participant said, this should be the responsibility of everyone, not just those who are BIPOC leaders: Make it everybody’s responsibility. That then takes some pressure off women to advocate for women because it gets exhausting and can lead to marginalization. People think you are a token. You will hear this from racialized minorities as well. They do not want to be the spokesperson for their race. (KII #7). In sum, the two most active ways participants were driven to pursue leadership positions were recognizing one’s leadership potential and seeking leadership opportunities of frustration with a current situation and seeking to change it for the better. Passive Approaches to Leadership Positions There are also passive ways participants advanced into leadership roles, whereby participants did not intentionally pursue specific opportunities. Passive paths to leadership roles refer to unintentional ways women leaders assume or recognize their leadership roles. This would include being around when an opportunity arises and being asked or encouraged to apply for specific positions. In these situations, participants did not actively pursue these opportunities for career advancement, but rather, other people thought they were well-suited to fill these leadership roles. Similarly, another passive way of recognizing one’s leadership is through reflection. By talking about past experiences, some participants recognized they had utilized leadership skills in certain situations; they did not consider themselves leaders then. In one of the interviews, one participant talked about an insight they had into influential people: Those people who are invested in power and responsibility, that is how I saw it, and people who influence others. So, when I thought about this insight, I thought, “Oh, okay, I guess I have been doing some of that.” (LL #4) Another participant talked about the impact this specific research project had on their self-awareness of personal leadership: I only just learned that I am a leader, by the way... I participated in the interviews as part of [this project] and met with the interviewer ... and I was like, oh my goodness, yes, I am doing leadership! Thank you for acknowledging that and helping me to think about these things! (OH #1) This experience suggests that women leaders may need to learn that they can be in leadership roles or are leaders. This sometimes requires someone or a reflective situation to enable them to recognize this insight. The Accidental Leadership Journey Several participants talked about how the opportunity to take on a leadership role presented itself, of which two participants described themselves as an “accidental leader” (KII #8). The sentiment of being open to possibilities and to “see where life takes you” (LL #3) was shared among the participants. Another participant talked about being at their workplace during an organization expansion: The school was growing. Lots of fascinating things were being done. They desperately needed people who were willing to do it. So, I did... It was because there was a real shortage of people on the ground, and I was there and willing to do everything. (KII #2) In these situations, participants were in the right place at the right time and, without intention, found themselves in leadership roles. They Were Tapped on the Shoulder Further to the notion of being an accidental leader in the right place at the right time, participants talked about how others encouraged them to consider specific leadership roles. Being tapped on the shoulder, an expression used by several participants, was how some women leaders fell into specific roles. Interestingly, being tapped on the shoulder was described in conjunction with a reflection on one’s career to date. One participant described a role for which she was asked to apply: I did get tapped on the shoulder and asked if I would put my name forward... I have not applied for a job since I started as a nurse. It would be a good experience to go through an interview to see what that was like because, at some point, I should move on. (KII #4) Another participant described how she saw herself as a clinician, and the suggestion to pursue a leadership role in a national association was coupled with an element of surprise: Advancing Women in Leadership Journal-Volume 43 142 They said, “Why don't you run? You should run; I think you would be fantastic.” Moreover, my initial gut reaction was, “Me? Why me? Who is going to vote for me?” ... I think of myself as a frontline clinician;... I have been in practice for 20 years now. I am the head of the section at my hospital in [place] and … had [other] leadership positions … I slept on it that night … and by the morning time, I hardly slept. I realized I wanted to do this because it terrified and inspired me, so I ran. (LL #7) When unsure about applying for a leadership opportunity, participants often talked about seeking advice from their colleagues, sponsors, or mentors. One participant sought guidance from a male colleague who offered this advice: “I went to a colleague, a male colleague that I had worked with ... and said, ‘What do you think?’ And he said, ‘Just be yourself. Lead from where you are, and you will earn the respect of the group’” (LL #6). Although many women leaders talked about active and passive ways they pursued leadership roles; they often needed to recognize their leadership potential or abilities themselves. One participant said, “I think the ‘lean in’ concept is interesting... it is very foreign to many women because they are not raised in an environment that was very preferential towards them” (KII #13). This quotation suggests that women often do not recognize their leadership because they are not socialized into that acceptance and speaks to barriers women leaders might experience in their journeys. Barriers to Advancing Women’s Leadership Reflected in our conceptual framework, different layers of barriers along women’s leadership journeys can be teased apart. We begin with the most prominent and salient to our participants–those related to their personal and familial lives– that reflected a gender-system level of women’s caregiving