Peer review—identified by the American Nurses Association (ANA) as part of professional self-regulation since 19731 —strengthens the profession by placing the primary accountability for nursing practice on nurses and encouraging internal regulation and evaluation. Without it, nursing practice is susceptible to control from other disciplines.2 The salience of peer feedback is reflected by its inclusion in the ANA's Code of Ethics for Nurses with Interpretive Statements,3 and by the fact that organizations seeking to obtain or maintain Magnet recognition must demonstrate a formalized peer review process.4
Peer review among various groups of health care professionals—including nurses, physicians, pharmacists, and physical therapists—has been associated with positive outcomes, including increased self-reflection,5, 6 satisfaction,7 and staff engagement7, 8; it has also been shown to improve patient safety and communication.6, 9-12
Limited literature exists on how to incorporate a peer review program in the clinical setting, and what little literature is available is primarily descriptive or focuses on quality improvement. However, the features most commonly identified in the literature as components of a successful peer review program include a formalized peer review committee; the use of a standardized tool; assigned peer reviewers who are not anonymous and are of the same rank as the person being evaluated; a nonpunitive process that has no impact on performance appraisal; inclusion of behavioral and clinical components; training of staff to provide and receive constructive feedback; comparing practice against a standard or guideline; and aiming at professional development and engagement.5-17
This article discusses the successful multiphased integration of a peer review program within a busy nursing unit, along with the resulting outcomes.
IDENTIFYING THE PROBLEM
At the Memorial Sloan Kettering Cancer Center in New York City, the pediatric service includes an ambulatory treatment center staffed by 36 RNs who care for as many as 130 patients per day. The unit has three clinical areas—the treatment area, the iv room, and the procedure room. In the treatment area, nurses provide such interventions as chemotherapy, biotherapy, and urgent care, and administer blood products, iv fluids, and cell infusions; in the iv room they perform blood draws, provide vaccines and iv push and short-infusion chemotherapy, and prepare patients for procedures; and in the procedure room they sedate patients for radiology imaging and for such procedures as lumbar puncture, bone marrow aspiration, and central line placements. Though the areas function independently, they share one nursing team.
In 2012, as the unit was undergoing changes in leadership, clinical operations, and patient flow, the nursing staff and leadership recognized that the team dynamic was poor and that communication among nurses was faltering. Results of the annual National Database of Nursing Quality Indicators (NDNQI) survey—which that year indicated that less than 10% of nurses were “satisfied” in RN-to-RN interactions—offered evidence that change needed to occur.
Initially, two senior nurses were charged with meeting with each nurse to discuss her or his shortcomings. But because these conversations were based on hearsay and biased opinions rather than substantiated practice issues, they did not offer any tangible solutions. The process had no positive impact and the staff remained dissatisfied.
As there was no peer review framework within the institution, a group of clinical nurses decided to form the first unit-based peer review committee. With encouragement from the leadership, they went on to conceive a process whose preliminary goal was to implement a system that strengthens professional relationships, establishes accountability to peers, and improves nursing practice through constructive feedback.
An early literature scan offered little guidance on creating a formalized peer review program. Other institutions we surveyed had structured peer feedback systems; however, none fit the dynamics of our nursing staff. Consequently, the group constructed its own specialized peer review process, which occurred over the course of four years in three phases: planning and process development, enhancement, and expansion.
CREATING A CULTURE OF FEEDBACK
Phase 1: planning and process development. After conducting a literature review, the group decided to form a committee, gather information from nursing departments at various institutions, and create a peer review process and assessment tools. A unit-based committee of 12 volunteer nurses was formed to develop the program, which initially had two components: incident-based peer review and annual performance peer review. However, the incident-based peer review was phased out after six months because it was similar to the hospital's event reporting system and root-cause analysis process.
