International Journal of Healthcare Management

ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: http://www.tandfonline.com/loi/yjhm20

Factors influencing career progression of working

women in health services: A case from Kathmandu
Valley in Nepal

Soniya Rijal & Sharada Prasad Wasti

To cite this article: Soniya Rijal & Sharada Prasad Wasti (2018): Factors influencing career
progression of working women in health services: A case from Kathmandu Valley in Nepal,
International Journal of Healthcare Management, DOI: 10.1080/20479700.2018.1444952

To link to this article: https://doi.org/10.1080/20479700.2018.1444952

Published online: 06 Mar 2018.

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INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT, 2018
https://doi.org/10.1080/20479700.2018.1444952

Factors influencing career progression of working women in health services:

A case from Kathmandu Valley in Nepal
a
Soniya Rijal and Sharada Prasad Wastib
a
National Open College (Affiliated to Pokhara University), Lalitpur, Nepal; bInstitute for Reproductive Health, Georgetown University, USA

ABSTRACT ARTICLE HISTORY

Background: Females working in health service organizations have ever-increasing pressure to Received 3 August 2017
develop their career in higher positions worldwide. Therefore, the study aimed to assess factors Accepted 21 February 2018
influencing the career progression of female employees in health service organizations.
KEYWORDS
Methodology: A cross-sectional mixed-method study in which a total 110 female employees Career progression; working
from health service organizations were interviewed for quantitative survey and 15 for in- woman; hospitals; health
depth interviews. service organizations;
Results: Individual factors: career preferences, individuals’ investment on education, and healthcare; gender;
individuals’ skill and hard work played a significant role in advancing career. Female harassment; work–life
employees were found to have dual responsibilities both at home and at the workplace. balance
Their career goals were changed after marriage and having children. They face discrimination
and sexual harassment and lack mentoring, coaching, and social support in the workplace.
Interplay between the socio-cultural and organizational factors was evident for career
growth. Maintaining the balance between work and family life with being subjected to
gender stereotypes making the respondents difficult to progress in their career.
Conclusion: Female employees are juggled between societal norms, family obligations, and
expectations of the organization. It was recommended that each healthcare organization in
Nepal needs to have a gender-balanced work environment and provide equal opportunities
to women employees.

Introduction
Economic, socio-demographic, cultural, and geo-
graphical factors contribute to transforming society
and hence have a direct or indirect impact on health
workforce issues. Globally, the labour force partici-
pation rate for women is 50% [1]. In the upper-
middle-income countries, more than one-third (34%)
of them are employed in wholesale and retail trade,
whereas in high-income countries mostly women are
engaged in the health and education sectors [1]. Gen-
der diversity at senior management levels is important
not only for women; it also has numerous benefits for
organizations, including increased availability of skilled
employees, stronger employee engagement, and higher
productivity [2]. Stereotypes and subtlety are often hid-
den forms of discrimination, which continue to limit
women’s advancement [3]. Although the USA com-
prises 78% of the workforce in the healthcare sector
[4] and more than 90% of the general nursing work-
force in the United Kingdom [5], they are under-rep-
resented in decision-making positions. Women at
various levels highlighted the importance of not assum-
ing that under-representation and constraints experi-
enced by Asian women employees throughout their
career are similar to those reported elsewhere [6].
Based on time, sector, or culture of a country, the
gender stereotypical belief of ‘think manager-think
male’ is found, which still holds back women with
feminine characteristics from moving up the career
ladder and restricts women from entering, being pro-
moted, and training in the industry [7]. Male and
female middle-level managers were different in their
career preferences; females had more preferences for
family, whereas males were significantly more willing
to consider promotions and reach a higher level[8].
Having children often results in slowing down of
career for female managers compared to male man-
agers in most cases. Female managers who are parents
take most of the leaves: the median for female man-
agers is 24 months but for male managers it is only
1–2 months [8].
The complexity of women’s careers in the healthcare
sector can be best understood using a relational
approach that highlights the inter-sectional between
gender, agency, socio-cultural realities, and organiz-
ational boundaries [9]. In India 5% of the women
responded that the attitude of the boss towards
women employees was abusive and more than half
(53%) of the females hesitate to work with male col-
leagues because they may get sexually harassed [10].
African cultural practices are also a great hindrance
to the advancement of women’s career where family

