The constructive path of the manager nurse: a grounded theory*

Objective: to understand how nurses experience the succession planning of manager nurses. Methods: qualitative study using grounded theory as a theoretical and methodological reference, with a sample of 20 nurses. Data collection took place through interviews, content analysis


Introduction
This millennium is characterized by a competitive environment, which encourages changes in management ideologies that presuppose adjustments and propose challenges to manager nurses (1) .There is also international interest in literature regarding the methods of choosing and preparing managers.As a result, succession planning is often a deliberate method, which allows identifying the professional and promoting the development of potential managers as new job placements become available (2)(3)(4) .In nursing, it is assumed that nurses have abilities related to a profile in the field of management, and that they are trained in the practice and supervision by their peers in order to have a faster transition process (5) .
The state of the art shows some studies on the topic, but also demands for economic and human resources in the planning of succession, which limits its implementation (6) .Elements which stand out are the necessity of identifying and choosing potential managers through a plan of succession, to guarantee that the passage of the management role will be successfully conducted, increasing worker satisfaction and retention (7) .A model based on workshops and mentorships was developed in a North-American hospital, and its cost benefit analysis showed lower turnover costs in the recruitment of professionals (8) .In another North-American health institution, managers were substituted in stages, including conferences with experts, mentorships, and coaching sessions (9) .
Despite the lack of systematization, current models share common elements, such as the need for organizational support, strategic planning, resource allocation, and determination of the roles to be replaced; a definition of the competences required by the job; an indication of a set of potential replacements; the encouragement to the professional development of identified successors; and the need to evaluate the procedures (6) .
In no place the need for succession planning is greater than in the difficult domain of health: a complex sector where excellence in the care of manager nurses must be assured (1,4) .Additionally, the planning of succession have the potential to guarantee the continuity of the legacy of generations of manager nurses (10)(11) .
When there is no integrated and systematic plan for succession in an institution, managers are often chosen with no knowledge of their ability to lead, previous experiences, or theoretical knowledge in the field.As a result, many of the new managers are not prepared, which increases the likelihood of resignations, with an impact on the organizations themselves (12) .
The ad hoc professional development of manager nurses requires urgent analysis.The corporate management of health institutions presents constant challenges to the manager nurse, requiring them to acquire new competences that can enable them to face changes and show their value for the organization (1) .Therefore, the necessary competences must be well-defined and developed, so successors can have the maximum performance.In reality, succession planning is a need and a key challenge for nursing management (5) .
In Portugal, the there is no information on whether a form of succession planning is used in health institutions, which is also a shortcoming of national literature.The relevance of this topic for the practice of nursing, and the urgency of investing in programs of succession planning, were the main motivations for this study.In addition, the coming retirement of current managers indicate how necessary this work is for the development of nursing, in the specific field of management.As a result, the guiding question of this study is: How do the different professional categories of nursing experience the issue of succession planning in nursing management?As a result, our goal was to understand how nurses experience the succession planning of manager nurses.

