1. Fray, Beverly PhD
  2. Sherman, Rose O. EdD, RN, FAAN

Article Content

Introduction by Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN


Professional case management is an integral part of today's health care system. As the industry changes and grows, the workforce ages. A key element to ensure that the case management workforce remains relevant is to develop and empower leaders who can shepherd the practice in adapting to changes without losing the fundamental focus of practice of professional case management. To do this, a succession plan must be in place.


As a result of the Institute of Medicine Future of Nursing Report, nurse leaders are starting to lay the ground work for meaningful succession planning that will meet Recommendation 7 of the report. Recommendation 7 calls for nurses to prepare and enable nurses to lead change to advance health (Institute of Medicine, 2010). Collaboration is key and professional case management leaders can incorporate this work to ensure that succession planning is a part of the framework of all case management departments and organizations. In the column that follows, the authors review a study that will assist nurse leaders as they develop Succession Plans within the State of Florida (Denker et al., 2015). Their observations can help professional case management ensure a strong workforce now and in the future.


In response to recommendations outlined in the Institute of Medicine (IOM) study on the Future of Nursing (IOM, 2010), the IOM and the Robert Wood Johnson Foundation (RWJF) partnered to create the Future of Nursing Campaign for Action to prepare nurses to lead change. This national effort is coordinated through the Center to Champion Nursing. Nurse leaders in Florida joined this campaign, forming the Florida Action Coalition (FL-AC) early in 2011, and efforts are now aligned with the 49 other states and the District of Columbia to address the 8 major recommendations outlined in the IOM (2010) report. The Florida Action Coalition is co-led by leadership from the Florida Center for Nursing and Florida Blue Foundation.


A steering committee of Florida-based nurse leaders and nurse champions conducted a strategic planning meeting in October 2011, and the IOM report was reviewed. Recommendation 7, to Prepare and enable nurses to lead change to advance health, was selected as a state priority. This recommendation urges that "nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses" (IOM, 2010).


An RWJF State Implementation Program Grant was awarded to the Florida Center for Nursing in 2013 to support the work of the Florida Action Coalition. This allowed the FL-AC to begin to systematically address nurse leadership in Florida. Initial goals were to describe and identify nurse leadership and promote and develop nurses as leaders across the state. One of the first objectives was to conduct a statewide survey. This was an effort to understand the current population of Florida nurse leaders, including demographics, role challenges, retirement plans, and their priorities for nurse leadership development. The research was also designed to address future nurse leadership development and current succession planning efforts. Conducted in late 2013, surveys were completed by more than three thousand current and emerging nurse leaders and provided a detailed snapshot of Florida's nurse leaders.


The sample included 1,354 nurse leaders who responded to questions related to competencies, barriers to nursing leadership, and succession planning initiatives. The survey revealed some key findings such as the following: 59% of the respondents were planning to retire in the next 10 years and 20% in 3 years; 74% had no succession plans in place. In terms of preparing for the loss of leadership, 7% were prepared for the impending loss; 42% were somewhat prepared; 68% were concerned about staff readiness to assume leadership positions; and 61% agreed that roles needed to be reevaluated.


Succession Planning: A Critical Need

The FL-AC found that the results indicated a clarion call to act urgently and that succession planning was the priority, including the development of a succession planning toolkit to facilitate planning. Before embarking on the development of the toolkit, the FL-AC decided to interview nurse leaders from exemplar organizations in academic and clinical settings to identify best practices to include in the toolkit. The FL-AC compiled a list of more than 20 exemplar organizations with a strong history of proactive succession planning. Interviewers reached out to these nurse leaders, to solicit their participation in the survey, which consisted of a list of questions that had been developed by members. To encourage participation, questions were e-mailed to those leaders who expressed the desire to participate while telephonic and face-to-face interviews were conducted with others who wished a personal contact. The final sample included 10 organizations and represented nurse leaders from throughout the state with the majority from south Florida.