CONTACT Soniya Rijal rijalsoniya@gmail.com Texas Woman’s University, Denton, Texas 76204, USA
© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 S. RIJAL AND S. P. WASTI

structure and women’s commitment to the family are Table 1. Socio-demographic characteristics.
the most significant barriers perceived by executive Variables Frequency Percent
women [11]. In the context of Nepal, not many efforts Marital status
Unmarried 40 36.3
have been made in identifying the factors influencing Married 70 63.7
career progression for Nepali women employees Have children
Yes 27 38.6
especially working in the health sector. In Nepal, Types of job positions
women developing their career is facilitated by their Hospital clinical staff 70 63.6
own hard work and performance, education, and Administrative and finance staff 23 20.9
Public health officers 12 10.9
exposure, which makes them confident. Women work- Others dietetic/faculties 5 4.5
ing in administrative jobs perceived organization- Types of healthcare organizations
General hospital 71 64.5
related barriers as most prominent, whereas women I/NGO 13 11.8
in other responsibility areas perceived the society- Teaching hospitals 16 14.5
Others (hospital management-related and 5 9
related barriers as the most prominent barriers [12]. health science academic institutions)
Qualification of respondents
Doctoral 7 6.4
Methodology Masters 45 40.9
Bachelor 58 52.7
A cross-sectional mixed-methods study was con-
ducted in early 2017. It included a quantitative survey
with 125 women working in 32 different healthcare who hold positions equivalent to officer or above are
organizations from Kathmandu. Similarly, a total of highly learned and qualified and more than 93.6%
15 in-depth interviews were also conducted with had attained a bachelors and a higher degree, with
women working in healthcare organizations primarily 7% holding a doctoral degree.
involved in the managerial level. The study was con-
ducted concurrently and both data (quantitative and
qualitative) were collected at the same time and the Individual factors
findings have been integrated in the results and dis-
More than half (50%) of the respondents strongly
cussion sections [13]. Literature shows that mixed-
agreed that they have to advance their career but
method research designs have offered strength of con-
only 12.8% women did not think that it is important
firmatory results drawn from quantitative analysis,
for them, Table 2.
along with ‘deep structure’ explanatory descriptions
Qualitative findings further stated that:
as drawn from qualitative analyses [12]. Structural
questionnaires were administered in the quantitative Due to family responsibility I have to leave many
survey. Statistical analyses were conducted using the opportunities to work because my first priority is my
Statistical Package for the Social Science (SPSS) soft- child and family then only my career.
ware. Similarly, in-depth interviews were conducted [IDI 3: Academic Director, Healthcare Management]
with the aid of an interview checklist and probes to
cover the questions for understanding the impact on An individual’s skill, tenure, and hard work have a
women’s career growth in healthcare organizations. significant effect on career progression. Almost all
The interviews were transcribed verbatim and coded (92.7%) women believed that one must have individual
using a thematic analysis. The quotations included skill, tenure, hard work, reputation, and performance
below best represent the range of ideas voiced around (Table 3). This finding is supported by a participant
key themes. working in a private hospital:
My own hard work, working skills and performance
have advanced my career the most. [IDI-4, Lab
Results technologist]
Table 1 shows 110 samples, which represent both mar- It shows that individual factors such as hard work and
ried (63.7%) and unmarried (36.3%) respondents. This working skill have a positive effect on career pro-
can largely be attributed to the fact that many married gression of working women. More than one-fourth
women these days continue working to advance their (27%) stated that their career goal had changed after
careers. Out of the total respondents, the majority of getting married and about half (51.8%) of them
respondents were clinical employees (63.7%); others reported that their career was affected after having chil-
were non-clinical working women (36%) working in dren (Table 3).
various types of organizations such as General Hospi-
tals (64.5%), Non-Government Organizations
Social factors
(11.8%), Teaching Hospitals (14.5%), and other aca-
demic institutions (9%). The findings indicate that Participants who were interviewed explained that
the women employees in the healthcare organizations women have difficulty in managing the double roles
 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3

Table 2. Individual’s investment in career.