For the annual performance peer review, the committee developed an assessment tool based on the institution's nursing standards of practice and role expectations. It encompasses all three components of relationship-based care (RBC): care of patient, care of colleague, and care of self.18 Unique to the needs of the unit and emphasizing the areas of practice most important to the nursing staff, the tool encourages productive feedback in each of the three designated RBC areas.
The next step focused on tailoring the process to encourage participation. While the literature suggests that feedback should not be anonymous,8 there was concern—based on the low score for RN-to-RN interaction in the NDNQI survey—that the nurses on the unit would not engage sufficiently. After consulting with other institutions, which reported a combination of anonymous and identified peer reviewers, the committee decided on a hybrid approach: each nurse would be reviewed by two randomly assigned, anonymous peers and one self-selected nonanonymous peer. The goal was to create a process that would provide constructive feedback openly and freely, without the fear of confrontation.
The process of compiling the reviews was designed to keep the feedback constructive and minimize bias. Each staff member was assigned a number, and an Internet-based number randomization program was used to assign three nurses to each committee member, who in turn was responsible for collating the reviews for each of the three nurses. Each collator sent standardized e-mails to explain the process to the nine nurse reviewers (three for each of the three assigned nurses), distributed the paper tools (which varied according to nurses’ clinical levels), and assigned a due date three weeks away. After the reviewers returned their completed reviews, the collator had two weeks to combine all the ratings and comments into one document for each nurse. Over time, the paper tool became electronic; allowing nurses to e-mail their responses—rather than provide handwritten notes—improved the process by facilitating its completion and decreasing the collators’ workload.
After all responses were compiled, each collator met privately with each evaluated nurse to deliver the peer feedback. The collator and the nurse discussed their reflections on the feedback and identified achievable goals. In total, the peer review cycle took 12 weeks (see Figure 1).
Management supported the process but had no direct involvement in its creation or in the distribution or results of the peer review, demonstrating to staff that the process was nonpunitive. After the feedback was completed, nurses were asked to fill out an exit survey, indicating their thoughts on the benefits of the peer review process and offering suggestions for improvement.
Phase 2: enhancement. After three cycles, a more comprehensive survey was sent to staff to evaluate the tool and to suggest how to improve it. The feedback indicated that the tool, which included 21 areas of competence, took too long to complete, and contained redundant questions. As a result, similar questions were consolidated under general topic headings.
The modified tool asks nurses to rate their peers according to four categories: patient care, collaboration with colleagues, professional development, and professional behavior. Questions were rephrased to be open-ended, and this provided more substantial feedback. Each category required a numerical rating on a scale of 1 to 4 (1 = needs major improvement; 2 = needs minor improvement; 3 = meets expectations; 4 = outstanding), along with a mandatory comment to justify the given score. The tool also included two additional comment sections, asking peers to share what nurses do well and how they can better support the unit. (See Categories of the Annual Peer Review Assessment Tool.)
Additionally, the assignment process was altered so that nurses received feedback from peers whose clinical rank was different from their own (both above and below). A section was added for setting personal goals—created by the evaluated nurse and her or his assigned collator based on the feedback—to be accomplished in a three-to-six-month time frame. Collators were responsible for following up with their assigned nurses to encourage them to meet their goals throughout the year.
Phase 3: expansion. When the peer review process was first implemented, staff was encouraged, but not required, to participate. Those who abstained said they were not comfortable sharing criticism because they believed it was not their place to judge a colleague's practices, or they felt defensive about receiving feedback on their own clinical aptitude. Initial participation rates were low: out of the 30 to 32 staff members on the unit during the first five years of the program, only 11 (34%) participated the first year. Participation grew to 26 (81%) and 24 (80%) the second and third years, 28 (93%) the fourth year, and eventually to 31 (100%) in year 5 (see Figure 2).
