Skip Navigation LinksHome > December 2009 - Volume 39 - Issue 12 > Healthcare Succession Planning: An Integrative Review
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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e3181c18010

Healthcare Succession Planning: An Integrative Review

Carriere, Brian K. MN, RN; Muise, Melanie BA, MA; Cummings, Greta PhD, RN; Newburn-Cook, Chris PhD, RN

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Author Information

Authors' Affiliations: Captain (Mr Carriere), Canadian Forces, Edmonton, Alberta; PhD Candidate, Faculty of Physical Education and Recreation, and Research Assistant (Ms Muise); Associate Professor and Principal Investigator, CLEAR (Connecting Leadership Education and Research) Outcomes Research Program (Dr Cummings); Associate Professor 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 T6G 2G3 (

Funding: Dr Greta Cummings is supported by a New Investigator Award, Canadian Institutes of Health Research, and a Population Health Investigator award, Alberta Heritage Foundation for Medical Research.

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Succession planning is a business strategy that has recently gained attention in the healthcare literature, primarily because of nursing shortage concerns and the demand for retaining knowledgeable personnel to meet organizational needs. Little research 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 consistencies in theoretical approaches and strategies for chief nursing officers and healthcare managers to initiate. Selected articles were compared with business succession planning to determine whether healthcare 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 recruitment, retention, mentoring, and administration activities and also provide insights for future development of healthcare succession planning frameworks.

Succession planning is an essential proactive business strategy to ensure that internal, qualified candidates 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 preparing 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.6 The number of entry-level nurses is already not keeping pace with those leaving the profession.7 If qualified personnel are not retained and prepared to assume leadership roles, facilities could find themselves lacking experienced personnel when most needed.8 This situation adds to the importance of succession planning within healthcare organizational practices. Before losing this wealth of knowledge and expertise, healthcare leaders and managers should be practising succession planning now to meet future organizational needs.

Within the business community, succession planning historically began with family-owned businesses3 but is now integrated into frameworks with common strategies and practices.4,5,9-12 In contrast, chief nursing officers (CNOs) and healthcare managers have been slower to recognize the need for succession planning in general, and there is little research regarding recommended best practices among succession planning frameworks within the healthcare literature. With recent increases in marketplace and financial pressures in healthcare management, concerns for more resources and attention are being 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 shortages 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 research in healthcare literature reveal best practices. The purpose of this article is to present findings from the integrative review of healthcare succession planning to identify similarities and differences among the theoretical frameworks in business and combine 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 succession planning within healthcare organizations. Three questions guided the integrative review: (1) How are healthcare succession planning frameworks 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 differences, and similarities with business models.

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The Review Method

Before conducting the integrative review, "succession planning" was differentiated from similar and commonly 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 business 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.3 In the literature, there are also similar strategies to succession planning. Succession management is a formalized process of role planning and leadership development 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 pursuing career goals,15 focused at the individual level. Career development is focused at an organizational level16 to meet employee needs through their career stages to reduce turnover, increase professional knowledge, and improve service quality.17 Although career 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 literature.3,9,11,12 Career ladders are a way of providing status and economic incentives, often professional development, to workers who stay within an organization.20 Mentorship is a distinct type of relationship where mentors provide professional or personal guidance to a protégé.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 combined with nurse, nursing, or healthcare. The results identified that enough pertinent literature was present in various databases using the term succession planning, a term historically important to business planning.3 Succession management, a synonymic equivalent, was used to capture all seminal articles.

Twelve online databases were searched using the keywords succession planning and succession management in separate searches for the time period of 1998-2008. These databases are recorded as an initial search in Table 1. Those meeting the following 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 approach 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 succession planning framework were excluded. For articles with business succession planning frameworks, Business Source Complete, ABI Inform Global, Academic Search Complete, PsycInfo, and Social Sciences Full Text were searched.

Table 1
Table 1
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To ensure that the most relevant articles were chosen, the primary author reviewed titles and abstracts using the inclusion criteria, and the selected articles were then agreed upon through consensus with a second reader to reduce bias. The theoretical frameworks and critical elements of the retained articles were described, and specific strategies for effective succession planning were extracted. Articles were analyzed using the questions guiding the integrative review to determine congruence, difference, and comparison with business succession planning frameworks.

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A total of 1,419 titles and abstracts were reviewed, with 122 meeting the inclusion criteria for healthcare 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 articles 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. Furthermore, all selected business articles stressed having a candidacy development plan and an evaluation process to ensure that the succession planning framework performed as expected.

Table 2
Table 2
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Theoretical Frameworks and Strategies

Of the 8 healthcare articles that discussed succession planning frameworks, 4 articles7,23-25 predominantly described the critical elements of effective succession planning strategies. Describing additional features of a succession planning framework, Collins and Collins8 reviewed the succession planning process as a systematic preparation of the next generation, whereas Rollins26 examined the success of implementing a succession planning conceptual framework through a case study. Two remaining articles1,27 illustrated how to follow a succession planning process. From all articles, 8 common strategies 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, detecting possible succession candidates, mentoring and coaching, further developmental processes, resource allocation, and evaluation.

