JONA
Volume 39, Number 12, pp 548-555
Copyright B 2009 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
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, and administration activ-
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 Leader-
ship 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 (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 Heritage
Foundation for Medical Research.
548
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Greta Cummings, PhD, RN
Chris Newburn-Cook, PhD, RN
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.6 The number
of entry-level nurses is already not keeping pace
with those leaving the profession.7 If qualified per-
sonnel are not retained and prepared to assume
leadership roles, facilities could find themselves lack-
ing experienced personnel when most needed.8 This
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-
nesses3 but 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
JONA  Vol. 39, No. 12  December 2009
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.
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.3 In 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
JONA  Vol. 39, No. 12  December 2009
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
career developments, thereafter setting and pursu-
ing 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 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 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 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.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 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
549
 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 1
Academic Edition Succession Management 1 1 0
HealthSTAR 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 9
Final included manuscripts 8

Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; EMBASE, Excerpta Medica Database; ERIC, Education
Resources information Center.
The ‘‘Selected’’ column numbers are associated with advanced searches, where articles were limited to those with full text and abstracts.

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 articles7,23-25 predom-
inantly described the critical elements of effective
succession planning strategies. Describing addi-
tional features of a succession planning framework,
Collins and Collins8 reviewed the succession plan-
ning 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 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.

550 JONA  Vol. 39, No. 12  December 2009

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 Table 2. Characteristics of Included Manuscripts
Author (Year) Journal Country Design Purpose/Objective Setting

Blouin and Nursing United Theory Discusses how healthcare lags Hospitals and
McDonagh Management States behind other corporate health systems
(2006) organizations in creating a
succession plan and provides
practical approaches for
succession planning, identifying
key elements
Bolton and Journal of United Theoretical Describes the critical elements of Healthcare
Roy (2006) Nursing States instruction a succession plan and suggests organizations
Administration ways to implement them
Bonczek and Journal of United Theoretical Describes steps for succession Healthcare
Woodward Nursing States instruction planning, stating its importance organizations
(2004) Administration
Collins and The Health Care United Theoretical Provides a framework for improving Healthcare
Collins Manager States analysis the systematic preparation of the organizations
(2007) next generation of managers
by analyzing the succession
planning process
Husting and Nursing United Theoretical Describes required steps for Healthcare facilities
Alderman Management States instruction succession planning and how
(2001) to phase it in
Noyes et al Seminars for United Theory Identifies how critical succession Hospitals
(2002) Nurse States planning can be to an
Managers organization and discusses
succession planning steps
Redman Journal of United Theoretical Identifies the essential needs that Healthcare industry
(2006) Nursing States instruction individuals face when developing
Administration a cadre of available leaders
through succession planning
Rollins (2003) Healthcare United Qualitative Identifies the benefits of succession Multi-institutional
Executive States analysis and planning and describes the healthcare
theoretical necessary steps using a specific system
instruction organization as an example

Strategic Planning planning for future leadership. 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 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 Collins8 also proposed
accurately evaluating short- and long-term organiza-
tional goals to ensure that they are consistent with
existing candidates. While Husting and Alderman24
recommended that strategic planning be part of suc-
cession planning, Noyes et al27 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
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 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 suc-
cession candidates is clear. Thus, the next strategy

JONA  Vol. 39, No. 12  December 2009 551

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 Table 3. Common Succession Planning Framework Strategies in the Healthcare Literature

552
Identification Other
of Desired Needs Identification of Detection of Mentoring and Developmental Resource
Author (Year) Strategic Planning and Skills Key Positions Candidates Coaching Processes Allocation Evaluation

Blouin and Demand forecasting Early and frequent Formal and informal Exposure to For leadership When desirable
McDonagh and gap analysis detection development development successors leave
(2006) for key positions competency the organization
opportunities
Bolton and Identify key and Identify potential Mentoring Commit time
Roy (2006) new positions candidates and financial
resources
Bonczek and Define strategic Current nurse Determine who Mentor and coach Develop an
Woodward imperative of leaders identify possesses aspiring leaders education and
(2004) organization leadership skills necessary growth plan
and talents to skills; possible
replace themselves acceleration pool
Collins and Evaluate short- and Examine gaps Identify key areas Analyze skills/ Identify Time, energy, Extensive evaluation
Collins long-term between existing and their core resources of development and employees program of
(2007) goals; match skills and core competencies available process of formalization,
organizational competencies of candidates proposed control and
goals with proposed position successor information
candidacy pool systems, political
and technical
criteria, staff role
and business impact
Husting and Conduct strategic Identify current job Assess current job Identify Mentoring and Assess learning and Part of the Extensive evaluation
Alderman planning requirement and requirements, high-potential coaching development evaluation process of program:
(2001) future positions future positions, candidates needs of organization,
and future participants objectives, and
competency participants
requirements
Noyes et al Determine purpose Identify and assess Mentorship Formalized
(2002) and vision of high-potential program developmental
organization; candidates plan involving
conduct strategic multiple skill sets
planning
Redman Identify desirable skills Assess specific Assess individuals Mentoring and Use a transparent, Assessment, periodic
(2006) and qualities for positions in terms of coaching flexible process evaluation, and
successors; analyze (competencies, leadership to develop improvement as
gaps comparing desired qualities, capabilities/ high-potential needed
talent pool future needs) potential employees
Rollins (2003) General Identify the talents, Plan describes skills
characteristics skills, and and experiences
and requirements characteristics needed, along with
of future leaders and assess the timeline to achieve
leadership skills these; assign
of those involved managers new

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responsibilities
outside area
of expertise

JONA  Vol. 39, No. 12  December 2009

deals with identifying key positions that require suc-
cession 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 es-
sential. 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. Gen-
erally, the authors7,23-25 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.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 succes-
sion planning framework.
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 rec-
ommended exposure to development competency
opportunities to broaden one’s career. Bonczek and
Woodward1 indicated that, generally, an educa-
tional growth plan should provide opportunities
for successful candidates. Husting and Alderman24
similarly recognized that the learning and develop-
ment needs of succession candidates should be
assessed and implemented to closely match organi-
zational growth requirements. Redman25 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 al27 approved
a packaged approach to development, suggesting
personal effectiveness management, financial man-
JONA  Vol. 39, No. 12  December 2009
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agement, conflict management, human resources
skills, case management, and preceptor develop-
ment skills.
In contrast, Rollins26 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. Rollins26 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 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 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 Ibarra11 implicitly stating
its need.
Evaluation
Last, evaluation was a common strategy for succes-
sion 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 evalua-
tion 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 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
553
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 Collins8 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
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 organi-
zational strategies from the creation and implemen-
tation 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 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.
554
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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.
JONA  Vol. 39, No. 12  December 2009
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