Keywords:   Nursing Leadership; Succession Planning; Sustaining; Saudi Arabia

Introduction

Globally healthcare needs continue to increase, and nurse leaders play a critical role in ensuring that better outcomes are achieved. According to [1] Saudi Arabia faces a shortage of nurses as well as an unfledged nursing education system. The Saudi Government vision 2030 addresses this problem by providing the nursing profession with development opportunities. New national healthcare programs are being designed and local nurses placed  in charge of the healthcare system with the aim of reducing the reliance on expatriate nurses. In 2018, a total of 184,565 registered nurses were working in Saudi Arabia of which 38.8% were Saudi nurses. (Ministry of Health, 2018). The country is highly reliant on expatriate nurses who occupy the majority of nursing leadership and specialist positions [2]. There is thus a requirement for succession planning, in which intensive learning and training take place to ensure that future local leaders are ready to lead, in order to meet the 2030 vision towards an improved healthcare system.

Wolfe (1996), defined succession planning as the “systematic step or design that allows one to follow another in time or place and a defined program that an organization systemizes to ensure leadership continuity for all critical positions by developing activities that will build personal talent from within”. [3], indicated that succession planning is a process in which organizations internally identify and develop new leaders to ensure that the right leaders are in place when a leader leaves the organization. Expanding the availability of leaders ready and prepared to assume leadership responsibilities, provides the best solution for any organization to grow and sustain its success. Failure to develop future nurse leaders could cause gaps in leadership that may negatively affect the organization’s management. Consequently, junior leaders could be left facing challenges due to a lack of experience and be unsure what to do or who to ask for help.

According to [4], a succession plan is of considerable benefit to any organization not because the number of “Unreplaceable leaders” decreases, but because staff retention may increase by involving them in a learning process to become future leaders. Early continuous preparation of new leaders through succession planning initiatives is the best strategy to ensure a smooth transition in leadership [5].

There is a requirement to prepare local nurses in Saudi Arabian healthcare facilities for leadership roles. However, as succession planning practices are limited [6] there is uncertainty about the type of strategy that should be adopted to develop or implement this.

This research project therefore aims to identify whether succession planning may be an effective strategy to develop leadership competence in this population. Additionally, it seeks to establish a succession plan program for senior nurses which will provide opportunities for professional development, and transform nursing services by ensuring the availability of local nurse leaders within Eastern Healthcare Cluster (EHC) facilities to meet vision 2030.

Literature Review

The current and projected global nursing shortage and economic,   political   and   social   factors   affecting   health?care delivery  world?wide  make  effective  succession  planning  an absolute necessity for the nursing profession [7].

The need for succession planning may be more acute in Saudi Arabia since the implementation of the Saudi Government’s policy change to develop the local workforce as leaders in meeting future healthcare needs [8]. The importance of succession planning to achieve this has been acknowledged within Saudi Arabia where it is identified as a primary goal to transform the healthcare system in the EHC [9].

There is burgeoning literature to support the implementation of succession planning to develop the local nurse population in the Kingdom of Saudi Arabia (KSA) and ultimately help to transform nursing services. Nursing became acknowledged as a profession in the Kingdom in 1954 under the direct administration and supervision of Ministry of Health [10]. Presently a high number of expatriate nurses occupy managerial positions [11]. Although internal promotions now favour the local Saudi Workforce, Saudi nurse managers lack the skills and experience needed to manage the healthcare facilities and meet the patient’s needs [12].

