Healthcare administration in the United States, particularly in the senior ranks, has been a male-dominated field for decades (Lantz, 2008). But the demand for capable healthcare administrators is as high now as ever. Women represent a large and qualified talent pool from which to draw healthcare leaders. Women make up more than half of the U.S. population and approximately three quarters of the healthcare workforce (Cheeseman Day & Christnacht, 2019). They are obtaining college and graduate degrees at higher rates than men (National Center for Education Statistics, 2019).
Discrimination in the workplace on the basis of gender is illegal and contrary to the American College of Healthcare Executives (ACHE) Code of Ethics (ACHE, 2017). Moreover, organizations that can attract and retain talented women executives have a competitive advantage over their peers. Data show that organizations with women in senior leadership roles and on the board perform better financially (Carter & Wagner, 2004,2011; Morgan, 2017; Turban et al., 2019). Having senior leadership and board membership reflect the community served is one of the three recommended steps toward eliminating healthcare disparities and improving quality of care (Totten, 2015). With women being both the major users of healthcare and often the healthcare decision makers for their families (Luce & Kennedy, 2015), it is important that healthcare organizations have leadership that reflects this reality. Further, the merging of healthcare providers into larger systems occurring today makes the leadership traits of emotional intelligence, cooperation, and the abilities to establish trust and empower others even more important, and women excel at those traits (Athey, 2016; Athey & Kimball, 2013).
Being an attractive workplace for capable women leaders is also a sustainability strategy for healthcare organizations. The up-and-coming generation of healthcare executives, in general, expects a greater degree of gender equity both at home and in the workplace and chooses workplaces accordingly (Rau & Williams, 2017).
There is no doubt that it is far more common now than it was 20 years ago for women to occupy senior leadership positions in U.S. healthcare. However, women still tend to be hired into more junior positions than their male counterparts, be paid less, and be less likely to be promoted into the most senior positions (Athey & Kimball, 2013; Mangurian et al., 2018; Waller, 2016).
ABOUT THE SURVEY
This special report presents results from a survey conducted by ACHE in 2018 comparing career attainments and attitudes of women and men healthcare executives, along with comparative data from earlier surveys conducted in 1990, 1995, 2000, 2006, and 2012, where appropriate.
In 1990, ACHE partnered with researchers at the University of Iowa to conduct a survey of members to compare their career attainments, examine factors that might explain differences in career trajectories between men and women executives, and gather their opinions and perceptions about their workplaces. ACHE has continued this project in five subsequent survey waves: in 1995, in partnership with researchers at the University of Alabama at Birmingham and Lamalie Amrop International, an executive search firm; in 2000, with Catalyst; in 2006, with researchers from the University of Kansas; and independently in 2012 and 2018. Results from the first five surveys have been published in other reports (Athey & Kimball, 2013; Weil, 1991, 1996, 2001, 2008). New samples of potential respondents were chosen for each wave, so the group of surveys represents a series of cross-sectional studies over time. The survey methods have been kept generally consistent over the years.
In each wave, the sampling frame was selected from ACHE’s database of full dues-paying members. Members who had provided information about current U.S. employment, work history, and gender were divided into 5-year cohorts of management experience, determined by the starting date of their first healthcare management position as coded by the research team. The survey samples for men and for women were taken equally from the three 5-year cohorts with 5 to 20 years of management experience. Members in the military and in religious orders were excluded because of their unique modes of career advancement.
As a check on the samples’ selection criteria, each instrument asked respondents the nature of their current employment and the date of their first healthcare management position. Respondents who reported that they were not currently employed or that they had fewer than 5 years or more than 20 years of healthcare management experience were excluded from the analysis. To facilitate year-to-year comparisons, results for all waves after the first were weighted to match the distribution of the first respondent pool by cohort within gender.
Persons in the survey sample were mailed a paper instrument along with a postage-paid reply envelope. If no response was received after 4 weeks, a reminder with a second copy of the instrument was mailed. The 2018 survey was largely composed of questions that were also asked in our past surveys, to allow us to look at key data about gender and healthcare careers over time.
In each wave after the first, the response rates of men and women from the previous wave were used to gauge the numbers of men and women to be sampled in the subsequent wave, with a view to equalizing their numbers and obtaining an adequate number of respondents. Beginning in 2000, the survey instrument was split into two versions to accommodate an increased number of questions about respondents’ perceptions of organizational fairness and similar matters. Also, the sample size was doubled, and members in the sampling frame were assigned randomly to the survey versions.