Strongly Strongly
disagree Disagree Uncertain Agree agree
Variables/factors (N = 110) # % # % # % # % # %
It is important to advance my career. 3 2.7 5 4.5 4 3.7 42 38.2 56 50.9
Personal investment in career 2 1.8 7 6.4 16 14.5 48 43.6 37 33.6
Individual’s skill, tenure, hard work, reputation, and performance 0 0 3 2.8 5 4.5 56 50.9 46 41.8

Table 3. Distribution of marriage influencing career goal. women have to work both at office, home, and have
Response Frequency Percent dual responsibilities when compared with men.
Did your marriage influence your career? (N = 70) A participant stated that women are bound by
Yes 19 27.0 different social norms. She stated that:
No 51 73.0
Did having children influence your career? (N = 27) All rules and regulations are made only for women
Yes 14 51.8 they are bound to follow including their ‘initiation
No 13 48.1
rites.’ They are taught to be obedient mother, wife, sis-
ters and work for their family day and night. But what
often we forget is she cannot always give her fullest
and maintaining a work–life balance after getting both at home and office. [IDI5: Wellness Officer,
married. Hospital]

It is difficult for women to gain a higher position as

compared to men. A married woman who wants to Organizational factors
continue her career has being facing double burden
maintaining a sound married life and active career. More than one-third (34.5%) of the respondents in the
[IDI 1: Hospital Manager] healthcare organizations felt discriminated in their
However, women who have supportive husbands workplace (Table 5).
did not have any difficulty in their career growth. These findings are confirmed by a human
A public relation officer working at a hospital stated resource officer working in a private hospital who
that: stated that she faced discrimination in her hospital
especially when there is a matter of promotion or
My husband equally support in household chores training:
which never hinders my office work and as well as it
has fostered my confidence to enhance my career. I do think they are treated differently just because of
[IDI 2: Public Relation Officer] their gender. We experience that women get promoted
based on their performance, and men get promoted on
Table 4 shows that on average working women allo- their potential. Women must prove that they are
cated about 67% of their time for household work, capable of succeeding in a role before they are pro-
whereas men only allocated 32.7%. It shows that moted into it, whereas men may be promoted on
their perceived potential. [IDI6:Human Resource
Officer, Hospital ]
Table 4. Household work as a perceived gender role.
Descriptive statistics
She further added:
Responses N Minimum Maximum Mean SD Although it seems like there is pay equality among
Estimated time allocated by 70 40 100 67.0 16.5 men and women but men are promoted very
women for household quickly or a new position will be created which
chores such as cooking,
results in automatic salary increment but female
washing clothes/dishes
etc. between husband staff will not get that opportunity they have to
and wife in percentages stick in same positions for years and the remunera-
adding up to 100 percent tions remains static. [IDI 6: Human Resource Offi-
Men on working on 70 0 60 32.7 16.4 cer, Hospital]
household chores such as
cooking, washing clothes/
dishes, cleaning houses
The participant further stated that bonus was given
etc. between you and more to male employees because they scored better
your partner in grades than their female counterparts.
percentages adding up to
100 percent
Time allocation for child 27 30 100 67.4 22.9
care by females in Table 5. Workplace conditions for women.
percentage adding up to Response
100 percent
Variables Yes No
Time allocation for child 27 0 80 34.0 25.6
care by males in Are you treated differently in your organization just # 38 72
percentage adding up to because you are a woman? % 34.5 65.5
100 percent Availability of flexible working hours # 44 66
Note: SD, standard deviation. % 40 60
4 S. RIJAL AND S. P. WASTI

