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Moving toward a more objective peer review process

Ray, Kristin BSN, RN, CPN; Meyer, Stephanie MS-FNP, RN

Nursing Management (Springhouse): January 2014 - Volume 45 - Issue 1 - p 52–54
doi: 10.1097/
Department: Performance potential

At Children's Mercy Hospital and Clinics in Kansas City, Mo., Kristin Ray is an assistant nursing department director for Surgical Services and Stephanie Meyer is the nursing department director of Surgical Services.

The authors have disclosed that they have no financial relationships related to this article.



The concept of peer review can be interpreted very differently among nurses and healthcare professionals. Some think of a subject expert reviewing a manuscript for a journal's editorial staff. Others think of regulatory bodies requiring hospitals to have an internal process to ensure that healthcare team members are competent and able to perform within their scope of practice.1 Still others think of peer review as a quality assurance process in which healthcare team members audit each other's documentation to validate care standardization.

We provide insight into a nursing peer review process designed to evaluate performance, and the journey to its implementation. A well-defined peer review process and tool, utilized in conjunction with a nurse's annual performance evaluation, is one way to infuse meaningful peer input into a performance appraisal. This system allows nurses to provide insight into one another's strengths and opportunities for growth. A detailed approach was used to create, develop, and sustain a nursing peer review program that's flexible enough to be used by all staff members within a pediatric hospital system. In addition to promoting professional growth among nursing staff, this process also meets the current peer review standards set by the Magnet Recognition Program® and The Joint Commission.

The ultimate goal of sharing this information is to help other organizations that are just beginning the peer review process and those that have struggled in the past with development and implementation to bring about a sustainable change. This, in turn, will promote nursing cohesiveness and professionalism as we work together to bring healthcare into a new era.

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Organizational standardization

Our organization embarked on an initiative to create a standardized peer review process that would be utilized by all nursing departments. The process needed to be integrated organizationally and applicable to clinical nurses within both inpatient and outpatient environments. This journey began with a review of the current literature and an examination of the current peer review practice at other Magnet® facilities. Through this process, it was discovered that the majority of these facilities utilized and defined peer review in a variety of ways. We identified variation in the management of the peer review process within our own organization.

Acknowledging the vast array of discrepancies within and external to the organization, a task force of clinical nurses was developed to redefine the way our organization administered the clinical nurse peer review process. This task force also included two leadership liaisons who served as resources to the clinical nurses during this development and provided insight into the management side of the peer review process. There were four steps in our process: (1) defining a peer, (2) developing a peer review form, (3) transforming the process, and (4) implementing the process.

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Who's a peer?

The first step in our work involved evaluating, discussing, and reaching a consensus on the definition of peer. In order to standardize the peer review process, the task force recognized a true definition was needed to measure success with the new process. Looking at previous peer review practice in the organization, many nurses and department directors had different definitions and ideas of what it meant to be a peer. Some departments included other disciplines in a nurse's specialty for evaluations, whereas others utilized only fellow nursing staff members.

The task force agreed that the purpose of peer review is to foster professional growth and development among staff members by utilizing a process through which measurable outcomes are assessed. After much dialog, the task force adopted the definition of peer utilized by the American Nurses Association, which defines a peer as an individual of the same rank or standing according to the established standards of practice.2

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Form development

The next step in redefining the peer review process was to develop a new peer review tool that could be transferrable and applicable among the various nursing specialties and departments. Key areas identified by the task force for development of this tool included creating a short, concise form that's easy to understand with limited directions and applicable to all clinical nursing departments. To achieve this goal, the task force worked collaboratively to establish eight domains that would provide nurses with a peer evaluation framework. These domains were established through open dialog, including question-and-answer sessions, review of current job descriptions, and evaluation of other tools utilized by various Magnet facilities.

Through this work, a common set of core expectations were identified and utilized in the development of each domain. These domains encompass the essential clinical nurse job functions, behavioral competencies, and basic roles and responsibilities throughout the organization. The domains can be found in Table 1.

Table 1

Table 1

To further guide and support high-quality peer feedback, three to five specific, measurable objectives were created and listed under each domain for nurses to measure performance. These objectives were developed to guide peers in evaluating each nurse by providing focused, pertinent feedback. The task force wanted to eliminate vague, nonspecific feedback that didn't facilitate the identification of future growth opportunities. The objectives created by the task force assist peers in identifying evidence from the nurse's daily work, communication, time management, and interdisciplinary interactions.

