Research Paper: What is the role of a manager in succession planning in a healthcare organization

JONAVolume 39, Number 12, pp 548-555Copyright B2009 Wolters Kluwer Health | Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Healthcare Succession Planning An Integrative Review Brian K. Carriere, MN, RN Melanie Muise, BA, MA Greta Cummings, PhD, RN Chris Newburn-Cook, PhD, RN Succession planning is a business strategy that has recently gained attention in the healthcare litera- ture, primarily because of nursing shortage con- cerns and the demand for retaining knowledgeable personnel to meet organizational needs. Little re- search has been conducted in healthcare settings that clearly defines best practices for succession planning frameworks. To effectively carry out such organizational strategies during these challenging times, an integrative review of succession planning in healthcare was performed to identify consisten- cies in theoretical approaches and strategies for chief nursing officers and healthcare managers to initiate. Selected articles were compared with busi- ness succession planning to determine whether health- care strategies were similar to best practices already established in business contexts. The results of this integrative review will aid leaders and managers to use succession planning as a tool in their recruit- ment,retention,mentoring,andadministrationactiv- ities and also provide insights for future development of healthcare succession planning frameworks.

Succession planning is an essential proactive busi- ness strategy to ensure that internal, qualified can- didates are continuously identified and available to take up leadership positions when vacancies occur. 1,2 It is a process that allows retention of intellectual and knowledge capital by identifying and prepar- ing potential successors to assume new roles, thus encouraging individual advancement. 3-5 Succession planning is a topic that has recently moved to the forefront of healthcare planning because of current and forthcoming nursing shortages. 6The number of entry-level nurses is already not keeping pace with those leaving the profession. 7If qualified per- sonnel are not retained and prepared to assume leadership roles, facilities c ould find themselves lack- ing experienced personnel when most needed. 8This situation adds to the importance of succession plan- ning within healthcare organizational practices. Be- fore losing this wealth of knowledge and expertise, healthcare leaders and managers should be practis- ing succession planning now to meet future orga- nizational needs. Within the business community, succession plan- ning historically began with family-owned busi- nesses 3but is now integrated into frameworks with common strategies and practices. 4,5,9-12 In contrast, chief nursing officers (CNOs) and healthcare man- agers have been slower to recognize the need for suc- cession planning in general, and there is little research regarding recommended best practices among suc- cession planning frameworks within the healthcare 548 JONA Vol. 39, No. 12 December 2009 Authors’ Affiliations: Captain (Mr Carriere), Canadian Forces, Edmonton, Alberta; PhD Candidate, Faculty of Physical Educationand Recreation, and Research Assistant (Ms Muise); AssociateProfessor and Principal Investigator, CLEAR (Connecting Leader-ship Education and Research) Outcomes Research Program(Dr Cummings); Associate Pro fessor and Associate Dean (Dr Newburn-Cook), Faculty of Nursing, University of Alberta,Edmonton, Alberta, Canada. Corresponding author: Dr Cummings, Faculty of Nursing, CSB 5-125, University of Alberta, Edmonton, AB, Canada T6G2G3 ( gretac@ualberta.ca ). Funding: Dr Greta Cummings is supported by a New Investigator Award, Canadian Institutes of Health Research,and a Population Health Investigator award, Alberta HeritageFoundation for Medical Research. 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. literature. With recent increases in marketplace and financial pressures in healthcare management, concerns for more resources and attention are be- ing devoted to its business operations. 13 This has led to a shift in focus toward a more business- oriented approach to healthcare decision making, placing the need for succession planning at the forefront of healthcare organizational planning by managers and leaders. Nevertheless, nursing short- ages remain a current and complex challenge faced by those who manage healthcare environments. To assist healthcare leaders in dealing with workforce challenges, an integrative review was performed to determine whether findings among available re- search in healthcare literature reveal best practices.

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The purpose of this article is to present findings from the integrative review of healthcare succession plan- ning to identify similarities and differences among the theoretical frameworks in business and com- bine these into a common strategy for healthcare managers. The authors believe that a precise succession planning framework that includes strategies from best business practices can guide and promote suc- cession planning within healthcare organizations.