The Study

A survey questionnaire was developed by the FL-AC. It is not a scientifically validated tool and consisted of questions that the team felt were appropriate to elicit the information necessary to assist in building the toolkit. The final survey consisted of 25 questions. Participants were given a choice as to how they would complete the questionnaires, due to their tight and busy schedules. Some opted to do telephone interviews; others completed them by e-mail while others agreed to face-to-face interviews. Interviews either occurred face-to-face in participant's offices or by telephone. Each interview lasted between 45 min and 1 hr. Our findings are given later.


How Is Nursing Management Promoted as a Desirable Specialty?

The majority of the respondents expressed that the best promotion for nursing management as a specialty is role modeling, promoted through leadership programs that often include mentorship. Others reported hand-picking people for managerial positions who exemplify what nursing should look like in their organizations, creating opportunities for shadowing current leaders, being visible as a chief nursing officer, and having discussions with potential leadership candidates as other ways to promote nursing leadership as a desirable specialty.


What Levels of Leaders Are Involved in Your Succession Planning?

Fifty percent reported that all levels of leaders were included. The other 50% had varied responses, starting with the director level, while others started at the unit manager level. One Dean stated the following, "the need for leadership is so great that one must always be looking for someone to fill those roles, and so everyone is a candidate to lead."


How Are Career Paths Conveyed to Staff?

Sixty percent reported that staff are informed about opportunities for career paths via face-to-face discussions in meetings with them. Thirty percent reported using a multimodal approach, including posting openings on their organizations' websites/Intranets, blast e-mails to staff, and word of mouth. The remaining 10% had no formal process in place because in their view "the bright ones usually rise to the top."


What Skills and Competencies Are You Seeking in Future Leaders?

High-priority skills for future leaders included excellent interpersonal and behavioral skills. For example, sociability, being kind, ability to make others feel comfortable, having composure, and modeling leadership were noted to be key behaviors. Fifty percent of the sample felt that both verbal and written communication skills were vital. Only a few enumerated financial acumen, innovation, and creativity as skills they were seeking. It is interesting to note that the latter named skills were associated with organizations that were Magnet (American Nurses Credentialing Center, 2016) designated. Other themes included being a servant leader, clinical skills, quality improvement, ability to forge relationships with the medical staff, ability to embrace fluid models of care delivery, possessing excellent program management skills, honesty, teamwork, coaching, flexibility, and being comfortable in embracing diversity.


Are Organizational Profiles of Current Leaders Done?

Organizational profiles of current leaders are considered a best practice in succession planning. In this sample, 30% said that they had not yet completed them. Another 30% reported that they were actively working on them, whereas 10% said that they had completed the profiles from manager up to vice president level. The final 10% said that they had completed them from the chief nursing officer level and below, whereas the remaining 20% had not yet started.


Are Organizational Profiles for Pivotal Roles Done?

As for pivotal roles being completed to facilitate succession planning, 20% of the executives reported having completed them. In terms of which level was completed, 30% reported having completed their own, which is the executive level. The rest remained undone.


Are Issues Related to Organizational Succession Planning Identified?

All nurses know that assessment is crucial for planning and one would expect that the nursing process would serve nurse executives well in succession planning. In this small but affirming study, 90% of nurse leaders acknowledged the importance of identifying organizational succession planning issues, but had not done so due to frequent leadership changes. Among those who had completed the assessment, they used the High, Middle, Low evaluation strategy to identify future leaders. The high performers are being groomed for succession planning roles. Interviewees were also asked whether organizational succession action plans had been established. Overall, 40% of the sample had 5-year plans, and another 40% had no plans, while the remaining 20% had a conceptual plan, which had not been operationalized.


How Are Leaders Held Accountable for Their Succession Planning Efforts?

There was a great difference between clinical and academic settings. Sixty percent of the sample reported having no accountability plan in place to hold their leaders accountable for succession planning. The leaders in academia had plans in place to hold leaders accountable by ensuring that their job descriptions reflect clear, specific job responsibilities outlined for new leaders.


What Are the Expectations for Current Leaders to Serve as Professional Role Models?