roles. Furthermore, women leaders described situations that challenged and required effective management of their own mental health and well-being. Individual Influences – Personal and Familial Circumstances When women leaders discussed the barriers they experienced to their career advancement, many spoke to the circumstances in their personal or familial lives. A common refrain was, “It was not a good time but...” which speaks to the tensions between their work and home or personal environment. One participant noted the specific barriers for women physicians: [They] carry out at least two and a half more times unpaid household and care work, and that persists even in medicine... [they] spend 48 hours per week working and the men spend 52 hours a week, and that is just our professional work hours, our clinical duties and our call duties. Add to that any duties with aging parents, childcare, and household duties, and you can see how all of this can drive emotional exhaustion and burnout. (LL #7) Similarly, another participant recognized the potential conflict and said, “I think if I did have a family and doing the work that I am doing and the amount of it, there would certainly be a conflict” (KII #1). These women recognized that there can be tension between their careers and personal lives, which can lead to burnout and possibly other adverse outcomes. Organizations must “consider selecting women for leadership positions and making the place women-friendly and family- friendly" (KII #5). These layers are complex to tease apart because they are enmeshed but any program to support women’s leadership must address this complexity head-on. Workplace Influences – Limited Mentorship Opportunities Lack of mentors or inappropriate mentorship is an element of work culture that does not set women up for successful leadership. Some men may be willing to mentor women colleagues yet can emulate gendered stereotypes related to women having less experience in leadership roles. One participant shared a story describing this very situation: I had started in a key leadership position, and somebody decided to take me out to lunch and… I hadn’t asked this person to mentor me or to give me advice, but he took it upon himself to do so. Some of the things were quite infantile. I found myself saying to him, you know, this is not my first job... I just could not see him doing that to one of my male counterparts and he was speaking to me as if I was a college graduate. (KII #1) Another participant reported a situation in which she was discouraged from applying for a leadership role because of an informal succession plan: I held other key leadership roles within my units, but when I decided to apply for head of the department, I was actually discouraged by colleagues within the department because I hadn’t been there that long. And what was said was it's so and so’s turn, and, you know, you should hold back. And I think that’s a message that often people do hear, particularly women. (KII #5) Certainly, obstacles in interpersonal communication at the workplace can hinder women's progress in attaining leadership roles. These challenges may vary among individuals or be indicative of a larger organizational work culture. Organizational Influences – Unconscious Biases, Microaggressions, and Tokenism Although many participants shared personal stories of their journey towards realizing their leadership potential, these journeys were not barrier-free. Women leaders in leadership roles said that at times, their efforts get undermined because they are perceived to be a threat to the status quo or a Advancing Women in Leadership Journal-Volume 43 143 disruption of the power balances that exist in their workplace. One participant recounted that “people can create situations that make it very hard for those women to effectively do the role. Sometimes it's just, the system itself is not ready, right?” (OH #1). Furthermore, KII #12 described the power imbalances experienced by Indigenous Peoples: Indigenous people in [Canada] who have an inkling of the systems at play, understand that this idea of leadership isn't about going to [university]. It is literally showing up and being there and sometimes it means though that if you are a leader in [your] community, … it means that this other world, this White world, doesn't recognize you. They don't even see you. That you literally don't exist. The narratives shared by participants underscore the pervasive challenges and systemic barriers faced by individuals striving to fulfil their leadership potential, particularly for women leaders confronting resistance and Indigenous Peoples navigating a world that often fails to recognize their existence. Unconscious Biases and Microaggressions Indirect and sometimes subtle forms of discrimination against BIPOC women leaders, unintentional or not, have been experienced in the workplace to varying degrees. Unconscious biases and microaggressions can be understood as interpersonal factors within an organization. LL #3 said, “As a woman, yes there are biases for me. I'm also a visible minority, for sure people have biases. I don't always see them, and I often don’t anticipate them, but I've experienced them to a certain extent.” Nuanced challenges faced by BIPOC women leaders in the workplace highlights the presence of indirect and sometimes subtle forms of discrimination. The discrimination, whether intentional or unintentional, is acknowledge as being experienced to varying degrees. One of the women leaders we interviewed (KII #8) gave an example from her workplace. The president of the [institution] was a woman, and she already had from her perspective: …driven away some other incredible leaders [at the institution] … people would say to me, you know, [KII #8 name], it’s going to be really hard for you because we know that this woman president doesn’t like to have other women who either are going to outshine her or be even in the same potential limelight. Women leaders said they have experienced contra power harassment, highlighting a disturbing trend within professional settings. Contra power harassment involves situations where subordinates or peers attempt to undermine or