Three questions guided the integrative review: (1) How are healthcare succession planning frame- works similar or different? (2) Are these frameworks similar to business literature examples? (3) What are the strategies implied by these frameworks for healthcare organization? Articles were reviewed and analyzed based on type of literature (theoretical, research, other), framework congruency and differ- ences, and similarities with business models.

The Review Method Before conducting the integrative review, ‘‘succession planning’’ was differentiated from similar and com- monly used terminology. Online database searches of career development ,career planning ,retention , career ladder , and mentoring confirmed that each had different definitions, meanings, and uses when compared with succession planning in both busi- ness and healthcare literature. Succession planning is a structured process involving the identification and preparation of a potential successor to assume a new role within an organization. 3In the liter- ature, there are also similar strategies to succession planning. Succession management is a formalized process of role planning and leadership develop- ment to ensure that the leadership pipeline is filled and the right talent is available when required. 14 Career planning is the process of outlining future career developments, thereafter setting and pursu- ing career goals, 15 focused at the individual level. Career development is focused at an organizational level 16 to meet employee needs through their career stages to reduce turnover, increase professional knowl- edge, and improve service quality. 17 Although ca- reer planning and career development were defined differently in the literature, several authors used them interchangeably. 18,19 Career development has been mistaken for succession planning, despite being identified as only part of the process in both business and healthcare succession planning liter- ature. 3,9,11,12 Career ladders are a way of providing status and economic incentives, often professional development, to workers who stay within an organi- zation. 20 Mentorship is a distinct type of relation- ship where mentors provide professional or personal guidance to a prote ´ge´.21 Identifying ambiguity in these terms is important to distinguish contrasts in healthcare succession planning frameworks. The integrative review, based on restructured methodology recommended by Whittemore and Knafl, 22 began with a preliminary literature search using the following keywords: succession planning and succession management individually, each com- bined with nurse ,nursing ,or healthcare . The results identified that enough pertinent literature was pre- sent in various databases using the term succession planning , a term historically important to business planning. 3Succession management , a synonymic equivalent, was used to capture all seminal articles. Twelve online databases were searched using the keywords succession planning and succession man- agement in separate searches for the time period of 1998-2008. These databases are recorded as an initial search in Table 1. Those meeting the follow- ing inclusion criteria were retained for screening: all articles relating to healthcare succession planning, for either the chief executive officer (CEO) or the CNO position, with a framework, template, or ap- proach to implement best practices as the article’s focus. Articles that specifically focused on research of succession planning were not chosen because of their limited number, and commentaries, editorials, and articles that did not present a complete succes- sion planning framework were excluded. For arti- cles with business succession planning frameworks, Business Source Complete, ABI Inform Global, Academic Search Complete, PsycInfo, and Social Sciences Full Text were searched. To ensure that the most relevant articles were chosen, the primary author reviewed titles and ab- stracts using the inclusion criteria, and the selected articles were then agreed upon through consensus with a second reader to reduce bias. The theoretical JONA Vol. 39, No. 12 December 2009 549 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. frameworks and critical elements of the retained articles were described, and specific strategies for effective succession planning were extracted. Arti- cles were analyzed using the questions guiding the integrative review to determine congruence, differ- ence, and comparison with business succession plan- ning frameworks.

Results A total of 1,419 titles and abstracts were reviewed, with 122 meeting the inclusion criteria for health- care succession planning. These were retrieved and rescreened, and duplicates were removed, leaving 8 retained from all databases (see Table 2 for the characteristics of the included studies). Eighteen arti- cles specific to business succession planning were selected separately, with 5 used for comparison with healthcare succession planning frameworks. 4,5,9-12 The healthcare succession planning models were comparable with the selected business succession planning models, which all recommended planning, recognizing the importance of clarifying expectations and future needs, and identifying future leaders as imperative steps in succession planning. Further- more, all selected business articles stressed having a candidacy development plan and an evaluation pro- cess to ensure that the succession planning frame- work performed as expected.

