IMPACT OF WORK-FAMILY BALANCE ON CAREER DEVELOPMENT OF FEMALE HEALTH PROFESSIONALS WITH MEDIATING ROLE OF JOB PERFORMANCE AND MODERATING ROLE OF GENDER FRIENDLY ENVIRONMENT

Nowadays, the challenge faced by healthcare organizations is that female healthcare professionals are not joining the medical workforce in Pakistan, and it creates a serious necessity to understand the effects of Work-Family Balance (WFB) on Women Career Development (WCD). This study addressed the gaps that how WFB was related to job performance (JP) and WCD; and whether gender friendly environment (GFE) would strong or weak this relationship. The focus of this research was to investigate the impact of WFB on the WCD of doctors, nurses and allied health professionals with mediating role of JP and moderating role of GFE. Using the convenience sampling method, a sample of 200 female health professionals was selected. The study design was cross-sectional, and self-administered questionnaires were used. Data were analyzed using correlation and regression analysis. The precise testing of the causal relationship was not possible due to the cross-sectional study design. This study was limited by its geographical area coverage and small sample size. A comparative study could not be done in public and private hospitals. Results show that the relationship between WFB and WCD was found to be insignificant, and this relationship was not mediated by JP. The moderating effect of GFE was found to be significant and suggests that high GFE supports WCD. Human resource managers should take measures and formulate strategies for GFE which will support the career development of female health professionals in healthcare organizations.


INTRODUCTION
Achieving a healthy work-family balance becomes challenging for female health professionals working in the healthcare sector as they have to balance both professional life and family life simultaneously and face great work pressure. They experience the exhaustive nature of work. Extended hours of work, increased stress, burnout and limited work flexibility have a substantial impact on the work-family balance and job performance of healthcare professionals (Dousin et al., 2019). The triple burden of work, family, and reproductive life is carried by a woman (Moser, 1989). Successful balancing between work and family life increases job satisfaction and job performance and, indirectly, personal life satisfaction. Female health professionals try to balance the requirements of professional and family roles. But, most of them experience inter-role conflict resulting in negative consequences on their family life, level of job performance, and career development. Work-family imbalance is taking a major toll on the career development of female health professionals. An imbalance between professional and family life contributes to work-family conflict. "The work-family conflict is an inter-role conflict that has discordancy in work and family life domains" (Greenhaus & Beutell, 1985). The reason is the multiple roles performed by working women within a limited time period, and this role conflict affects the performance of the employee (Abdulraheem, 2014). Aminah (2008) found that work-family conflict negatively affects the job performance of employees, and work-family conflict increases burnout among employees. It reduces job satisfaction and job performance. It is a tough situation for women when they select between their family life and professional development (Claes, 1999;Valentova, 2005). According to Thielst (2005), female health professionals constantly perform work and family responsibilities and become more vulnerable to stress. Emergency situations, night duties, long hours of work, patient care, trauma, administrative roles, and managing family responsibilities lead to increased levels of burnout and emotional exhaustion among doctors (Srivastava et al., 2019). Most married female health professionals complain that their career objectives change after they marry and after they have children (Rijal and Wasti, 2018). However, the conflict between work and family roles is not an issue for only married women who have children; single women also face this problem.
Women's career development depends not only on work-family balance (Dousin et al., 2019) but also on the gender-friendly environment of an organization. World Economic Forum (WEF) published the Global Gender Gap Index 2020 report in which Pakistan is ranked 151 out of 153 countries. It is explained by this fact that in traditional Pakistani society, men perform dominant roles as wage earners while women perform reproductive and domestic roles (Siddiqui et al., 2006). Moreover, women face greater barriers than men during their careers due to social and cultural factors instead of the abilities of women (Tlaiss & Kauser, 2011). Most females do not agree with hiring, evaluation procedures (Mohsin & Syed, 2020), salary level, and fairness of the promotion scheme of the organizations (Bombuwela & Alwis, 2013). This situation does not seem to differ for female health professionals. Broad et al. (2018) concluded that the level of complaints by female health professionals against sexual harassment in healthcare settings is low. It is due to the fact that they perceived it as ineffective. Mohsin & Syed (2020) explained the problem of female healthcare professionals not joining the medical workforce in Pakistan. It is due to assumptions based on gender that healthcare settings make about an ideal doctor. An ideal doctor expects to perform long hour's duties. It analytically rules out married women who have young children. Mohsin & Syed (2020) concluded that social resistance and domestic resistance have an indirect impact on the career development of lady doctors, such as unequal division of domestic responsibilities and social expectations from newly married women. This resistance contributes to an imbalance between professional and family life that results in quitting their careers. One of the studies revealed that the ambitions of professional lady workers are affected by managing many roles simultaneously (Kuranga et al., 2020).
In Pakistan, few studies addressed the issue of work-family balance and the career development of doctors and nurses (Arif, 2011;Hanif & Naqvi, 2014;Malik et al., 2010). However, there is no local study done on work-family balance and career development of female allied health professionals. It reflects an important research gap. Allied health professionals are also important members contributing to the healthcare sector. Their job performance and productivity are also affected due to an imbalance between work and family life which have an indirect effect on their career development. Women's Career development is very important and essential in the healthcare sector because they will achieve their goals by supporting their professional life and also contributing to the economy of Pakistan.
This research will focus on the issue of career development of doctors, nurses, and allied health professionals in developing countries like Pakistan. It aims to extend the understanding of the relationship between work-family balance with women career development in the healthcare sector. As the beliefs, traditions, and morals of the Pakistani community are changed in Western countries, it is essential to prove the relationship between work-family balance and women career development in the Pakistani environment ( Figure 1). This study will investigate and explore mediating effect of job performance between work-family balance and women career development. This study will also investigate and explore the moderating effect of a gender-friendly environment on the career development of female health professionals in Pakistan. It is necessary to create awareness among human resource practitioners about women career development in the healthcare industry. It is noteworthy for future research as it will make available more information on the work-family balance that affects the professional lives of women. It will also help female health professionals to climb up their careers. Thus, On the basis of the above discussion, it is hypothesized that: 1. H1: Work-Family balance will have a significant positive impact on women career development in health sector.
2. H2: Job performance will mediate the relationship between work-family balance and women career development.
3. H3: Gender friendly environment will moderate the relationship between job performance and women career development in such a way that the relationship will be strong when gender friendly environment is highly present.