The plan is to reduce the reliance on expatriate nurses but this will be difficult to achieve as there is a current shortage of nurses in Saudi Arabia and the demand for nurses will more than double by 2030 to meet the needs of an increasing population [13]. The shortage of nurses is exacerbated by a high nursing turnover rate [14] that can partly be attributed to low job satisfaction [15]. Additionally, there is also a low rate of enrolment in nursing programs due to the poor reputation of the nursing profession across the community [16]. The implementation of a succession planning program may alleviate these problems by providing opportunities for personal and professional development [17] while simultaneously reducing recruitment expenses, increasing leadership continuity, and decreasing role-transition stress [18,19] identify that succession planning is a strategic process that focuses on developing a workforce to occupy leadership positions below the senior healthcare executive to ensure that there are sufficient nurse leaders to manage the Saudi healthcare system   in future. [20] identifies the succession process as a continuum. This begins by identifying successors for limited positions where there is little or no development and ends where successors are identified and developed regularly at all managerial levels within the organization. This ensures that vacancies can be filled in key positions when needed. Despite the need for succession planning at all managerial levels, practices are limited and tend to focus on the top executive leaders in the healthcare field [19,20] identify that strategic planning based on the organizations needs and desired leadership competencies is required to ensure that key leadership positions are filled by local nurses. [21] , further asserts that organizational commitment is essential for identifying and developing individuals with high leadership potential. However, as the process of successor identification can be relatively subjective. Criteria must be set and candidates chosen according to their level of experience and potential, without bias or a lack of professional integrity in the selection process [22] if they are to 

perform to the highest standard. [23] emphasizes the importance of implementing a detailed succession plan in order to effectively cultivate new leaders and identifies that processes which involve simply checking the boxes at the end of a meeting or providing a list of candidates to indicate that the organization has a prepared succession plan is inadequate. However, it should be noted that   a simple, basic succession plan is better than facing the risks of replacing a leader without developing a succession plan at all [24]. Failure to develop and implement succession plans will create challenges for the healthcare system in sustaining effective health services. It could also have a negative impact on the social, cultural and economic growth of the country.

Further to [25] for succession planning, the Chartered Institute of Personnel Development (CIPD,2015) provides clarification about how to develop talent by identifying that training and development activities are required to facilitate the growth of future leaders and specifying that succession plan programmes typically include the provision of practical tailored mentorship work experience relevant to future senior or key roles.

[26] are proponents of Experiential Learning and emphasize the importance of the mentor’s role in developing competence. [27], asserts that education, assessment, coaching and experiential learning should be core components of a leadership succession plan if it is to be successful. [28] identifies that there is a need to retain expatriate nurses as mentors because their experience and competence can be transferred to Saudi’s within the workforce to develop management skills. [28] suggests that future leaders can also be developed through leadership programs. In the United States, Succession planning has been shown to improve nurse manager competency and retention rate while also helping to identify and develop new generations of nurse leaders through the implementation of a formal leadership development program [29]. However, there is evidence to suggest that leadership programs may not be supported by managers if they are perceived to be a waste of money and that “actual work” and “job assignments”  are deemed to be more useful to develop future leaders [30,31] attempted to evaluate strategies for nurse succession planning in seven Saudi Arabian hospitals. The study found that, although effective succession planning is built into the framework of organisational vision and policy, it was not reflected in practice in the hospitals involved in the study.

There is a large body of literature which identifies that succession planning is a global requirement in healthcare systems but there is a lack of evidence to support the development of nurse leaders through succession planning in the Kingdom of Saudi Arabia.

The low number of Saudi nurses in management positions, highlights the importance of developing local nurse practitioners if they are to lead nursing services in the future. However, most published research focuses on the nursing profession in general  in Saudi Arabia and the challenges Saudi Arabian nurses face in health care organizations. A significant research contribution on succession planning within the Saudi Arabian healthcare sector  is yet to be made. This study therefore seeks to provide valuable evidence about how to develop nursing leadership competency through succession planning in this nurse population which currently appears to be empirically under researched.

Materials and Methods

The study used a qualitative descriptive research design to identify leadership characteristics developed by Saudi nursing practitioners as this type of design is widely used to describe health care and nursing-related phenomena [32].

Setting: The study took place in EHC which consists of 22 hospitals: 5 Specialist, 5 Health Network and 12 Rural Healthcare network and 137 Primary Health Care centers that provide primary, secondary and tertiary level care to Saudi Nationals and citizens of the Gulf States, which is situated in the Eastern province of Saudi Arabia.

Participants: The study was conducted over a nine months period from March 2020 until the end of December 2020. The study used a purposive sampling technique to identify how leadership competency may be developed whereby all nurses and midwives working in EHC facilities were invited to participate in the study that met the following criteria for eligibility: succession plan position identified and available, requirements met regarding qualifications, work experience and recent performance evaluation and Key performance Indicator targets if applicable. The aim of recruiting this population was to ensure that all nurses working within EHC facilities with potential for career development would be provided an equal opportunity to develop leadership skills.