Theoretical Frameworks and Strategies Of the 8 healthcare articles that discussed succes- sion planning frameworks, 4 articles 7,23-25 predom- inantly described the critical elements of effective succession planning strategies. Describing addi- tional features of a succession planning framework, Collins and Collins 8reviewed the succession plan- ning process as a systematic preparation of the next generation, whereas Rollins 26 examined the success of implementing a succession planning conceptual framework through a case study. Two remaining articles 1,27 illustrated how to follow a succession planning process. From all articles, 8 common strat- egies were identified, using a qualitative content analysis, and are discussed in relationship to their application to succession planning in healthcare organizations (Table 3). These succession planning strategies are strategic planning, identifying desired skills and needs, identifying key positions, detect- ing possible succession candidates, mentoring and coaching, further developmental processes, resource allocation, and evaluation. Table 1. Search Strategy Database 1998-2008 Search Terms Returned Selected Included CINAHL Succession Planning 106 7 1 Succession Management 6 1 0 Medline Succession Planning 620 26 6 Succession Management 321 1 0 Health Source Nursing Succession Planning 48 7 1Academic Edition Succession Management 1 1 0HealthSTAR Succession Planning 593 12 6 Succession Management 431 0 0 EMBASE Succession Planning 2,292 8 4 Succession Management 523 0 0 ERIC Succession Planning 510 0 0 Succession Management 71 0 0 Global Health Succession Planning 546 1 0 Succession Management 79 0 0 Business Source Complete Succession Planning 2,294 8 1 Succession Management 122 0 0 ABI Inform Global Succession Planning 4,285 2 0 Succession Management 99 0 0 Academic Search Complete Succession Planning 601 7 1 Succession Management 24 0 0 PsycINFO Succession Planning 1,441 1 0 Succession Management 216 0 0 Social Sciences Full Text Succession Planning 546 0 0 Succession Management 967 0 0 Total manuscripts after removal of duplicates 9Final included manuscripts 8 Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; EMBASE, Excerpta Medica Database; ERIC, EducationResources information Center.The ‘‘Selected’’ column numbers are associated with advanced searches, where articles were limited to those with full text and abstracts. 550 JONA Vol. 39, No. 12 December 2009 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Strategic Planning An integral part of succession planning is strategic planning, which was identified by several authors as a key and primary component within healthcare organizations. 1,8,24,27 For instance, Bonczek and Woodward 1suggested defining the strategic imper- atives as the first action for succession planning, along with identifying skills required to meet the organization’s objectives, and before identifying tal- ent from within. Collins and Collins 8also proposed accurately evaluating short- and long-term organiza- tional goals to ensure that they are consistent with existing candidates. While Husting and Alderman 24 recommended that strategic planning be part of suc- cession planning, Noyes et al 27 indicated the im- portance of obtaining clarity on the organization’s purpose and vision through strategic planning be- fore understanding the necessary skills and people talent to develop. Although the strategic planning components differed slightly across articles, the main focus was ensuring that organizational goals were realized by current leaders as part of succession planning for future leadership. Strategic planning also distinguishes succession planning from career planning. 1,8 Desired Skills and Needs The goal of succession planning is to identify cur- rent talent in the organization for future leadership, and to do so, desired skills and needs for succession candidates are identified as a key process by several writers. 1,8,24,25 Husting and Alderman 24 contend that administrators must asses current and future work details for future competency requirements, and Collins and Collins 8suggest that examining gaps between existing skills and core competencies of the position to be filled should be completed at organizational levels. Redman 25 identified both of these strategies, supporting the notion that neither concept should be excluded, given their apparent importance in ensuring that succession candidates are successful. The need for desired skills and suc- cession candidates is clear. Thus, the next strategy Table 2. Characteristics of Included Manuscripts Author (Year) Journal Country Design Purpose/Objective Setting Blouin andMcDonagh(2006) NursingManagement UnitedStates Theory Discusses how healthcare lags behind other corporateorganizations in creating asuccession plan and providespractical approaches forsuccession planning, identifyingkey elements Hospitals andhealth systems Bolton andRoy (2006) Journal ofNursingAdministration UnitedStates Theoreticalinstruction Describes the critical elements ofa succession plan and suggestsways to implement them Healthcareorganizations Bonczek andWoodward(2004) Journal ofNursingAdministration UnitedStates Theoreticalinstruction Describes steps for successionplanning, stating its importance Healthcareorganizations Collins andCollins(2007) The Health CareManager UnitedStates Theoreticalanalysis Provides a framework for improvingthe systematic preparation of thenext generation of managersby analyzing the successionplanning process Healthcareorganizations Husting andAlderman(2001) NursingManagement UnitedStates Theoreticalinstruction Describes required steps forsuccession planning and howto phase it in Healthcare facilities Noyes et al(2002) Seminars forNurseManagers UnitedStates Theory Identifies how critical succession planning can be to anorganization and discussessuccession planning steps Hospitals Redman(2006) Journal ofNursingAdministration UnitedStates Theoreticalinstruction Identifies the essential needs thatindividuals face when developinga cadre of available leadersthrough succession planning Healthcare industry Rollins (2003) HealthcareExecutive UnitedStates Qualitativeanalysis andtheoreticalinstruction Identifies the benefits of successionplanning and describes thenecessary steps using a specificorganization as an example Multi-institutionalhealthcaresystem JONA Vol. 39, No. 12 December 2009 551 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 3.