Sample and Data Collection
Data were collected from female health professionals working in the hospitals of Rawalpindi and Islamabad, Pakistan. The participants were professional lady doctors, nurses, and allied health professionals who were approached online and by on-site visits. The convenience sampling technique, cross-sectional design of the study and self-administered questionnaire were used. A cover letter on the front page of the questionnaire assured the strict confidentiality of the data to the participants, the purpose of the research and their voluntary participation. The questionnaires were distributed to participants online and in hard copy. The questionnaire was created through google forms, and the link was shared through social media to get their responses online. Questionnaires were given in hard copy to the participants in order to get their responses by visiting the healthcare settings. 190 questionnaires were distributed online, and 82 responses were received. 80 responses were usable, and the response rate was 42%. 140 questionnaires were distributed in hardcopy, 135 responses were received. 120 responses were usable, and the response rate was 86%. Approximately 37.5% of the participants were married, and 62.5% of them were unmarried. Approximately 76% of the participants had no children, 20% had 1 to 2 children, and 4% had 3 to 4 children. Approximately 28% of the participants were lady doctors, 14.5% were nurses, and 57.5% were allied health professionals. Approximately 64% of the participants were working full-time, and 34% of them were working part-time. Approximately 73% of the participants worked in the public sector, and 27% worked in the private sector. Approximately 84% of the participants had work experience of 0 to 5 years within the current organization, 8% of them had work experience of 6 to 10 years, and the remaining 8% of them had work experience of 11 to 30 years.