Each domain also included a comment field, allowing nurses the autonomy to provide open-ended feedback and elaborate on outstanding work or opportunities for the employee's growth and improvement. The comment section was extremely important in the solicitation of meaningful feedback because it allowed nurses to provide examples to reinforce the ratings selected for the objectives. The directions on the new tool clearly state that comments are mandatory for certain ratings to allow for elaboration and examples.

The task force believed a Likert rating scale was essential to standardize the peer review process. The previous process utilized a vague, numerical score that hadn't historically provided nurses with adequate descriptions of their work ethic and performance. Lower scores were considered negative responses, whereas higher scores equated to positive responses. After review of the current literature, the task force employed a 4-point Likert scale comprising “not met,” “approaching,” “meets expectations,” and “exceeds expectations.” In addition to the scaled questions, an open-ended question “Do you feel comfortable working with this nurse?” was added to the form. Utilizing a mixed-method methodology, Likert scale, and open-ended question format allowed the evaluating nurse a better opportunity to provide real-life contextual examples related to the evaluated nurse's care.3

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Process transformation

After the peer evaluation tool was created, the task force focused its attention on creating a framework to aid departments in implementing the new peer review process. Throughout our hospital, there are units of vastly different sizes. Some nursing departments have four to six clinical nurses, whereas other departments have as many as 150 to 200 clinical nurses on staff. The variability in staff sizes meant that the task force had to be creative in determining how many peer reviewers should evaluate each nurse annually and how these reviewers should be selected.

With the new process, each nurse receives feedback from two to four RNs. Limiting the number of peer evaluations eliminated the previous dissatisfaction and/or barrier of evaluators being asked to fill out 20 to 30 peer evaluations a month due to exceedingly large nursing departments. The task force also allowed clinical nurses to select one to two peers of their choice to provide feedback; the management team selected the remaining peers.

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After the task force completed the new peer review tool and process recommendations, the nursing department directors and the CNO gave the approval for implementation. The standardized peer review form, along with the revised process, was implemented using various educational modalities. The first presentation was provided to the inpatient and outpatient nursing directors to inform them about the new form and the revised process. The directors were provided with handouts outlining the changes and educational fact sheets for the staff members to use as a reference. The task force increased its availability to ensure educational consistency to all clinical nurses by attending and presenting at unit-based councils, charge nurse meetings, and department-wide staff development programs.

The feedback received from the different educational presentations was extremely positive. Feedback discussed the tool's ease of use, applicability to all nursing departments, appropriate form length, and measurable objectives that allowed nurses to comment on focused job roles and responsibilities. Other feedback included the improved functionality of the new rating scale and the process change that limited the number of requests for peer evaluations.

Some directors expressed resistance to changing their current peer review practice. Certain directors thought feedback from four nurses wasn't enough if the department had a high number of nursing staff members. After an open discussion with the task force chairperson and the directors of large departments, it was agreed that meaningful feedback from four people would be adequate. Other directors mentioned that they liked the idea of adding specific clinical skills for peer evaluation. However, we couldn't add specific skills because they wouldn't universally apply to the various nursing department specialties.

The task force collected all comments and feedback, and created a frequently asked questions document to address these concerns and explain the thought process behind the decisions made about the tool and recommendations. Directors were then provided with answers to and rationales for their specific questions and concerns, creating a consistent message and clarity to all departments.

All education and implementation occurred over the course of 4 months. During this time, the task force worked with web development to formulate an electronic version of the peer evaluation document for the purpose of online submission. The electronic document was widely popular because it eliminated the use of paper and facilitated tool access for all clinical nurses. Staff members were able to complete the tool online and submit the evaluation through the organization's intranet directly to the person who requested the feedback. The task force also concluded that in order for this new tool and process to remain functional and meaningful, continued evaluation of its use would be essential.

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Reaching the top

As we diligently work to move the nursing profession forward, it's important to remember that peer review can positively impact not only an individual's nursing practice, but also an entire hospital system. Nurses are at the forefront of healthcare transformation and are integral to sustainable practice improvement. By empowering clinical nurses to lead this initiative, we've been able to successfully introduce, develop, and support a valuable peer review process across our organization. Utilizing a comprehensive peer review tool can help organizations improve patient outcomes and patient satisfaction.

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1. The Joint Commission. 2013 Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources, Inc.; 2012:MS28-MS30.
2. American Nurses Association. Peer Review Guidelines. Kansas City, MO: American Nurses Association; 1988.
3. Creswell JW, Klassen AC, Plano Clark VL, Smith KC.Best practices for mixed methods research in the health sciences.
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