Methods
Qualitative report, following the recommendations from the Consolidated Criteria for Reporting Qualitative Research (COREQ).
The Grounded Theory (GT) was chosen as a methodological reference for this work due to the wish to acquire a complete and broad notion or perception of what succession planning, as a social process, means for nurses, coupled with our desire to create a theory capable of reflecting this notion (13) .
To guarantee coherence, we chose the Strauss line of GT in its original version, eschewing later theoretical developments.We chose this line as it follows a more formalized structure for the data analysis and the construction of the theory, in addition to the need to review the literature before data collection (14) .
Data collection was carried out in a hospital center in the North of Portugal, from November 2021 to February 2022.The target population were nurses from this center, after a non-probabilistic sampling through rational choice, defined as "theoretical sampling" in GT (13) .Participants were selected according to the phenomenon investigated, experience, and social interaction (15)(16) .Inclusion criteria were: nurses with 10 years or more of experience (assuming this increases their social interaction and knowledge of the topic) and with managerial experience.We excluded nurses who were absent during the period of data collection.
We contacted 23 nurses, following the principle of theoretical sample.It was not necessary to use multiple groups to clarify the phenomenon.The study included 20 nurses.Data saturation was achieved when the collection of further points of data no longer reflected on the production of new information (15) .In this case, saturation took place when the categories were congruent and the participants were diversified.
The interviews were carried out according to the availability and place/type of interview preferred by the workers (in person or through video calls).Most interviews (n=12) were carried out in person, lasting from 12 minutes to 1 hour 30 minutes.The choice for video call interviews did not compromise the interaction between interviewer and interviewee and allowed us to attend to the preferences of some participants, while attending the isolation measures required by the COVID-19 pandemic and minimizing the impact of the study on the practice of care.
Regarding the type of study, we used a semistructured interview based on an script, as an instrument for data collection which helped us guarantee the content was uniform and reach the goals of the study with its questions (17) .Before data collection, three nurses were interviewed (they were not included in the analysis).They were chosen at random, and the script of the interview was adjusted afterwards.
The interviews were carried out individually, in an environment where privacy could be assured.We made specific questions related to the sociodemographic characterization of the participants, following questions that made it possible to discuss the experiences and perceptions of the participants about succession planning.All interviews were conducted by a researcher trained in qualitative research, cultural sensitivity, empathy, and communication skills.We also adopted a reflective, ethical, and rigorous practice of research.Data analysis included transcription; a coding process; the use of software; and validation processes.With the permission of the participants, interviews were recorded to guarantee the accuracy of the discourse, and then transcribed (verbatim), resulting in 108 pages of written text.Data were presented via the creation of codes.The letter N was used indicating the word for nurse; a second letter followed, indicating the professional category; and finally, a number was included, indicating the chronological order of the interview.However, it should be noted that the points of data were collected and analyzed simultaneously, according with the principle of theoretical sampling (13) .
The procedure of coding had three stages, considering a continuous and integrative approach: open coding, axial coding, and selective coding.During open coding, we found the main categories, based on the memorandums and diagrams, since these are mandatory elements to form the theory (14)(15)(16) .The memorandums, as informal notes, allow the capturing of points of data and the establishment of relationships between them.The diagrams, as graphic representations of the relationships between the concepts, were elaborated using ATLAS.ti® .

Causal conditions
Lead In the third stage, that is, the selective coding, we grouped the categories and improved the theory: all categories were associated and systematized around the central category of the study, which emerged from the data (15)(16) .As a result, six categories and nine subcategories emerged.Data analysis was concluded with the determination of the theoretical conceptual model "Constructive path of the manager nurse".
To guarantee the application of ethical precepts, we ensured the confidentiality of data, the privacy of participants, the validity of results, and followed al legal regulations.We also requested and obtained ap-During axial coding (second stage), we related the categories to the subcategories, according to their dimensions and properties.Data collection was then better directed and the questions to be asked in future interviews were identified.We grouped the "pieces" of open coding data, and the relationships and connections of data gave birth to the paradigm (Figure 1).proval from the Health Ethics Committee of the Centro Hospitalar de Vila Nova de Gaia e Espinho, with number 201/2021.Furthermore, the participants gave their informed consent before the interviews.