Measures
All the study variables were measured on a five-point Likert scale where 1 represented "strongly disagree" and 5 represented "strongly agree." As English is a compulsory subject in all educational institutions at all levels and all participants had a better understanding of English, questionnaires were designed in English. Every participant in the study had a graduate degree. Therefore, the urdu translated questionnaires were not required.

Work/Family balance
The researchers used a 4-item scale developed by Aryee et al. (2005) to measure work-family balance. A sample item was "Your job reduces the effort you can give to activities at home." Cronbach's alpha reliability of the scale was 0.62. Cronbach's alpha reliability was less than the acceptable value, so item-3 and item-4 were deleted to get an acceptable value of Cronbach's alpha reliability.

Job performance
The researchers used a 7-item scale developed by Williams and Anderson (1991) to measure job performance. A sample item was "Fulfills responsibilities specified in the job description." Cronbach's alpha reliability of the scale was 0.70. Cronbach's alpha reliability was less than the acceptable value, so item-2 was deleted to get an acceptable value of Cronbach's alpha reliability.

Gender friendly environment
The researchers used a 15-item scale developed by Faisal (2010) to measure gender friendly environment. A sample item was "Males and female employees are appreciated and rewarded equally for their efforts." Cronbach's alpha reliability of the scale was 0.84.

Women career development
The researchers used a 12-item scale developed by Jawahar and Hemmasi (2006) to measure women career development. A sample item was "Sufficient opportunities exist in my organization for women to advance into senior management positions." Cronbach's alpha reliability of the scale was 0.73. Cronbach's alpha reliability was less than the acceptable value, so item-4 was deleted to get an acceptable value of Cronbach's alpha reliability.

Control Variables
One-way ANOVA was performed to control variation in job performance, gender-friendly environment, and women career development based on demographic variables. Findings (Table 1)  .02* n=200, *p value<0.05.

Descriptive Statistics and Correlations
Means, standard deviation and correlations are presented in Table 2. Table 2 indicated that work-family balance was found to have no correlation with women career development (-.09, p= ns), which is contrary to hypothesis 1. On the other hand, a Gender-friendly environment exhibited a significant positive correlation with women career development (.55, p<0.05), thus providing preliminary support for hypothesis 3.

Regression Analysis
The findings of simple linear regression analysis are shown in Table 3. Simple linear regression was used to assess the direct relationship as well as the mediation of the study variable. The outcomes indicated that the direct relationship between work-family balance and women's career development was statistically insignificant (= -.02, p=ns). Thus, hypothesis 1 was not accepted. Moreover, variables were controlled for mediated regression analysis. The mediating effect of job performance between work-family balance and women's career development was also insignificant (p=ns). Thus, hypothesis 2 was not accepted. The findings of moderated regression analysis are shown in Table 4. Variables were controlled for moderated regression analysis. Moderating effect of gender friendly environment on the relationship between job performance and women career development was found to be significant (=.48, p<.05). Therefore, hypothesis 3 was accepted. As the value of R-sq was 0.41, that indicates a variation of 41% in women career development due to the interaction effect. For testing the low and high (M ± SD) values of the moderating variable, a graph was plotted. Figure 2 shows that the effect of interaction terms on women career development was positive for high levels of GFE and negative for low levels of GFE. In this study, a simple slope test showed that for low levels of GFE, the slope was negatively significant (= -0.16, p<0.05), while for high levels of GFE, the slope was positively significant (=0.36, p<0.05). These findings supported hypothesis 3 in such a way that the relationship between job performance and women career development will be strong when the gender-friendly environment is highly present Figure 2. Moderated regression analysis.