A REVIEW OF THE 2018 DATA
The 2018 survey was sent to 2,909 men and 2,229 women who were members of ACHE. Responses were received from 670 men and 726 women, resulting in an overall response rate of 28%. Women were more likely to answer the survey, with a 33% response rate compared to a 23% response rate for men. Members were more likely to respond if they had reported their race/ethnicity as white, had received a master’s or doctoral degree, had a degree in healthcare management, or were working in hospitals and health systems. Overall, respondents were similar to nonrespondents in age and position level.
Experience and Education of Men and Women
The sample design ensured that comparisons could be made between men and women with similar years of experience in the field. Men and women respondents also reported similar levels of education; in 2018, 93% of men and 92% of women reported having attained either a master’s or doctorate degree (p > .05).
Overall Job Satisfaction
A high proportion of both men and women healthcare executives in the study reported being satisfied (i.e., satisfied or very satisfied) overall with their position (Table 1). These proportions were 87% among men and 81% among women. This is similar to results from the previous studies, where proportions of men and women executives reporting satisfaction with their position in general ranged from 78% to 86%. However, the 2018 study was the first time that the proportion of women executives reporting overall satisfaction with their current position was significantly lower than that of men (p < .05).
Satisfaction With Compensation
When asked to consider their employment history over the past 5 years, 42% of women respondents said they failed to receive fair compensation due to gender, as opposed to 2% of men. This difference is significant (p < .001). A similar gap between the perceptions of men and women regarding fair treatment in compensation in the past 5 years has existed in the previous surveys since 1995, when the question was first asked. By contrast, in the 2018 study, only 2% of men and 1% of women responding to the survey felt they had been advantaged in hiring, promotion, or compensation because of their gender. Again, this is similar to reports in the four previous studies conducted in 1995 and later that included this question.
Regarding current employment, women in the 2018 study were also less satisfied than men with their compensation compared with others in the organization at their same level (Table 1). The proportion of men satisfied or very satisfied with their compensation was 81%, while it was lower among women at 71% (p < .01).
Hiring, Evaluation, and Promotion
Only small percentages of men or women in the 2018 survey felt they had failed to be hired over the past 5 years because of gender. However, the proportion of women who said this, 9%, was significantly higher than the 3% of men who did (p < .001). Similarly, the 17% of women respondents who felt they had failed to be promoted in the past 5 years because of gender was significantly higher than the 4% of men who said this had been the case (p < .001). Both findings are consistent with the previous four surveys in which these questions were included. It is worth noting that the proportion of women who felt they had missed out on promotions because of gender has decreased somewhat over time. In the 1995 study, 33% of women respondents felt they had been passed up for promotion over the past 5 years because of their sex. This proportion decreased to 20% in 2000 and remained below this mark at 14%, 16%, and 17% in the three surveys that followed in 2006, 2012, and 2018, respectively.
A significantly higher proportion of women, 18%, than men, 10%, in the 2018 study felt they had been evaluated with inappropriate standards over the past 5 years (p < .001). This is similar to findings in the 1995 and 2006 surveys. However, it is at variance with the results from the 2000 and 2012 studies when higher proportions of women than men reported having these experiences (20% and 10% of women reported being evaluated with inappropriate standards in 2000 and 2012, respectively, compared with 16% and 6% of men), but the differences could not be distinguished statistically.
When evaluating their current job situation, more than 80% of both men and women reported being satisfied (i.e., satisfied or very satisfied) with their overall advancement in their organizations (Table 1). However, a higher proportion of men, 87%, reported satisfaction with this aspect of their employment than did women, 81% (p < .05). This is similar to results last seen in the 2000 study, the first year this question was included in the survey. There were no statistically distinguishable differences between the proportions of women and men satisfied with their advancement in their current organizations in 2006 or 2012.
Women in the 2018 study were also less satisfied than their male counterparts with the job opportunities offered by their current employers. (Table 1). Sixty-four percent of women, as opposed to 75% of men, reported being satisfied or very satisfied with the job opportunities offered to them by their organizations (p < .01). The disparity between the proportions of men and women satisfied with this aspect of their employment appeared in results beginning in 2012 but was not present in the results from the 2000 and 2006 studies.