Results
Most participants were female (n=16), aged from 40 to 63, with a mean age of 51 and a standard deviation of 7.36.Their work experience varied from 17 to 40 years, with a mean of 28.5 and a standard deviation of 7.4.Regarding their title, according to the Order of Nurses, five participants were Nurses, while 15 were Specialist Nurses.
Most participants, currently, have managerial roles (n=16), but some only performed these roles in the past (n=4).In some cases, the exercise of managerial functions was or continues to be in the same institution the person is working at the moment (n=14); in other cases, it was in a private clinic or residential structure for the elderly (n=2).Seven participants are manager nurses and 55% have training in management, especially post-graduation in management and administration (n=8).Of the 16 nurses who currently occupy managerial roles, 6 have formally recognized extra competences in management, which corresponds to 30% of the sample.
Data found indicates that succession planning is a procedure implemented informally in the diagnosis of manager nurses, but there are some gaps in the systematization of the process.The selection processes, the leadership profile, and the professional experience stand out in the diagnosis of manager nurses, which is made clear by the following statements: How should the administrator choose a management leader?Selection process, it has to be a selection process!(NB2).And profile, yes, to be a good leader!And a leader is not the same as a boss or a manager (NB5).The thing is: I think they should select, in the services, the workers with the most years of experience and competences associated with the field of management (NA3).
On the other hand, casual experiences in management are quite important to prepare these workers: The know-how of management doesn't come through osmosis, it has to come from practice, there is no way around it (ND3).Education in management, although one of the alternative explanations to this study, is clear in the processes of identification, choice, and professional development of the nurse manager: No one should be a manager with no post-graduation or a master's in the field (NA4).I think they must have been to some type of education course regarding health service management and hospital administration management (NB4).
On the other hand, there is a glaring omission in the statements in regard to the process of training the manager nurses, in contrast with the myriad data regarding the diagnosis of future managers: For example, they are identified... when it comes to preparation, they are not prepared (NB5).When I took office as a chief nurse, I was not prepared for it (ND4).
Statements showed a positive attitude towards the relevance of planning the succession: I think so, I think it would make sense for us to create a plan of succession.(NB3); I think it's a very... pressing issue.It has to be discussed and strategies must be created to, if possible, to start to implement it and see how we're doing it (NA1).Nonetheless, there are many hindrances/ obstacles to the practice, which is made more difficult due to the fact the participants do not know the process and lack resources: We have to do a lot of things in our personal time... there is a lot of effort, and we have to dedicate our time to this stage of learning, constructing, planning (ND3).
Our results show the benefits of succession planning, but managers are remarkably resistant to actively participating in the process: I, nurse manager, can be investing on nurse A or nurse B... but that is not taken into consi-

deration... (NC5). There are managers who don't let you do anything!
The manager does everything and more and doesn't want anyone to get in the way.This leaves no options and has to change!(ND5).
The barriers found include the COVID-19 pandemic and the changes in Administrative Councils, which hinder the necessary sequence of the process: But I never imagined COVID would come and do what it did, but since its here, I had to make good plans forward (ND3).This has to be an institutional project, has to come from the Administration Council.If the nursing administration was constant, we could implement such a process in this space, it would be possible (ND5).
Similarly, the participants mentioned appointments for managerial roles: If the chief nurses continue to be appointed informally... with no structure, no structured training, we will lose some if not all our strength in decision making (NB1).I can't see in some of the people appointed that they have formally recognized managerial competences...At this point, I know nothing about the methodology in the choice... (NC5).
In turn, motivations to implement the succession planning, mentioned by the participants, included retirements, absenteeism, and the opening of new services: When there is a retirement, someone will retire in one year or two... if possible, things could start to be prepared for the successor (NC1).A challenge I made to the nurse director was to plan the succession, namely in areas of competence that could be lost because people will retire (ND3).So I think that unpredictable replacements are challenging in all services, there should always be one extra person prepared in the field of management to take on in case of a disease, an impediment of some sort... (ND5).
Finally, the benefits of succession planning, referred to as favorable outputs, include professional recognition and satisfaction; quality assurance; human resource management; and the guarantee of transparency in the process.Here are some statements that corroborate these assertions: And when I say profitability, I mean resource profitability, right?Of human, material, and equipment resources (ND2).There would be an increase in productivity, due to both professional motivation and satisfaction.In my service there would be increased profitability, for example, regarding resources (NB5).Essentially... professional satisfaction, it is very important for a person to work satisfied.