Instrument: The succession plan program was developed by senior nurse leaders working in EHC Nursing Affairs department. The program utilized the Structure, Process and Outcome (SPO) framework to examine and evaluate the development of leadership competency [33] and was supported by a document package with the following contents:

• Structure

• Identification of candidates according to their career pathway and facility needs
• Individual Development Plan where candidates had to provide demographic information, identify their career stage and core career values and complete a Self-Reflection Tool to identify their level of skill and knowledge relating to leadership traits and attributes and complete a Developmental Training Needs plan to identify short, intermediate and long-term goals.

· Process

• Gibbs Reflection Tool to reflect on the development process
• Overall Experience Reflective Essay
• Mentoring Agreement Form
• Attending    Professional    Development    Workshops    for Leadership and Management

• Outcome

• Competency Assessment Framework
• Evaluation of The Professional Development workshop
• Mentee Evaluation Form
• Mentor Evaluation Form

Experiential Learning: Kolb’s experiential learning theory (1984) was chosen as a strategy to develop leadership competency as it provides a structured process for nurses to learn through experience to in order to gain the necessary knowledge, attitude and skills to be effective leaders. The utilization of this strategy as an effective way to develop leaders is supported in the literature [34].

Kolb’s Experimental Learning Cycle (1974) consist of four stages: (1) completing a concrete experience by doing an activity, (2) reflecting and observing the experience, (3) forming abstract concepts by thinking about the experience, and (4) using the experience for planning future tasks.

Although Kolb identifies that reflective observation is a core component of the learning cycle, he does not provide a process for this. Gibbs Reflective Cycle (1988) provides a six-stage model that can be applied to give structure to learning from experiences.

Mezirow’s transformational Learning Theory, (1981) also underpins the learning process. Kolb identifies that experiential learning can be defined as “the process whereby knowledge is created through the transformation of experience. Knowledge results from the combinations of grasping and transforming the experience.

Data Collection /Pilot: Directors of Nursing in EHC facilities were asked to identify potential candidates for succession planning and submit names of those eligible, according to criteria, to EHC Nursing affairs department. The succession plan documentation package was then distributed to each candidate at the beginning of March 2020 with instructions to complete and return the Individual Development Plan (IDP) and Gibbs tool,    to reflect on their own development by the end July 2020. In many cases the IDP was returned incomplete and it was apparent that candidates experienced difficulty setting goals. Despite the Covid-19 pandemic and the many opportunities it presented to develop leadership skills, candidates also struggled to apply Gibbs reflective cycle in practice to identify learning that had occurred. A series of workshops were held from the 25^th August 2020 until 2^nd September 2020 to support students with learning needs in relation to setting goals, applying Gibbs reflective cycle (1988) and completing all aspects of the IDP. Candidates were then given an extended deadline until the end of September 2020 to complete and submit the documents to the required standard.

Following submission of the IDP at the end of September 2020. Participants met to discuss their goals and training needs with the Executive Director of Nursing. A mentor was then assigned to facilitate the learning process during a period of practical placement, in order to achieve their learning objectives/ competencies. Participants were required to take ownership for learning by reflecting on learning opportunities encountered during their practical placement using the Gibbs Reflection Tool, that they have become familiar with, to identify what they had learned, both personally and professionally, identify areas for improvement and develop action plans to further advance their attitude, knowledge, and skill relating to leadership competency.

The quality of the program was evaluated by a panel of expert nurse practitioners who assessed construct validity to ensure that it met its objectives in measuring leadership ability. Additionally, a pilot study was tested on five program participants to confirm reliability through the clarity of questions and effectiveness of instructions (Burns and Grove, 2017). No variables were identified which it was felt may impact on the study (Kermode and Roberts, 2007). Nonetheless as the pilot size was small, the possibility cannot be excluded that certain problems may not have been detected.

A leadership workshop was developed by EHC Nursing Affairs department, in collaboration with EHC Nursing Professional Development to further support the professional development of candidates during the succession plan program.