Flexible work hours and career progression Table 7. Distribution of organizational practices affecting
career progression
Two-thirds (66%) of the respondents said that the Not Very
organization does not have a provision for flexible Responses at All Neutral Somehow Much Much
working schedules to accommodate female employees. Credibility of fellow # 13 16 45 29 7
staff % 11.8 14.5 40.9 26.4 6.4
This finding was supported by the statement of the Autocratic # 2 12 42 35 19
director in a healthcare organization. management % 1.8 10.9 38.2 31.8 17.3
style
In health care setting, every employee have to work Gender inequality # 8 23 32 24 23
from 8 am to 9 pm. There is no problem for male % 7.3 20.9 29.1 21.8 20.9
Male chauvinism # 7 18 33 33 19
staff because they have less family responsibilities (feeling of % 6.4 16.4 30.0 30.0 17.3
compared to women. So, organization values the superiority)
employees who work for late hours. [IDI 3: Academic Sexual harassment # 29 11 61 25 13
Director, Healthcare Management] % 26.4 10.0 55.5 22.7 11.8
Organizational # 7 8 44 33 25
Working with a male supervisor also impedes the pro- structure % 6.4 7.3 40.0 30.0 22.7
Discrimination # 15 12 39 30 29
gression of women’s career. A participant stated that: % 13.6 10.9 35.5 27.3 26.4
Culture # 15 13 50 30 17
Male supervisors with female subordinates or vice % 13.6 11.8 45.5 27.3 15.5
versa generally feel very awkward on providing men-
torship. And this will limit the knowledge and capacity
of female employees and has effect on career pro-
gression of women. [IDI 7: Nursing Department Male members also try to extract sexual favours, if
Incharge, Hospital] they do not respond positively to their proposal they
start spreading rumours on women’s characters. In
More than one-third (39%) of the respondents indi- this process not only male colleagues report these
cated that they had changed employers because of types of rumours even females follows it and become
judgmental of such type of mental torture and harass-
being offered a higher pay, fewer working hours ment. [IDI8: Nursing Incharge, Hospital]
including weekends, family commitments, occu-
pational stress, sexual harassment at workplace, and
lack of promotional opportunities (Table 6). Barriers to career progression
All the above factors mentioned in Table 8 are barriers
to career progression of working women. Among all
Existing practices of health service organizations the factors, respondents have identified sexual harass-
Table 7 shows that the practice of an autocratic man- ment as a major barrier to career progression.
agement style organizational structure, male chauvin- Women responded that lack of a support system at
ism, credibility of fellow staff, discrimination, and work is another factor, which is a major barrier to
sexual harassment were the key factors which directly career progression.
affected the career progression of women in healthcare. Women significantly face lack of equal promotions;
Among the total respondents, 44.5% of women had training and job opportunities in my organization
faced some kind of sexual harassment in the workplace and this have greater effect on confidence and self-
and it had affected their career progression. Interviews development of women and they work as an obstacle
for career progression. [IDI10: Laboratory Technol-
with a respondent working in a nursing department
ogist, Hospital]
also revealed that women faced sexual harassment in
healthcare organizations:
Table 8. Distribution of barriers to career progression
A
Not a Minor A Major
Table 6. Factors influencing the decision to change the Variables barrier Barrier Neutral Barrier Barrier
employer. Conflict with # 20 27 13 40 10
family % 18.2 24.5 11.8 36.4 9.1
Factors influencing Not Very responsibilities
job change at all Neutral Somehow Much much
Job characteristics, # 14 18 16 45 17
Higher paying offer # 2 3 18 11 9 e.g. irregular % 12.7 16.4 14.5 40.9 15.5
% 4.7 7.0 41.9 25.6 20.9 work hours
Fewer working # 5 8 6 16 8 Lack of equity in # 9 9 11 44 37
hours including % 11.6 18.6 14.0 37.2 18.6 pay % 8.2 8.2 10.0 40.0 33.6
weekends Lack of equity in # 8 11 13 35 43
Family # 0 6 4 21 5 training % 7.3 10.0 11.8 31.8 39.1
commitments % 0.0 14.0 9.3 48.8 11.6 Sexual harassment # 11 4 11 32 52
Occupational stress # 6 7 2 14 14 % 10.0 3.6 10.0 29.1 47.3
% 14.0 16.3 4.7 32.6 32.6 Lack of # 4 13 8 53 32
Sexual harassment # 14 2 1 17 9 mentoring/ % 3.6 11.8 7.3 48.2 29.1
in workplace % 32.6 4.7 2.3 39.5 20.9 coaching
Lack of promotional # 7 2 7 18 9 Lack of support # 1 11 12 40 46
opportunities % 16.3 4.7 16.3 41.9 20.9 systems at work % 0.9 10.0 10.9 36.4 41.8