Common Succession Planning Framework Strategies in the Healthcare Literature Author (Year) Strategic Planning Identificationof Desired Needs and Skills Identification ofKey Positions Detection ofCandidates Mentoring andCoaching Other Developmental Processes ResourceAllocation Evaluation Blouin andMcDonagh(2006) Demand forecastingand gap analysisfor key positions Early and frequentdetection Formal and informal Exposure to developmentcompetencyopportunities For leadershipdevelopment When desirablesuccessors leavethe organization Bolton andRoy (2006) Identify key andnew positions Identify potentialcandidates Mentoring Commit time and financialresources Bonczek andWoodward(2004) Define strategicimperative oforganization Current nurseleaders identifyleadership skillsand talents toreplace themselves Determine whopossessesnecessaryskills; possibleacceleration pool Mentor and coachaspiring leaders Develop aneducation andgrowth plan Collins andCollins(2007) Evaluate short- andlong-termgoals; matchorganizationalgoals withcandidacy pool Examine gapsbetween existingskills and corecompetencies ofproposed position Identify key areasand their corecompetencies Analyze skills/resources ofavailablecandidates Identifydevelopmentprocess ofproposedsuccessor Time, energy,and employees Extensive evaluationprogram offormalization,control andinformationsystems, politicaland technicalcriteria, staff roleand business impact Husting andAlderman(2001) Conduct strategicplanning Identify current jobrequirement andfuture positions Assess current jobrequirements,future positions,and futurecompetencyrequirements Identifyhigh-potentialcandidates Mentoring andcoaching Assess learning anddevelopmentneeds ofparticipants Part of theevaluation process Extensive evaluationof program:organization,objectives, andparticipants Noyes et al(2002) Determine purposeand vision oforganization;conduct strategicplanning Identify and assesshigh-potentialcandidates Mentorshipprogram Formalizeddevelopmentalplan involvingmultiple skill sets Redman(2006) Identify desirable skillsand qualities forsuccessors; analyzegaps comparingtalent pool Assess specificpositions(competencies,desired qualities,future needs) Assess individualsin terms ofleadershipcapabilities/potential Mentoring andcoaching Use a transparent,flexible processto develophigh-potentialemployees Assessment, periodicevaluation, andimprovement asneeded Rollins (2003) General characteristicsand requirementsof future leaders Identify the talents,skills, andcharacteristicsand assess theleadership skillsof those involved Plan describes skillsand experiencesneeded, along withtimeline to achievethese; assignmanagers newresponsibilitiesoutside areaof expertise 552 JONA Vol. 39, No. 12 December 2009 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. deals with identifying key positions that require suc- cession planning. 7,8,23-25 Blouin and McDonagh 23 used this strategy to conduct demand forecasting and gap analysis by CEOs and other senior leaders; however, identification and needs of future leaders were not explicitly stated, only that identification of where, when, and what type of leader was es- sential. Distinctively, Bonczek and Woodward 1 proposed that current nurse leaders should look for future leaders by identifying talent and skills in their staff to meet future organization needs. Gen- erally, the authors 7,23-25 concurred in proposing the identification of key organizational positions as a crucial component of succession planning.