(ND1).
If there is planning, the passage to leadership will be much easier, much more fluid, much less stressful for both the team and the person, leading to an increased quality (NB2).We could certainly have a more qualified management, I say.That would certainly impact on the quality of care, I mean, the goal is simply to provide good nursing treatment and care (ND2).There would be transpa-

rency for the general population regarding what can happen (NA4).
The data found suggests that succession planning is informally implemented in the diagnosis and preparation of manager nurses, but there are still limitations preventing the systematic and formalized implementation of succession planning.The results found generated the conceptual-theoretical model "Constructive path of the manager nurse", which was named as so as a reference to its own schematic representation (Figure 2).This conceptual model is a schematic representation of interrelated concepts and transmits a visual illustration of the phenomenon "succession planning".Its goal is to represent, in an organized and systematic fashion, an innovative approach to succession planning for nursing managers.
The precepts of this conceptual model are: processes to identify and select future managers can be simultaneous to the diagnosis of future managers; professional experience is a facilitator of learning processes in the context of the practice of management; Nursing specialization allows guaranteeing a more efficient use of the abilities, attributes, and competences of nursing managers; Training in management is necessary to improve the professional development of the manager nurse; The co-construction of the manager role must be a responsibility shared between education institutions and the health institutions themselves; The co-construction stage of the manager nurses generates learning and increases their own abilities and competences.
The concepts that form the same model included the theoretical description and the idea of the phenomenon of succession planning.As a result, the concept "Diagnosis of the future manager" includes procedures to identify (criteria that allows classifying future managers) and select (strategies to choose future managers among those identified) managers.The concept "Co-construction of the role of manager" includes preparing and developing professionally the future managers, while the concept "Limitations of the constructive path of the manager nurse" regards unfavorable conditions or obstacles that hinder the planning of succession.The concept "Motivations for the planning of succession" are defined as a set of causes that drive the planning of succession, and finally, the concept "Favorable outputs of succession planning" refers to the benefits of planning the succession.
The theoretical enunciates of this theoretical model include: The education and professional experience are references for the co-construction of the role of manager nurse; The favorable strategies to select nurse managers include the mapping of competences, the selection processes, the evaluation by peers, and performance evaluations; Favoritism and appointments from service commissions are unfavorable criteria for the diagnosis of a manager nurse; Appointments due to influence from third parties, changes in administration councils, and the pandemic contexts are conditions extrinsic to the profession, thus limiting the constructive path of the manager nurse.The co-construction strategies of the manager role include: Training in management, mentorship, occasional experience in management, previous integration, internships, and motivation; Retirements, prolonged absenteeism, and the replacement of managers for other reasons, while the opening of new services can better the constructive path of the mana-

Diagnosis
Co-construction  ger nurse; Lacking knowledge about the succession planning process, selection processes, and the lack of a career path, as well as the resistance of manager nurses to implementing the same process, are conditions intrinsic to the profession which limit the constructive path of the manager nurse.