Women and men were equally satisfied with several aspects of their current positions (Table 1). About 85% of men and women in the 2018 study said they were satisfied (i.e., either satisfied or very satisfied) with their job security. Roughly three quarters of men and women were satisfied with the balance between work and personal/family commitments that their current employment offered, 68% were satisfied with the recognition and rewards they received, and 67% were satisfied with the availability of mentors and coaches to them. There were no detectable disparities between the proportions of men and women satisfied with these areas of their employment in past studies, with the exception of the 2000 study, when the proportion of women satisfied with the availability of coaches and mentors to them was less than that of men.
Since the 2006 study, survey respondents have been asked whether they agree or disagree with a number of statements about their current employers (Table 2). In the 2018 study, significantly lower proportions of women than men felt their current employers took a gender-neutral stance toward hiring, promotion, giving feedback, making downsizing decisions (p < .001 for all), or giving assignments in accordance with employees’ skills and abilities (p < .01). About one quarter of women said they felt they had received different treatment because of their gender (p < .001). These differences in the views of men and women have been present in our study data since the questions were added to the 2006 survey. The only exception was in 2006, when the differences between women’s and men’s views of their organizations’ track record with fair downsizing decisions could not be distinguished statistically.
Women respondents who agreed that their organization had treated them differently on account of their gender, and who disagreed that there was gender equity in their organization, were less satisfied with their positions, more likely to agree that they did not feel as if they belonged there, and reported that they were more likely to leave within a year (Table 3). All of these relationships were highly significant. Those men respondents who disagreed that there was gender equity were also less satisfied with their position and reported they were more likely to leave. (Men who said they had been treated differently because of their gender were not significantly different from men who said they were not treated differently.)
WHAT THE DATA SUGGEST
As political consultant Lee Atwater famously stated several decades ago, “Perception is reality,” and women healthcare executives will make decisions about where they work accordingly. Talented and capable women executives are more likely to be attracted to, and remain in, healthcare organizations where they perceive they are respected; treated fairly with respect to all important aspects of employment, including hiring, evaluation, promotion, and compensation; and can pursue lifetime goals outside of their careers. The results of this study suggest that as a group, women healthcare executives are much less likely than their male counterparts to perceive their employing organizations as gender-neutral in some of these key aspects of employment. Further, our results suggest that both women and men who do not perceive gender equity were more likely to be considering leaving their organizations.
Some of the lack of satisfaction on the part of women executives in the study about their compensation is warranted. As has been reported elsewhere (Athey, 2020), women responding to the 2018 study earned a median salary that was 16% less than their male counterparts in 2017. Having attained approximately equal levels of education and experience, in 2017, women healthcare executives earned a median salary of about $155,200, and men earned a median salary of about $183,700. This represents an improvement from 2011 when the gap was 20%. It is comparable to prior studies in 1990, 1995, 2000, and 2006 when women with similar characteristics to their male counterparts earned 18%, 17%, 19%, and 18% less, respectively, than men did in the previous years.
Similarly, data suggest that women tend to be more likely than men to have been hired into their current organizations in positions of department head or department staff, whereas men tend to be more likely than women to have been hired in senior vice president or C-suite positions (Athey, 2020; Athey & Kimball, 2013; Lantz, 2008; Weil, 2001, 2008). Further, evidence suggests that women healthcare executives are less upwardly mobile from vice president positions than their male counterparts (Athey, in press).
Another result emerging from the study is the slowness of the pace at which the field of healthcare administration appears to be moving toward gender neutrality. With respect to the key measures of perceptions about the workplace presented here, the data from the 2018 study differ little from that in 2000 and 2006; the disparities between women and men executives noted in the earlier studies have remained.
We should note the limitations to the surveys discussed in this report. Questionnaires were sent only to ACHE members, who are not a random sample of healthcare executives. Data are based on self-reports, and reports about readiness to leave are not the same as actual behavior. Further, women, those who reported their race/ethnicity as white, those who had received an advanced degree (master’s or doctorate), those with degrees in healthcare management, and those working in hospitals and health systems were more likely to respond to the survey.
Data from the 2018 survey of men and women members of ACHE indicate that women healthcare executives with 5 to 20 years of experience in the field are significantly less likely than their male peers to perceive their employers as gender-neutral regarding key employment factors such as hiring, promotion, evaluation, and compensation. There has been little to no improvement in these outcomes since ACHE began measuring them more than a decade ago. Healthcare organizations looking to attract and retain talented women executives need to take a hard look at their practices and policies in these areas.
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