Ninety percent of the nurse leaders interviewed reported having specific expectations for their leaders to be role models. These expectations are incorporated into their job descriptions; the remaining 10% did not. Some leaders used the terms role model and mentors interchangeably; however, there are distinctions between the two. A role model is "a person looked to by others as an example to be imitated, someone who another person admires and tries to be like" (Merriam-Webster, 2016), and a mentor is "someone who teaches or gives help and advice to a less experienced and often younger person" (Merriam-Webster, 2016, p. 2). Role model expectations of nurse leaders include mentoring nursing students at all levels of the academic spectrum; mentoring incoming department chairs of nursing schools and colleges; displaying positive interpersonal relationships, as well as being a part of the branding image of the organization in which they work.


What Are the Expectations for Current Leaders to Serve as Mentors?

Seventy percent of the sample expected nurse executives and managers to mentor students because they are given the tools, resources to do so, and will be held accountable for the outcomes. Twenty percent (20%) had no expectations of their leaders to be mentors and the remaining 10% had not thought about specific expectations for mentors.


What Mechanisms Have Been Established to Provide for the Early Identification and Mentoring of Staff With Leadership Potential?

Among respondents, 30% invite/sponsor potential nurses with leadership qualities to participate in formal leadership programs such as Emerging Leaders and Nursing Leadership Institute for RNs. Another 30% recruit those who scored High on the High, Medium, Low evaluation scale to determine who becomes a nurse leader. Twenty percent had a formal process in place, whereas 10% had no formal process. The remaining 10% reported that they, basically, let every employee know they are leaders in any capacity in which they are hired and some leadership roles are rotated among team members based on the needs of the team and the individual employee's strengths.


Are Leaders Held Accountable to Develop a Succession Plan for Their Own Position?

Eighty percent of the respondents reported having a succession plan for their own positions as this was a requirement of the position, with at least 1 or 2 potential replacements always ready to assume their positions, if needed. The remaining 20% did not report holding their leaders accountable for having any succession plan.


What Structured Leadership Development Programs Are in Place and at What Leadership Levels?

Seventy percent of the respondents reported having structured leadership programs in place; a list of 10 such programs follows in the Appendix. Another 20% reported that the programs available are offered through human resources (HR) department and not nursing whereas the remaining 10% had no programs in place.


What Percentage of Current Leadership Succession Planning Is Happening From Within the Organization?

With regard to succession planning from within their own organization, 40% reported that 50%-100% of their vacancies are filled from within. The 60% remaining did not have any succession plan in place for several reasons, ranging from size of their organization and other challenges outlined in the next question.


What Are Your Organizational Challenges in Promoting Succession Planning for the Future?

Several challenges were enumerated as barriers to succession planning by respondents. These barriers are as follows: lack of funding to attract special talent, limited opportunity for promotion due to size of the organization; lack of adequate/updated technology; cultural mindset about longevity and promotions versus actual readiness; aging workforce; incoming nurses' lack of interest in 24-hr nursing leadership; managers' and leaders' negative view of their work and roles.


What Are the Costs of and What Resources Have Been Made Available for Succession Planning?

In terms of costs related to succession planning, 90% did not know how much their organizations spend or have spent on succession planning. Ten percent of the organizations represented in the sample reported spending more than $80,000.00 annually on succession planning activities, including training, conferences, and other relevant activities. Another 10% reported that "millions of dollars" were spent in this regard and notably, these again, were Magnet-designated hospitals. Resources allocated for succession planning included information technology, human resources and talent management staff for training and mentorship, and resources dedicated to conference attendance.


How Are Leadership Development Opportunities Conveyed to Staff?

Ninety percent (90%) of respondents utilized several methods to convey leadership opportunities to staff, including e-mail, personal calls, notice boards, Intranet announcements, flyers, huddles, and meetings. A small percentage (10%) reported not conveying such opportunities to staff at all.


What Organizational Leadership Development Is Occurring Beyond Nursing in the Organization?

Seventy percent reported that organizational leadership development was being conducted for all leadership groups across their organizations. These training sessions included Dale Carnegie Leadership Essentials, Creating a Disney Culture for Medical Staff, Change Management, and Dealing with Difficult Clients for Nurse Leaders. Thirty percent reported that very little or nothing was being conducted beyond nursing continuing education.