Discussion
Specific education in the field of management is present in all stages of the construction of a manager nurse.It is one of the requirements of formally recognized advanced competences in management (18) and of the nursing career as a whole (19) .However, there are still important shortcomings in the educational processes, and, as a result, this concept is not a consensus.In fact, as the results found here exemplify, literature suggests that the particularities of institutions should be considered, and training should be a responsibility shared between educational institutions and employers (5,12) .Several authors advocate that the formation should include training in practice, and highlight the importance of institutional support, such as the flexibility of schedules, grants, and courses in management (5)(6) .
On the other hand, a consensus between our participants and literature regarding the concept of experience.In reality, experience learning is essential for the development of competences, as Benner's theory states (9,20) .Furthermore, the Order of Nurses defines this concept as a preferable condition to obtain formally recognized advanced managerial competences (18) .
Although the appointment by a service commission was pointed out as a diagnostic criteria, it is also seen as an adverse criteria for successor selection.Appointments, as an informal way of access, have become more prevalent than selection processes where qualification and experience were considered.In practice, the requirements considered for appointments are unknown, unsystematized, and the opinion of collaborators is not consulted.Thus, the appointment and replacement of manager nurses is often a confidential administrative process (5) .
In the scope of professional development strategies, those that stood out prescribed interaction between experienced managers and their successors, so they can assume their roles with more security (21) .The sharing relationship that emerges brings many bene-fits: managers are encouraged to perform better and successors build their confidence and competence in clinical practice (6,9,22) .
Mentorship, as an organized and integrative method to guide the successors (12,(22)(23) , implies on a commitment, an alliance between mentor and mentee (5,12) .Despite its benefits, which were described by the participants, literature indicates that its implementation in health institutions can be challenging, expensive, and have several obstacles, including the lack of time or motivation on the part of the managers (12,23) .
Some benefits of succession planning described in literature include a reduction in nurse turnover (5)(6)(23)(24) ; internal promotions more beneficial than external recruitment; talent retention; increased work performance; and improvement of potential management candidates (2,5,12) . The saisfaction and recognition of professionals is also mentioned in literature, in accordance with the results found, since succession planning increases the motivation of workers from a perspective of professional progression (7) .In fact, many seek to have their curricula recognized to reach their career path goals (5) .
On the other hand, professional satisfaction is increased by succession planning, since it implies a systematized and transparent process, as to guarantee a successful passage of successors into managerial roles (7,12,23) .
Finally, literature is in accordance with our results, considering the perspective that succession planning favors transparency in the constructive process of the manager nurse.This transparency depends on the involvement and support of the organization, and high-ranked nurse managers reassure the development of their workers, on the promotion of a healthy work environment, and on the reduction of bureaucratic procedures (5,12,24) .It implies in defining, explicitly, the criteria that allows reaching managerial roles and defining the stages of succession planning chronologically.These stages include: the creation of work groups; the identification and selection of potential successors; the professional development of the candidates identified; the evaluation of procedures; information on remuneration and indication of the roles to be filled (12,24) .
Concerning the limitations that challenge the constructive path, the COVID-19 pandemic stands out, with all its challenges and complexities in the field of nursing management.Work overload, associated with the complexity of the disease, led to evident unbalances in the work processes.Nonetheless, the role of the manager nurse was shown to be essential in the organization, productivity, and guarantee of the quality and safety of the care provided in this particularly adverse context (25) .
Our results made clear that the construction path of the manager nurse must take place in a decentralized way and be adapted to each specific context, considering its specific needs, characteristics, and culture.The elaboration of evidence-based guides has the potential to encourage participation of manager nurse in the process and guarantees that succession will be individualized, that is, will consider the specific characteristics of each work context (7) .Furthermore, manager nurses have a privileged role in the process of constructing future managers, reuniting key-competences for the professional development of their successors.

Study limitations
From this research, the theoretical-conceptual model "Constructive path of the manager nurse" emerged.However, an operational improvement of the links and relationships between the concepts is still necessary.Similarly, time limitations associated to the academic path have prevented a robust development of validation processes or the test of the current theory.In addition, studying the particularities of succession planning in other contexts (primary health care; private entities) is an important gap in this study, that could lead to future investigations.

Contributions to practice
Since the succession planning in nursing management is not nationally developed, this work improves the discussion on the topic, consequently having the potential to catalyze changes in the field of nursing management.We hope this line of research can be an inspiration, consolidating succession planning in Portuguese nursing management.We also expect the theoretical-conceptual model developed here to represent the constructive path of the manager nurse, so it can be recognized and applied in a practical context.The identification of conditions that promote and limit this path means that this study is a substantial contribution for the management of human resources in nursing.We also hope these outcomes will significantly encourage the diagnosis, education, and professional development of manager nurses

Conclusion
Portuguese nurses mentioned several benefits of a succession planning for manager nurses, but there are still challenges to its implementation and some reluctance on the part of current managers to have a more interventive and participative role in this process.In fact, the greatest contribution current managers could have to the future would be to assume the responsibility of preparing their successors.

-Figure 2 -
Figure 2 -Diagram of the conceptual-theoretical model "Constructive path of the manager nurse".Porto, Portugal, 2022