Annual in-service education on the importance of peer review, along with the committee members’ guidance on how to offer constructive feedback, helped to improve staff engagement. A formal presentation prior to each review cycle included suggestions for reviewing and providing feedback. The guidelines—which focused on being succinct, specific, objective, and growth oriented—were based on a combination of recommendations extrapolated from the literature and from the nurses’ constructive criticism regarding the process (see Guidelines for Giving Feedback).
In the earliest years of the program, some staff members didn't receive a completed peer review because their colleagues hadn't filled out their assessment tool. During subsequent peer review cycles, committee members became more diligent in sending reminders to have the reviews returned, staff became more comfortable with the peer review concept, and overall participation increased. After four cycles, with the support of the unit nurse manager, the peer review process was mandated for all nursing staff on the unit.
The success of the peer review process is reflected in the consistent improvement in the 2012 to 2015 NDNQI surveys regarding RN-to-RN interaction: our scores went from the bottom 10th percentile to the top 50th to 75th percentiles in a nationwide comparison. In a survey conducted after year 3, almost 89% of nurses agreed that peer review strengthened their professional relationships with their peers, which had been one of the committee's primary goals. Additionally, 81% of nurses agreed that the feedback they received helped improve their nursing practice. The quality of the feedback also significantly improved from year to year. While the nurses initially described their peers’ behaviors in terms that were terse and not specific, over time their feedback became more substantive and included specific examples, objective comments, and suggestions for growth and development (see Table 1).
By championing the positive outcomes that result from a robust peer review, the committee garnered sustainable support from the unit's nurses, who recognized that strong professional relationships, accountability to peers, and improved practice through feedback were necessary to the profession. As the nurses acclimated to the process, they became more comfortable in giving and receiving feedback, recognized the impact of their practice on colleagues, and realized that their insights improved the professional practice of others.
Thoughtful feedback and concrete examples were found to be the most meaningful part of the process, as they helped nurses appreciate their own strengths, identify areas for improvement, and set goals. Developing the right questions was also essential, because questions needed to address all areas of practice without being too extensive or repetitive. After four cycles, the committee improved its method of operation and the performance of peer review. Each year may require further updates.
The committee members—backbones of the peer review process—have been instrumental to its adoption. They not only meet with nurses to offer constructive peer feedback, they also help guide the staff on how best to provide feedback, even outside of the peer review process. To properly distribute the workload, membership in the committee is maintained at about a third of the total staff. And to keep the exchange of ideas robust, committee members consist of a multigenerational group with varied experiences, knowledge, and backgrounds. Voluntary membership has ensured that members believe in the process, are committed to its success, and collaborate annually on continuing to improve it. Leadership support has also been crucial to the successful implementation of the peer review process.
For the nurses, challenges included finding time away from patient care to thoughtfully complete peer review; for the committee members, an ongoing hindrance was having to remind staff to turn in their reviews. To facilitate the process, deadlines were set for the committee members to send out reminders, and for the nurses to turn in their reviews.
During development of the peer review process, support from staff was initially low. This was not surprising considering the unit morale at the time. We concluded that staff would be more receptive to feedback if the surveys were anonymous. With continued improvements each year, the process has now become fully integrated within the unit, leading to enhanced morale and increased collaboration. The nurses have even embraced spontaneous and constructive face-to-face conversations, out of a sincere desire to elevate each other's practice and to improve patient care. As the process remains fluid, improvements will continue to be made toward a nonanonymous peer review process.
Peer review—essential to professional development and enhancement of nursing practice—is not a welcome process to most nurses. But with education, support, and training, it can become an ingrained characteristic of professional practice.
The assistance of leadership and the ongoing encouragement of a committee dedicated to developing a method for offering and receiving feedback are crucial to the successful implementation of a peer review program. The process and corresponding tools should be created by those who use them and adapted to the needs of each unit, thereby increasing the likelihood of their adoption. Continuing education and support are necessary to help staff develop and strengthen their feedback skills, and in time, the annual peer review will help nurses become accustomed to offering and receiving constructive feedback all year long.