How Is a Need for Diversity Promoted as a Value in Succession Planning?

Despite the growing number of Hispanics in the State of Florida, only 30% of the respondents had a specific plan to address diversity in culture, race, and gender. Only 20% of respondents reported making a conscious effort to ensure that frontline and leadership staff mirrors the communities they serve and reported that no specific effort was made to address the issue, even though 90% of their patients speak Spanish as their primary language. One person even remarked, "we're actually low on African Americans, so we're actively recruiting."


One leader shared the following story, as a testament to her commitment to diversity. She was a cardiopulmonary resuscitation (CPR) instructor and 1 day during class, someone asked why there were no black mannequins; all the mannequins were white. She then embarked on a journey to procure mannequins who were black even though it was a tremendous task, at that time, to find black CPR mannequins. When she finally found and acquired the new mannequins, the staff voiced their appreciation for her efforts.


Can Staff Self-Identify as Being Interested in Leadership Development Opportunities?

All the leaders interviewed reported that staff members interested in leadership positions may identify themselves as being interested in such positions and they are highly encouraged to do so. Despite self-identification by staff, executive approval may be required for some positions.


How Is Success Measured in Your Program?

All of the leaders interviewed had a different standard for measuring a successful succession plan. The standards ranged from professorship in academia, to promotion from within rates of 15%-25% and retention rates of 85%-87%. Patient satisfaction scores are also used to measure success. Much work is needed to utilize more universal evidence-based methods and criteria for measuring the success of succession planning strategies.


Is a Competency Model Used in Succession Planning?

Fifty percent reported using no formal model. Ten percent of those in academia reported having a homegrown, evidence-based model used for succession planning and provided a copy. These plans consist of major factors and concepts related to the care environment. Employees who demonstrate behaviors related to such factors are considered for promotion. Another 10% reported using a model at both the leadership and executive levels; however, the models were not shared. Ten percent (10%) reported that the model used was part of the evaluation process; again no specifics were shared. Another 10% reported using a model as part of the basic evaluation process, the results of which are considered for promotion. This is based on the Studer model of High, Middle and Low performers to determine who are eligible for promotion. Ten percent reported that a model consisting of a list of competencies/programs must be completed by leaders who are being promoted. Classes are role-specific and include employee engagement survey results for yearly evaluation of nurse managers who must receive at least 4.1 out of 5 points. If parameters are not being met, employee engagement surveys are repeated at 3, 6, and 12 months.


Do You Use Any HR Software in Your Succession Planning?

Eighty percent of the sample reported using no Human Resource software for succession planning and expressed the need for such a software program. Some reported that their organizations were contemplating the purchase of specific software, such as Press-Ganey's, for succession planning. Of the remaining 20%, 10% reported having a structured program called Grow our Own, which is organized and prescriptive. It covers every aspect of succession planning. Every leader must have an "heir apparent" identified or a strategic plan to develop someone. The remaining 10% reported that some of the key five year data needed included turnover rate, average vacancy rates and identification of hard to fill positions. Overall, the sample felt that such a software program would be helpful.



The most important lesson learned from this small, unscientific study is the succession planning among nursing leadership in Florida. It is an immediate need and this is a call to action, when 60% of this sample who was identified by experts in the state as having exemplar leadership development has no formal succession plans in place. Another finding is that, despite the power inherent in the titles of nurse executives, their power is limited by the environments in which they practice. It is clear from this study that nurse leaders in Magnet-designated facilities had more power and flexibility to exercise the power inherent in their titles.


Current nursing leadership models are challenged by their inflexibility and possible obsolescence. For instance, to attract members of the "millennial generation," nursing leadership must question the validity of a nurse manager having 24-hr responsibility for a unit. An additional challenge to future recruitment is that current managers speak negatively about their roles, a practice that drives potential future leaders to consider other specialty tracks. Another challenge is that the majority of the nurse leaders interviewed do not assign to the degree of importance to diversity that it deserves, especially in a diverse state like Florida, where caregivers do not mirror the population they care for. Diversity in all forms is taken for granted and it does not happen. This needs to be a deliberate effort. In fact, only 30% of the sample, 2 Magnet-designated facilities and 1 academic institution, recognize the need for diversity and consciously hire with an eye toward creating a diverse work environment. Finally, nurse executives are not easily accessible, hence the small sample size.