Discussion
This study revealed that gender disparities in work-
place exist in the healthcare organizations of Nepal.
Individual, organization, and societal factors are the
three key factors that directly impede women’s career
growth. Results on individual factors are supported
by a study [14] which revealed that women have a
desire to advance their careers, but are limited by key
factors such as gender role, work–family commitments,
work and family conflict, stereotype of women as man-
agers, male-dominated environment, organizational
structure (autocratic), and culture of gender discrimi-
nation and sexual harassment at the workplace. Most
of (89%) the women think that they must advance
their career. Moreover, they were interested to study
further and get a challenging job. Similarly, 12.85% of
married women do not think that they have to advance
their career which was comparatively higher than the
women who were unmarried. The finding appears to
be ontradictory to other studies [15] in which it was
indicated that women are not concerned about meeting
work demands or focusing on advancing their
careers. However, the truth of the matter is that
women have a desire to reach the top in their careers.
A study found that female healthcare managers prac-
tice Contextual Intelligence (CI) with some frequency
having certain personality preferences such as extro-
version and intuition, education level, and minority
status [16].
Findings show more than one-third (38.6%) of mar-
ried women’s career progression slowed down after
marriage and after having children which are similar
to other studies [17] where married men were more
likely to have a wife willing to relocate for their hus-
band’s career advancement than in the case of married
women. Women have to choose between their career
and family. Sixty percent of the women in our study
saw the possibility to combine career and family [18].
Furthermore, a study done in western Australia
found that ‘although the majority of our subjects
believed they had sacrificed some aspects of their per-
sonal career and educational goals after their children
were born, most were still strongly attracted to their
careers and would actively seek self-initiated or
employer-sponsored solutions to help achieve a satisfy-
ing balance of work and family priorities’ [18].
Furthermore, it was found that the load of women’s
career decision is on the family and husband. The
healthcare setting demands alert employees who can
respond and are available 24 hours physically or on
phone. Perceived gender role and double burden was
another social factor that affected the career pro-
gression of working women. On average, working
women allocate about 67% of their time for household
work, whereas men only allocate 32.71%. Women
spend their time with their children and other family
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5
members. These results make it evident that the key
responsibility of managing the household chores and
family still falls disproportionally on women even
though we live in modern times where gender balance
is assumed to have been attained [19]. It was found that
two-thirds (66%) of the respondents responded that
their organizations do not have a provision for flexible
working schedules to accommodate female employees.
For women, being able to work with flexible time sche-
dules makes it easier to balance work and life demands
and, consequently, makes it easier to progress into
higher-level positions [20]. This study found that
about 28% of women felt or felt uncomfortable while
working with a male supervisor compared to a female
supervisor. This result is supported by a study which
was done in India [10] where the researcher explored
that females were hesitant to work with male colleagues
and said that they were not comfortable working with
male colleagues.
Around half (44.5%) of the respondents had experi-
enced sexual harassment in their workplace and
around two-thirds of the respondents (62.7%) stated
that they changed their employment because of sexual
harassment at the workplace. The results were consist-
ent with the study of ILO [21] conducted in Nepal
where 48.4% of female employee/workers themselves
had experienced sexual harassment at the workplace.
A study conducted in Nepal revealed that doctors ask
sexual favours from the nurses; about 40.3% of the
nurses had faced some form of sexual harassment, ver-
bal harassment being the most common form, and it is
seen to be more prevalent in workplaces and occu-
pations that involve people working alone or at night
[22]. Similarly, more than one-fourth (26%) of the