challenge the authority of women in leadership roles. These experiences create an additional layer of complexity for women leaders, as they not only navigate the responsibilities of their positions but also contend with resistance or opposition from those who may find their leadership unconventional or challenging. Tokenism - the “Tick Box” Tokenism was said to occur when women and diverse women leaders were asked to serve on committees, boards, or panels to give the appearance of equality. The impact of tokenism can lead to exhaustion and less representation because although women leaders will take on leadership roles with good intentions, they may not be able to “balance all the demands” (OH #1) between their careers and personal responsibilities. KII #3 spoke about being on different committees where she “was so often the only woman and often the only social scientist.” She mentioned that it felt like, “Oh, tick. If we ask [participant], we’ve got a woman. We’ve got a social scientist. Tick, tick. The box is ticked with one person.” Similarly, KII #2 said, “a bit like that Monty Python thing—we’ve already got one. If you have a Black head of department, you can say, “Oh, no, we’re good. We don’t need any more Blacks. We’ve got one.” Thus, organizations bear the responsibility of actively welcoming a more diverse range of individuals into their midst. This approach ensures that the burden of workload is not disproportionately shouldered by a select few who are already part of the organization. Enablers to Advancing Women’s Leadership Enablers support the advancement of women’s leadership and, like the barriers, can be categorized at the individual, workplace, and organizational levels. Individual Influences – Networking Networking was the main individual factor that enabled women throughout their leadership journeys. Women leaders referred to networking as an enabler to advancing their leadership because networking enabled women to meet others, in particular other women, who might be in a similar area of work. The purpose of networking for many women leaders was initially to expand their own professional contacts and become involved in their professional networks. Through their active involvement, women leaders become more visible among a wider audience. This network entails special benefits for women who have demonstrated excellence in their positions. Their achievements and personal journeys come to the forefront, offering valuable examples and inspiration for fellow members within the organization. These connections might provide greater visibility to women who have been successful in their work, thus serving as possible role models or mentors. One of the women we interviewed described how she encourages medical residents to network: One of the things that I found very informative and successful for me is being involved in groups of other women, especially other surgeons who are women, and I recommend this all the time and take my residents to meetings where there are groups of women surgeons who have actually been successful. And that speaks to you can’t do it if you can’t see it. (KII #13) Advancing Women in Leadership Journal-Volume 43 144 The ability to leverage networks and develop professional relationships was seen to enable women to navigate socio- political workplace situations. According to another woman leader we interviewed, women tend to focus more on outcomes and less on the “political groundwork to get them to the next level” (KII #7) such as networking and building relationships. These relationships could lead to women being mentored or sponsored by others within or outside of their organization. Workplace Influences – Mentorship Mentors and sponsors are strong forces to enable women to become leaders. Based on participants’ responses, unlike networking to expand one’s own professional contacts, mentors may not necessarily work within the same organization whereas sponsors might. Both roles might advise women leaders on strategies for their advancement; however, a sponsor might take a more active role since they are in the same organization. What came through in the analysis of the data was exemplified by OH #3’s statement, "For women to enter leadership… support of mentors is required. It takes a village to raise a leader.” This comment might suggest that for women to become leaders, different types of mentors and sponsors are needed throughout their leadership career. In addition to having mentors throughout one’s career, a consistent message shared by many women leaders was that they “leaned in” when they found themselves in new leadership roles, which meant being willing to be mentored by others. Although women leaders might be proactive in seeking leadership opportunities, mentorship proved to be a necessary support for women to succeed in those roles. On occasion, women might pursue opportunities without support and OH #2 said it was “like I was kind of being thrown into the swimming pool without knowing how to swim...” She embraced the idea of seeking out leadership training and importantly seeking out female leaders and mentors in leadership at several levels. So, mentors can encourage women to pursue opportunities and enable them to succeed in those roles. There are different reasons why individuals have a variety of mentors. Mentors demonstrate how they utilize self-leadership and demonstrate leadership character. Mentors role model leadership characteristics, which can shape how mentees conduct themselves in the workplace. One of our interviewees said that she “saw as the kind of leader that I would like to be. And it was a really great balance of being able to direct and make decisions while at the same time being compassionate and a warmth towards other people.” (KII #1) Several women leaders shared how they are cognizant that a balance between their professional and personal lives is needed. They talked about how mentors and sponsors can support women leaders in balancing their personal and familial responsibilities. For example, one participant talked about a “good mentor” who had a holistic view of work-life balance. Mentors have a key role in demonstrating leadership character