Table 3
Table 3
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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 Woodward1 suggested defining the strategic imperatives as the first action for succession planning, along with identifying skills required to meet the organization's objectives, and before identifying talent from within. Collins and Collins8 also proposed accurately evaluating short- and long-term organizational goals to ensure that they are consistent with existing candidates. While Husting and Alderman24 recommended that strategic planning be part of succession planning, Noyes et al27 indicated the importance of obtaining clarity on the organization's purpose and vision through strategic planning before 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

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Desired Skills and Needs

The goal of succession planning is to identify current 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 Alderman24 contend that administrators must asses current and future work details for future competency requirements, and Collins and Collins8 suggest that examining gaps between existing skills and core competencies of the position to be filled should be completed at organizational levels. Redman25 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 succession candidates is clear. Thus, the next strategy deals with identifying key positions that require succession planning.7,8,23-25 Blouin and McDonagh23 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 essential. Distinctively, Bonczek and Woodward1 proposed that current nurse leaders should look for future leaders by identifying talent and skills in their staff to meet future organization needs. Generally, the authors7,23-25 concurred in proposing the identification of key organizational positions as a crucial component of succession planning.

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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. Detection of successor candidates should be early and frequent,23 using an acceleration pool to identify potential successors.1 An acceleration pool is a group from which a candidate could be selected to provide a resource when a talent gap occurs. Although Collins and Collins8 did not identify mentoring/coaching as a strategy, the overwhelming emphasis on mentoring/coaching within healthcare makes this a necessary ingredient for a successful succession planning framework.

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Other Development Processes

Although not identified as a common strategy, many offered other development processes. Collins and Collins8 suggested that a development process needs to be identified, and Blouin and McDonagh23 recommended exposure to development competency opportunities to broaden one's career. Bonczek and Woodward1 indicated that, generally, an educational growth plan should provide opportunities for successful candidates. Husting and Alderman24 similarly recognized that the learning and development needs of succession candidates should be assessed and implemented to closely match organizational growth requirements. Redman25 was more precise in identifying alternative developmental processes to coaching/mentoring, suggesting that they be transparent, geared toward linchpin positions at all levels, flexible, and regularly measured, thus proposing that design and implementation of leadership development programs have both generic and individualized components. Noyes et al27 approved a packaged approach to development, suggesting personal effectiveness management, financial management, conflict management, human resources skills, case management, and preceptor development skills.

In contrast, Rollins26 recommended that development 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 requirements. Rollins26 suggested assigning managers to areas outside their expertise to fill gaps between desired and actual skills. The remaining recommendations for developmental processes were all valuable, useful for any succession planning framework depending on organizational and candidate needs and goals.

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Resource Allocation

Although the importance of resource allocation is implied, only 3 articles7,8,23 discussed it as a required strategy. While Blouin and McDonagh23 focused resource allocation toward leadership development, Bolton and Roy7 and Collins and Collins8 both identified allocating time and energy as imperative resources for successful succession planning. Bolton and Roy7 recognized finances as key to successful succession planning. Husting and Alderman24 addressed resources only through the evaluation process by ensuring that appropriate resources were available. The other succession planning frameworks did not mention resource allocation, perhaps in oversight. This oversight, or implying of resource requirements, was also present in the business literature,4,5,9,10,12 with only Ibarra11 implicitly stating its need.

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Last, evaluation was a common strategy for succession planning. Redman25 identified that evaluation of succession planning frameworks was important for improvements to both the plan and the process. Blouin and McDonagh23 did not identify evaluation as an imperative strategy but recommended that it be performed when desirable successors leave the organization. Husting and Alderman24 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 performance, to ensure that the program contributes to organizational goals; second, by determining whether program objectives are met, course evaluations are positive, and all stakeholders remain satisfied; third, by recognizing individual participants 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 necessary and feasible.

Collins and Collins8 suggested multiple approaches to evaluate the succession planning process. These included evaluating policies and procedures used in the succession planning process (formalization), ensuring delivery of equal and appropriate use of power and attention (control systems), evaluating 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 financially measured (business impact). These processes included return on investment, patient satisfaction, and evaluation of resource allocation. Only this framework identified transition issues of predecessor to successor, possible feelings of rejection by those not selected, and means to address them.

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Differentiating Frameworks

Beyond these 8 strategies, the separation of succession planning into 2 distinct processes differentiated the succession planning frameworks. Collins and Collins8 treated the first 5 strategies of succession planning as one process and the evaluation phase of succession planning as another. Alternatively, Noyes et al27 separated the development of organizational strategies from the creation and implementation of personalized plans. Redman25 replicated this approach using Noyes et al27 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 succession planning framework. The desired skills of candidates need to be identified, ensuring that organizational needs are met. Key positions that require 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 processes 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 necessary to ensure that the succession plan has appropriate 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.

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In examining the current literature, we found examples of approaches to succession planning in healthcare contexts; however, to date, no best-practices framework for implementation has emerged. To mitigate knowledge loss, current CNOs and healthcare leaders need to integrate succession planning with organizational needs by developing and promoting its best resources into future leadership positions. Although there is a body of literature on succession planning in healthcare organizations, the lack of a best-practices succession planning framework 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 succession 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 strategies 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 organizations. Furthermore, fostering mentoring/coaching relationships initiates camaraderie as staff members and leaders develop relationships, recognizing similarities 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 predecessors and successors to participate in the evaluation process will ensure that the succession plan addresses 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 planning in healthcare but also establish frameworks conducive to optimal employee satisfaction, organizational efficiency, and better patient care. These positive responses could resonate outside the healthcare facility and attract long-term employees who are looking for an enduring employer-employee relationship that will hone their skills. Implementing a successful succession planning framework will ensure that healthcare organizations survive leadership changes as effectively as possible, supporting organizational goals and the opportunity for employees to develop to their potential.

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