respondents from India also felt discriminated against,
which is a lower finding than our study [17].
Respondents indicated that male members also try
to extract sexual favours from female employees and
if they do not respond positively they spread rumours
about women’s character. In a study done in India, 47%
of the respondents reported chauvinism issues at the
workplace. One-fifth (21%) of the respondents indi-
cated gender inequality and 19% indicated discrimi-
nation at the workplace, which affects career
progression of women [19]. More than two-thirds
(70.9%) of the women responded that gender stereo-
types in the workplace have played a significant role
in advancing their career. The findings are consistent
with the study [23] revealing that the slower career pro-
gress of women and fewer opportunities are because of
stereotypes against women as managers.
Almost 90.9% of the women indicated that mentor-
ship, supportive work relationship and close guidance
(mentor support) are required to develop their skill
and knowledge. A study done in developing countries
[9] supports the findings in which it was found that
career advancement was also hindered by lack of
6 S. RIJAL AND S. P. WASTI
organizational support and absence of mentors and role
models, as men who prefer to mentor other males
occupy most of the senior management positions.
Conclusion and recommendations
This study was conducted to understand the gender dis-
parities against working women in healthcare and was
majorly focused on three key factors: organization, indi-
vidual, and societal factors. Findings from the study
show that evident problems and difficulties of women
are multi-dimensional; therefore, they require further
probing. Women who had experienced some kind of sex-
ual harassment in their workplace were bound to change
their employment. It can be concluded that the gender
difference in healthcare organizations directly impeded
women’s career progression.
Recommendation for practice
It is vital to understand that human capital forms the
most important part of every organization; therefore,
it is encouraged to ensure the following actions are
taken into account:
1) Working women themselves should create a culture,
to change the embedded traditions that dictate
unnecessary rumours, which harass other employees.
2) A gender-friendly mechanism should be estab-
lished to address gender imbalances which guaran-
tees equal treatment for both women and men.
3) Provide adequate leaves for childbirth and mater-
nity-related issues and adopt work, life, and gen-
der-friendly policies.
4) Abolish the traditional view such as ‘male and
female professions’.
Recommendation for research
This study has revealed factors that affect and help
women to advance their career; however, these factors
are contextual. Future research can explore to under-
stand how these factors affect women’s career advance-
ment in health service organizations in a continual
way. Likewise, other comparative studies with women
in terms of different sectors, positions, and responsibil-
ities should be conducted. This study has only investi-
gated the perception of working women; hence another
study can give information on the perspectives of male
staff and management perception on the mentioned
factors.
Implications for practice
Organizational working foundation comprises the
spatial and temporal arrangements of work, prescribing
rules, and behaviours. The relation of the workplace
with their homes and personal lives are set with an
assumption that work is separate from the rest of life
and the organization has its first claim on their employ-
ees. On the one hand, the ideal workers are those who
fulfil these prescribed demands of an organization
which are generally masculine in nature and on other
hand women are more responsible for family, children,
and reproductive activities. This type of phenomena
increases workload of female employees and they may
or may not be able to work as an ideal employee. So,
by providing various facilities such as day care centres,
parental leaves, and flexible work hours can be an effec-
tive tool to attract and retain more competitive female
healthcare employees which may require additional
investment.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Soniya Rijal holds a Masters in Healthcare Management and
has worked in the field of organization management (NGO,
hospitals/healthcare), research over 5 years.
Sharada P. Wasti holds PhD in Public Health from UK and
has worked in the field of public health research over 14
years in Nepal.
ORCID
Soniya Rijal http://orcid.org/0000-0003-0571-2878
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