and how to find work-life balance (James et al., 2024). Women leaders then apply this to their own way of leading. Men as Mentors Some women leaders mentioned the role men had in their leadership journeys. These men mentors demonstrated leadership character, which was perceived by the participants in different ways. For some participants, the men were willing to share their experience and modelled positive leadership characteristics such as confidence. One of the women leaders said, “the majority of the influence in my life and in my career were men... certainly I learned confidence from observing men.” (KII #1) Other participants also said that “it would be helpful to have male mentors more if people don’t have them.” (KII #2) Men as mentors were seen to have leverage in supporting women in advancing their careers. On the contrary, male mentors were also seen to be a part of an “old boys' network” (KII #4) and other participants said they did not learn interpersonal skills from them but rather how to navigate sociopolitical situations at work. As one said, “I did not learn the empathy, listening, those kinds of softer skills from those men who were my mentors, not at all. They didn't have them. They didn't possess them... What I learned from them [men] was ... the politics of healthcare” (KII #4). KII #6 adds: We've all seen where women try to act like men, and that's when they are least successful as leaders. Then, the reality is that women have strengths, and they need strengths. It makes them different from men and actually gives them added advantage when it comes to emotional intelligence and being to read the room, and hopefully some aspects of self-awareness. The varied perspectives on the role of male mentors in women's leadership journeys highlight both the positive impact of learning confidence and career navigation from them, as well as the potential limitations, such as the absence of certain interpersonal skills, emphasizing the importance of recognizing and leveraging the unique strengths that women bring to leadership. Mentoring Forward Women leadership also talked about how they provide mentorship for others. Mentoring forward was seen as a responsibility of a leader (KII #3), wherein they contribute to the development of others such as colleagues or students. LL #4 described how she mentors forward: In terms of the ripple effects of this, the mentoring that I've been doing actually, I've also extended that to my colleagues in Nigeria that I've worked with over the years, and so I take PhD students from there sometime and mentor them here and they go back to work as faculty members, and they've invited me back and we've been able to mobilize and create a nursing research foundation. Women leaders shared insights from their experiences with mentees to help them be successful as the progress in their careers. For example, one said she tells those she mentors that Advancing Women in Leadership Journal-Volume 43 145 they need to “stay one step ahead of everybody else,” which has been a “mantra in [her] life” (KII #4). Organizational Influences – “Open Door” to Diversity Women leaders recognized the importance of having inclusive and diverse representation in leadership within an organization. Several women leaders acknowledged that an inclusive and diverse workforce is not simply a “tick in the box” (KII #3) but rather understanding how the system works: If you haven’t got some diversity, then people assume that it’s a closed door. … As leaders, we must be broad thinking enough. So, whether you’re a healthcare leader or a health sciences [sic] or any other kind of leader, you’ve got to understand how systems work. (KII #5) Similarly, other participants suggested that leaders must actively consider who might not be represented. OH #4 said, “if we’re not actively looking around the table to see who's missing and to remove those barriers, [you’ll] ending up with an echo chamber instead of getting the most robust solutions for what's ailing health care out there.” The findings also suggest that there are unique barriers for BIPOC women leaders that cuts across personal, work, and organizational factors. A lack of understanding of “how structurally disempowered Indigenous people have been because of colonization” (OH #1) continues. This reveals distinct challenges faced by BIPOC women leaders, spanning personal, work, and organizational domains, with an ongoing lack of awareness regarding the structural disempowerment of Indigenous people due to historical colonization. Discussion The leadership journeys of women leaders in healthcare and health sciences are complex, especially those from racially diverse backgrounds. Their deeply personal stories highlighted the impetuses for their career advancement as well as barriers and facilitators. Their internal motivation or personal drive was described as active reasons for embarking on their leadership journeys. Active reasons included recognizing one’s own leadership potential, frustration with a current situation, and responding to inequitable situations. Women leaders also embark on their leadership journeys in unintentional ways. The accidental journey was a shared experience among several women leaders, whereby leadership role happened to arise at an opportune time. Another common experience was being tapped on the shoulder or asked by someone to consider a specific leadership role. Since these could be considered more passive pathways to leadership, women leaders nevertheless had to be actively open to explore these novel leadership opportunities. Whether the pursuit for leadership progression is driven by an active or passive approach, women leaders require support at individual, workplace, and organizational levels to overcome the various entrenched barriers at each stage. Networking, mentorship and sponsorship, and continuing to have inclusive and diverse representation at the top were considered essential facilitators for women’s leadership journeys. Other researchers have similarly found these facilitators to women’s leadership (Alli et al., 2021; Perez, 2021). Harris and Norlander (2023) found that top performing organization have successfully