All candidates were invited to attend the workshop which was held as a one- day course in September 2020. Course content was developed according to identified learning needs and aligned with AONE Nurse Executive Competencies (2015) which were adopted to evaluate competency outcomes. Benner’s Novice to Expert Rank (1984) was also utilized as a framework to assess nurses at different levels of expertise. Directors of Nursing in each facility, in collaboration with the mentors, were asked to oversee the competency completion process. A deadline was set for the end of December 2020 to identify the number of participants that had successfully completed competencies and were deemed suitable for promotion to leadership positions. Alternatively, they were asked to indicate if any participants demonstrated potential but needed more time to develop competency or were found to be not suitable.

Data Analysis / Findings: A total of 121 potential candidate names were submitted to the EHC Nursing Affairs for consideration and acceptance on to the Succession plan program. After reviewing all applications, 50 candidates were finally accepted, 12 were provided an alternative succession plan track with a focus on nursing education and 59 were excluded because they failed to submit their completed IDP or did not meet the requirements for qualifications or experience. Additionally, international nurses that applied were also not accepted on the program due to a revision of criteria for eligibility aligned with the 2030 vision. A total of 46 candidates attended the workshop as 4 initially selected failed to attend due to changes in personal circumstances.

On completion of the workshop participants were asked to provide feedback about their learning experience. The following insights were received from, Senior Nurse Leaders, who attended the workshop to motivate participants, which acknowledged the value of the succession plan program:

• “The succession plan supports the need to develop new  nurse leaders within the EHC by identifying candidates with leadership potential and providing a structured plan to develop their competence.”
• “The succession plan program provides an opportunity to invest in Saudi nurses who are qualified and willing to shape the future of the nursing profession.”
• Further feedback received from workshop participants provided insight into the benefits of the succession plan program:
• “Great presentations, many opportunities to ask questions and develop leadership knowledge about SWOT analysis, interview  techniques  and  budget  management.  I  have  also learned how to identify weaknesses and find areas for improvement.”
• “Provided an opportunity to develop knowledge about accountable care organizations and the importance of cost- effective leadership in transforming nursing services.”
• “A variety of different teaching strategies were used which kept participants engaged and motivated. I learned a lot about useful tools, such as Gibbs reflective cycle, that can be used to evaluate and improve performance. I am confident to work in a team solving problems related to daily conflicts.”
• “Provided an opportunity to share experiences and learn from each other.”
• “My way of thinking changed as I opened my mind to reflect on practice-based issues to identify new ways of doing things.”

At the end of December 2020, when the deadline was reached for competency completion, data was retrieved from Executive Directors of Nurses to indicate the progress of the 46 participants on the succession plan program. A total of 31 had completed competencies aligned to the workshop and were found to be suitable for succession plan positions, the remaining 15 demonstrated leadership potential and extended their deadline to provide more time to develop competency.

Discussion

The limited number of Saudi nurses with leadership skills poses a threat to transforming healthcare services in Saudi Arabia where the availability of local nurses is a requirement to meet   the 2030 vision. Effective Succession planning is essential in    the nursing profession if capable nurse leaders are to be readily available to meet the growing demands of the healthcare service [14]. The importance of designing and implementing a succession plan program with the potential to develop nurse leadership competency amongst local nurses in Saudi Arabia cannot be underestimated. It is hoped that an analysis of findings from this study will provide insight into the effectiveness of the program and provide assurance for leadership continuity in the future.

The current study of 46 nurses working in EHC facilities aimed at developing leadership competency showed that 67% of participants were deemed competent and suitable for succession plan positions, 33% demonstrated that they had potential to be developed as nurse leaders and none of the candidates were found to be unsuitable for leadership positions after attending the succession plan program. Insights received in relation to the workshop component of the program identified its benefits in developing knowledge about leadership through the use of different teaching strategies and knowledge sharing with each other, learning about educational models and how they can be applied in practice to evaluate and improve leadership performance, and reflecting on practice to discover new ways of doing things.