Recommendations for the Future

Based on the results, the following recommendations are being proffered. First, all nurse leadership roles and job descriptions must have explicit expectations and verbiage, respectively, for succession planning. Second, there can be no succession planning without understanding the factors related to nurse turnover. Consequently, any succession planning kit should include retention strategies, such as robust, meaningful mentoring programs. Third, this study indicates the need for immediate action related to designing, implementing, and evaluating a specific succession planning toolkit for Florida's nurse leaders, utilizing best practices from exemplar organizations. If nurse leaders have easy-to-use, evidence-based, practical templates and guides to assist them in developing succession plans tailored to their organizations, chances are that they would engage in succession planning activities. Fourth, having leadership that reflects the patient and staff populations is important. Diversity in nurse leadership is a critical part of succession planning. Succession planning is also necessary because the population of nurse leaders is quickly aging and the nursing environment has been and continues to be rapidly transformed.



Succession planning is urgently needed. More resources need to be allotted to the effort of attracting and retaining new and experienced nurse leaders. In a study conducted by Buerhaus (2005), it was noted that "while most recruitment and retention strategies were perceived as valuable by at least half of the nurses surveyed only one retention strategy was observed by more than half of the nurses surveyed: mentoring programs for new nurses" (p. 61). Sign-on bonuses are attractive but are not the most effective strategy to retain nurses. In fact, more than two thirds of the nurses in Buerhaus' study perceived that the most effective strategies for retention were mentoring programs for recent graduates, paying for continuing education, and reimbursement for conferences. These findings were also reflected in a study by Liebermann, Muller, Weigl, and Wegge (2015), among German nurses who reported that remaining in the same job until retirement age is positively related to work-time control, role clarity, and colleague support. Supervisor support was also found to exert an indirect effect in terms of job resources. Importantly, as the researchers hypothesized, relationships retention factors were different for younger (<30 years), middle-aged (30-50 years), and older (>50 years) nurses (Lieberman, 2016). Finally, only health care organizations with enriching leadership and staff development programs, specific strategies for increased cultural diversity, collaboration with human resource management, and information technology departments are the ones, so far, that have demonstrated high retention and low turnover rates among nurses. Any toolkit for succession planning must include all these critical elements.



The survey was conducted by Beverly Fray and Lenora Yates, DNP, EdD. The authors and surveyors thank the Jonas Foundation for providing the opportunity to work with the Florida Action Coalition on this project and implementation of the Institute of Medicine's Recommendation #7. We thank all the executives who gave of their time and talent to make this survey possible.




American Nurses Credentialing Center. (2016). ANCC Magnet recognition program. Retrieved from the American Nurses Credentialing Center website: http:// [Context Link]


Buerhaus P. I. (2005). Is the shortage of hospital nurses getting better or worse? Finding of two recent national surveys of RNs. Nursing Economics, 23(2), 71-96. [Context Link]


Denker A. L., Sherman R. O., Hutton-Woodland M., Brunell M. L., Medina P. (2015). Florida nurse leader survey findings: Key leadership competencies, barriers to leadership and succession planning needs. Journal of Nursing Administration, 45(7/8), 404-410. [Context Link]


Institute of Medicine. (2010). The future of nursing leading change, advancing health. Retrieved from https:// [Context Link]


Liebermann S. C., Muller A., Weigl M., Wegge J. (2015). Antecedents of the expectation of remaining in nursing until retirement age. Journal of Advanced Nursing, 71(7), 1624-1638. [Context Link]


Merriam-Webster. (2016). Role model. Retrieved from Merriam-Webster Learner's Dictionary https:// [Context Link]

Appendix. Succession Leadership Development Program Examples [Context Link]