Finding and Mentoring Succession Candidates Two strategies cited in 6 of the 8 frameworks were detection of possible succession candidates and mentoring/coaching of succession candidates. Detec- tion of successor candidates should be early and frequent, 23 using an acceleration pool to identify po- tential successors. 1An acceleration pool is a group from which a candidate could be selected to provide a resource when a talent gap occurs. Although Collins and Collins 8did not identify mentoring/ coaching as a strategy, the overwhelming emphasis on mentoring/coaching within healthcare makes this a necessary ingredient for a successful succes- sion planning framework.

Other Development Processes Although not identified as a common strategy, many offered other development processes. Collins and Collins 8suggested that a development process needs to be identified, and Blouin and McDonagh 23 rec- ommended exposure to development competency opportunities to broaden one’s career. Bonczek and Woodward 1indicated that, generally, an educa- tional growth plan should provide opportunities for successful candidates. Husting and Alderman 24 similarly recognized that the learning and develop- ment needs of succession candidates should be assessed and implemented to closely match organi- zational growth requirements. Redman 25 was more precise in identifying alternative developmental pro- cesses to coaching/mentoring, suggesting that they be transparent, geared toward linchpin positions at all levels, flexible, and regularly measured, thus pro- posing that design and implementation of leader- ship development programs have both generic and individualized components. Noyes et al 27 approved a packaged approach to development, suggesting personal effectiveness management, financial man- agement, conflict management, human resources skills, case management, and preceptor develop- ment skills. In contrast, Rollins 26 recommended that devel- opment processes describe and include skills and experiences needed for candidates to obtain rounded- out executive competencies, carried out in a time frame dependent on succession planning require- ments. Rollins 26 suggested assigning managers to areas outside their expertise to fill gaps between desired and actual skills. The remaining recom- mendations for developmental processes were all valuable, useful for any succession planning frame- work depending on organizational and candidate needs and goals.

Resource Allocation Although the importance of resource allocation is implied, only 3 articles 7,8,23 discussed it as a required strategy. While Blouin and McDonagh 23 focused resource allocation toward leadership development, Bolton and Roy 7and Collins and Collins 8both identified allocating time and energy as imperative resources for successful succession planning. Bolton and Roy 7recognized finances as key to successful succession planning. Husting and Alderman 24 ad- dressed resources only through the evaluation pro- cess by ensuring that appropriate resources were available. The other succession planning frame- works did not mention resource allocation, perhaps in oversight. This oversight, or implying of resource requirements, was also present in the business lit- erature, 4,5,9,10,12 with only Ibarra 11 implicitly stating its need.

Evaluation Last, evaluation was a common strategy for succes- sion planning. Redman 25 identified that evaluation of succession planning frameworks was important for improvements to both the plan and the process.

Blouin and McDonagh 23 did not identify evalua- tion as an imperative strategy but recommended that it be performed when desirable successors leave the organization. Husting and Alderman 24 identified evaluation as an important aspect, recommending that assessment processes be in-depth and programs evaluated in 3 separate ways: first, through the organization’s key positions, within 3 months of implementation and after 1 year of successor per- formance, to ensure that the program contributes to organizational goals; second, by determining whether program objectives are met, course evalu- ations are positive, and all stakeholders remain sat- isfied; third, by recognizing individual participants JONA Vol. 39, No. 12 December 2009 553 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. who exhibit behaviors and values outside of the training environment. Proper regular evaluation to ensure a framework’s performance is optimal and meets the organization’s expectations is both nec- essary and feasible. Collins and Collins 8 suggested multiple ap- proaches to evaluate the succession planning process.