Discussion
This study attempted to explore the career development of female health professionals. Few studies addressed the issue of work-family balance and the career development of doctors and nurses in Pakistan. However, there is no local study done on the career development of female allied health professionals reflecting an important research gap. Previous studies suggested that female employees often face gender discrimination in the workplace that hinders their progression to top management. This is the first-ever study of work-family balance on the career development of doctors, nurses and allied health professionals in Pakistan with mediating role of job performance and the moderating effect of a gender-friendly environment.
An insignificant relationship was found between work-family balance and women career development, which is contrary to the proposed hypothesis H1. It was also in contrast with the findings of Mohsin and Syed (2020), Rijal and Wasti (2018), Shadab and Arif (2015) and Rahman (2013). There is a presence of a joint family system in Pakistani culture, due to which female health professionals do not face the problems of work-family imbalance. But, achieving a sound work-family balance by female health professionals has no impact on their career development, as shown by this study. This may be due to the fact that in the patriarchal society of our country, women are not provided equal career development opportunities.
Working female health professionals have been increasing rapidly in the public and private health sectors for decades but are trapped at middle levels. They face many barriers such as gender discrimination, gender stereotypes, unequal promotion opportunities for male and female employees, negative perception about women that they cannot manage work at the top level and need supervision, absence of anti-discriminatory regulations and many other invisible barriers. These barriers are supported by past research done on Pakistani culture (Amin et al., 2020). To conclude that the work-family balance has secondary worth and does not have an impact on the career development of the female health professionals of Pakistan in the same way as in Western countries.
The mediating effect of job performance between work-family balance and women's career development was also shown to be insignificant, which is contrary to the proposed hypothesis H2. In other words, job performance is not a mediating variable. It was in contrast to the findings of Dousin et al. (2019). This may be due to the fact that female health professionals who have balanced work and family life are often satisfied in the middle level, and they do not want to take on the responsibilities of top management. As a result, they do not strive to improve their job performance and career development. Personal factors such as lack of motivation and commitment to a career might not allow job performance to mediate the relationship. Previous research has explained the direct relationship between job performance with workfamily balance or women career development. This study explored the mediating relationship of job performance between two variables to fill the existing research gap.
Moderating effect of gender friendly environment on the relationship between job performance and women career development was found to be significant that supported the proposed hypothesis H3. Findings of the interactive effect of job performance and a gender-friendly environment on women career development suggested that a highly gender-friendly environment supports women career development. This may be due to the fact that working in a place where male and female employees are respected equally and given equal career development opportunities allows them to just focus on their work. The supportive environment enhances their job performance, motivation and job satisfaction. Moreover, female health professionals find more opportunities to develop their careers. It was also in line with the findings of Kitana and Karam (2017) and, Rijal and Wasti (2018), but these previous researches have explained the significant direct relationship of work environment with women career development in other cultures. This study explored the moderating effect of gender friendly environment on the relationship between job performance and women career development to fill the existing research gap in Pakistani culture.

CONCLUSIONS AND POLICY IMPLICATIONS
Results of this study show that work-family balance does not affect women career development in Pakistani society, and this relationship would not be mediated by job performance. However, results suggest that high gender-friendly environment supports women career development in Pakistani society. Human resource managers should develop approaches and strategies for gender friendly environment which will support women career development in health organizations. Organizational managers should provide a supportive environment to all their employees where gender equity is given top priority. They should promote gender diversification in the workplace. They should provide sufficient opportunities for female health professionals to advance to senior management positions. Managers should also put emphasis on anti-discriminatory practices in the workplace.
There are few limitations regarding this study that need to be addressed. The design of this study was crosssectional in nature, and data were collected by using a convenience sampling technique. This study was limited by its geographical area coverage and small sample size because it was difficult to access female health professionals due to their exhaustive nature of work. Another limitation was that the comparative study could not be done on female health professions in private and public health organizations due to the limited time frame. These limitations have limited the precise testing of the causal relationships between the study variables.
Future researches are recommended to use a larger sample size and perform a prospective study to bring out a clear understanding of the relationship between work-family balance and career development of female health professionals with mediating role of job performance and moderating role of gender-friendly environment. They should compare the study variables in public and private healthcare organizations. Furthermore, they should also explore the effects of other moderating variables such as occupational stress, emotional intelligence, personal social support, professional social support and cultural factors on the relationship between the work-family balance and career development.