The success of the succession plan program in developing leadership competence may be due to several factors. The literature 

emphasises the importance of organizational support in achieving success (Titzer, 2016) and the EHC Nursing Affairs department was highly committed to developing nurse leaders which is demonstrated through the diligent planning and implementation of the succession plan program. It may also in part be attributed to the screening and selection process, the importance of setting criteria to ensure that the candidates with the most potential are selected has been identified [15]. A stringent selection process was followed whereby candidates were chosen objectively based on qualifications, experience and ability. [16] acknowledges the importance of a detailed plan in developing competence, rather than measuring competence against checklist standards, if new leaders are to be effectively developed. The Donabedian model was embedded in the succession plan program as a framework   to develop leadership competence. This provided a clear and detailed plan which appears to have been beneficial in guiding the development of succession plan program and identifying how it can be implemented and evaluated in clinical practice.

The CIPD (2015) highlights the importance of training and development activities in facilitating the growth of future leaders. Gibbs reflective cycle was introduced to study participants during the succession plan program as a theoretical concept to explore practice-based issues. Insights participants, received after the workshop, acknowledged the benefits of the tool in allowing them to explore and analyse issues and modify nursing practice to achieve improved outcomes. Participants also acknowledged the importance of educational initiatives in generating new knowledge to support the development of leadership competence.

Evidence  suggests  that  experiential  learning  activities are often embedded within succession plan programs (CIPD, 2015). The use of experiential learning as a strategy to develop leadership competence is well supported in the literature where the role of the mentor is pivotal in achieving success [17]. Kolb’s experiential learning model (1984) was used as a framework to develop leadership competence in the succession plan program because it provided participants the opportunity to bridge the gap between theory and practice to develop leadership competence. The workplace provided a rich learning environment to develop leadership competence due to many challenges faced within the healthcare environment caused by the COVID -19 pandemic. However, it is unclear how the role of mentor influenced the outcome of the succession plan program. As the mentors had not received any formal training for this role, it is possible that the results may have been further improved had educational support been provided.

Recommendations & Implications for Nursing

Continue to maintain and sustain the succession plan program by developing additional workshops and align competencies to further develop Nurse Leaders. Provide mentorship programs with the aim of sharpening the mentor’s skill set to provide mentees with the necessary support to successfully develop leadership competence.

Limitations

Despite the encouraging results the study has some limitations. The possibility of sampling bias cannot be excluded  although steps were taken to reduce the possibility by inviting   all eligible nurses and midwives working in EHC facilities to participate in the study. However, as Directors of Nursing were asked to nominate suitable candidates, they may have actively taken steps to prevent nurses from participating in the program. The principle of succession planning may have been perceived  as a threat by some Directors who may not want to prepare a successor if they feel insecure in their position. Additionally, as criteria was set for eligibility to the program it may be that some nurses with excellent leadership potential were excluded from the sample, this is therefore seen as a second limitation of the study. Thirdly, mentors had not received any formal training to develop mentorship skills and therefore may not have the ability to facilitate the development of leadership competence. Fourthly, although the leadership workshop was evaluated, the succession program was not evaluated overall. A full valuation may have provided useful insight and information about how to develop the  succession plan program in the future. Furthermore, as the sample excluded international nurses it was not representative of the total nursing population in EHC in terms of its potential to develop leadership skills. However, the sample is aligned with vision 2030 to develop capability within the Saudi workforce. Nonetheless, the use of a total population sample of nurses with Saudi nationality may limit the generalisation of findings to a broader multicultural nursing population. Replication of the study may provide assurances for the validity of the findings. Finally, the study used a qualitative descriptive design, the utilization of mixed method research combining both qualitative and quantitative forms, may provide more comprehensive data about how to develop leadership competence through the succession plan program in Saudi Arabia.

Conclusion

Nurses in EHC facilities developed leadership competence through the succession plan program. However, there is a lack of empirical evidence to suggest how leadership competence is being developed amongst local nurses through succession planning programs nationally which may further inform the development of succession plan programs or how successful succession planning may be in providing leadership continuity  in  Saudi Arabia  in the future. Thus, there is a requirement for further studies to be conducted in this nursing population which is currently under- researched.

Acknowledgement

The authors would like to Nursing Administrative services in all EHC facilities for their support and encouragement with this study. The IRB at King Fahad Specialist Hospital is also appreciated for their approval of this study.