These included evaluating policies and procedures used in the succession planning process (formal- ization), ensuring delivery of equal and appropriate use of power and attention (control systems), eval- uating how selection decisions are based (technical criteria), criteria for selection (political criteria), degree of involvement of all applicable personnel (staff role), and how data are statistically or finan- cially measured (business impact). These processes included return on investment, patient satisfaction, and evaluation of resource allocation. Only this framework identified transition issues of predeces- sor to successor, possible feelings of rejection by those not selected, and means to address them.

Differentiating Frameworks Beyond these 8 strategies, the separation of succes- sion planning into 2 distinct processes differentiated the succession planning frameworks. Collins and Collins 8treated the first 5 strategies of succession planning as one process and the evaluation phase of succession planning as another. Alternatively, Noyes et al 27 separated the development of organi- zational strategies from the creation and implemen- tation of personalized plans. Redman 25 replicated this approach using Noyes et al 27 as a template for his recommended framework. Nevertheless, from the common strategies in all frameworks, a best-practices model would include the need for strategic planning before considering a succession planning process or developing a suc- cession planning framework. The desired skills of candidates need to be identified, ensuring that or- ganizational needs are met. Key positions that re- quire succession planning need to be recognized and possible succession candidates identified. Then, a development plan should be implemented to ensure that potential succession candidates acquire all skills required for the position. This includes pro- cesses that focus on both individual and generalized components; however, from the literature, it is imperative that mentoring/coaching be included.

The appropriate allocation of resources is also neces- sary to ensure that the succession plan has appro- priate funding, time, and energy. Once the succession plan is implemented, evaluation is essential to ensure that the framework is on track and includes all aspects of the process. Summary In examining the current literature, we found exam- ples of approaches to succession planning in health- care contexts; however, to date, no best-practices framework for implementation has emerged. To mitigate knowledge loss, current CNOs and health- care leaders need to integrate succession planning with organizational needs by developing and pro- moting its best resources into future leadership posi- tions. Although there is a body of literature on succession planning in healthcare organizations, the lack of a best-practices succession planning frame- work may be due to inconsistently defined concepts, leading to potential confusion and lack of concept clarity. This is not conducive to best practices and may lead to inconsistent implementation of succes- sion planning. Findings from the integrative literature review suggest the need for best practices in succession planning, and 8 such strategies were identified for healthcare managers. Implementation of these strat- egies will assist CNOs to identify internal successor candidates. This will provide employees with a leadership goal to strive for and may also reduce poaching of established leaders from other orga- nizations. Furthermore, fostering mentoring/coaching relationships initiates camaraderie as staff members and leaders develop relationships, recognizing sim- ilarities in skills and aptitudes, as opposed to differences. The establishment of team building, although not specifically identified within the current literature as an outcome of the mentoring/coaching strategy, is a logical progression considering that personal interactions will occur. Encouraging both predeces- sors and successors to participate in the evaluation process will ensure that the succession plan ad- dresses stakeholder needs. More research needs to be directed toward establishing a best-practices succession planning framework for healthcare that is informed by business succession planning. This will not only provide consistency in succession plan- ning in healthcare but also establish frameworks conducive to optimal employee satisfaction, organi- zational efficiency, and better patient care. These positive responses could resonate outside the health- care facility and attract long-term employees who are looking for an enduring employer-employee relationship that will hone their skills. Implement- ing a successful succession planning framework will ensure that healthcare organizations survive leader- ship changes as effectively as possible, supporting organizational goals and the opportunity for em- ployees to develop to their potential. 554 JONA Vol. 39, No. 12 December 2009 9 Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. References 1. Bonczek ME, Woodward EK. Who’ll replace you when you’re gone? Nurs Manag . 2006;37(8):31-34. 2. Schmalzried H, Fallon F Jr. Succession planning for local health department top executives: reducing risk to commun-ities. J Community Health . 2007;32(3):169-180. 3. Garman AN, Glawe J. Succession planning. Consult Psychol J Pract Res . 2004;56(2):119-128. 4. Rothwell WJ. Succession planning for future success. Strateg HR Rev . 2002;1(3):30-33. 5. Rothwell WJ. Putting success into your succession planning. J Bus Strategy . 2002;23(3):32-37. 6. Goudreau KA, Hardy J. 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