advanced women beyond the token status. Interestingly, while women leaders reported mentorship as a key facilitator for their advancement, they also reported a lack of mentors and in some cases, even inappropriate mentorship. While there might be individuals such as mentors and sponsors committed to supporting women advancing into leadership, organizational factors that retract these advancements include unconscious biases, microaggressions, and tokenism. There is a need to provide tools for those who choose or are sought to mentor women leaders (Bourgeault et al., 2022). The most common barrier for women to advance into leadership was described at the individual level. Although more women are advancing into leadership roles, they continue to be faced with tensions between their work and personal care circumstances. The scoping review that provided the framework for this research included the importance of explicitly considering the experiences of caregiving in the context of healthcare leadership, such as family care needs (James et al., 2024). The categorization of caregiving as an individual level barrier, however, has the impact of reinscribing a gendered system of caregiving wherein women bear the brunt of the burden; reimagining caregiving as a system level barrier to be addressed and integrated at every turn is an approach we encouraged to decouple caregiving from gender. The ability to manage one’s mental health and work-life balance emerged from the narratives not previously captured in the leadership literature, which is an opportunity to embellish the care dimensions of the orienting conceptual leadership framework. The narratives of the women leaders we interviewed and who presented their journeys in our project activities also address another invisibility in the leadership literature, that of their role and responsibilities for carework in the home and how this influenced their decision-making around leadership positions and leadership style. Vancour (2023) found that when academic administrators focused on providing opportunities for women at all administrative levels on their campuses, it can improve retention and succession planning, saving valuable financial resources and time. Reducing multi-tasking and redistributing household responsibilities can also enhance women’s productivity and well-being; while organizations should adopt policies that support a more equitable division of labour and recognize the negative impacts of traditional gender roles on career advancement and health (Guramatunhu-Mudiwa & Cherry, 2023). Prioritizing work-life considerations and support provisions is likely to yield the highest return on investment, but these initiatives should be carefully crafted (Vancour, 2023). Developing qualified faculty members with aspirations Advancing Women in Leadership Journal-Volume 43 146 to become future administrators is a smart business move, especially during challenging recruitment and retention efforts with constrained budgets. Amidst the abundance of normative and proscriptive literature dictating the actions women ought to take avoidance of such carework responsibilities—through contracting out to nannies, cooks, and cleaners—is actively encouraged. The not-so-subtle message is to become a leader one must exhibit qualities and lifestyles that are without any caregiving and responsibilities in the home. Another element that can be added to the conceptual framework, which focused primarily on structural factors, are the process elements of women’s leadership journeys, which are also notably absent from much of the literature. Our analysis here begins to address a gap in leadership literature that tends to quantify women’s exclusion and underrepresentation rather than explore how this comes to be. Barriers related to both gendered roles at work and at home are often obstacles women leaders not only face but actively navigate in their career advancement. Accumulating evidence suggests that greater diversity across multiple characteristics, including gender, improves staff experience, organizational performance, and patient outcomes (Penfold, 2019). Our paper, and the purposive and snowballing selection of a diverse set of women and non-binary participants, enable us to respond to a body of literature that is focused only on gender, and often as a male/female binary. Although we did not ask our participants and presenters specifically about their gender identity and whether they would identify as gender non-binary, we were able to reflect on the leadership journeys from an intersectional lens that was inclusive of non-binary gender identity, racialization, and age. These factors need to be accounted for in supporting the advancement of diverse women leaders in health (Decady & Bourgeault, 2023). To achieve this dismantling of racism, sexism, ableism, and other harmful structures, strong allies who actively work to challenge the status-quo are required (Decady & Bourgeault, 2023). The leadership journeys of BIPOC women may require “exceptional” support systems to overcome extant barrier to emerge in positions of leadership and power (Johnson & Fournillier, 2023, p. 311). Conclusion To effect gender transformative change in support of women leaders, it is critical to capture the ways in which women leaders have been active in shaping their leadership journeys. Women leaders in health face unique barriers to their career advancement, which are related to gendered roles at work but also at home. Women leaders in health have advanced into key leadership positions through strategic mentorship and sponsorship, and in so doing, have affected change thereby changing the landscape for emerging women health leaders. The leadership journeys of the women leaders we engaged with enabled an enhancement of our understanding of the various layers of barriers and facilitators. Applying our enhanced framework of barriers and enablers helps to capture the intersectional experiences of women’s leadership journeys in health. Our unique research contribution has been to add a process dimension to literature that is dominated by these structural concerns. 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