How to Construct an Peer Review Process

Development of a Nursing Peer Review Process at Cypress Fairbanks Medical Center

Task 1: Project Proposal

Clinical/Organizational Problem

The need for establishing a nursing peer review (NPR) process has been identified by researchers in the healthcare industry (Bergum, Canaan, Delemos et al., 2017). Cypress Fairbanks Medical Center currently has no NPR process in place and thus has no means by which nurses can receive peer evaluation when a patient care problem has been identified. As Garner (2015) notes, NPR is an accepted method that facilities can utilize in order to “improve nursing quality and safety” (p. 271). NPR can also help to improve the workplace culture in the healthcare organization (Cisic & Frankovic, 2015). While the Cypress Fairbanks Medical Center has always had a good workplace culture, improving the culture even more is a topic that management often discusses.

Description of Problem

Cypress Fairbanks Medical Center is an advanced-care facility in Houston, Texas, that maintains 180 beds and employs approximately 500 physicians, staff members and continuum of care providers. Since 1983, the facility has provided a wide range of health care services to patients in the community, offering 24-hour emergency care, a Primary Stroke Center, a Chest Pain Center, pediatric care, bariatrics, ob-gyn services among other specialties.

While the facility has achieved great success in its more than three decades of service, it has to date no nursing peer review process to help nurses obtain feedback from their peers when patient care problems arise. Nursing peer review can be an effective means of communicating to nurses issues that might otherwise go unaddressed and lead to further complications down the road (Roberts & Cronin, 2017). Additionally NPR can help to improve quality and safety in the facility (Whitney, Haag-Heitman, Chisholm & Gale, 2016). To improve quality at Cypress Fairbanks Medical Center, an NPR process should be developed.

Explanation of Causes

The problem of how to improve quality care is one that has myriad factors to analyze. One can approach it from innumerable directions. Patient wait times may be excessive, for instance, leading to low patient satisfaction (Institute for Healthcare Improvement, 2018). Nurses may be overworked or experience alarm fatigue (Horkan, 2014). A lack of good leadership could be contributing to a poor workplace culture (Schyns & Schilling, 2013). All of this can have a negative effect on quality care. One way that researchers have identified as having a positive effect on improving quality care, however, is the NPR process (Garner, 2015).

However, one of the reasons that each of these patient care problems may exist is that there is no nursing peer review process that will support overall nursing care development (Garner, 2015; Bergum et al., 2017). When nurses are not subject to routine peer review, their patient care may slide through negligence or any of the other factors described above. Engaging in peer review can help professionals to ensure that top quality care is being delivered, just as peer review among academics who publish their work in journals helps to ensure that research is produced and routinely checked for quality.

The NPR process enables nurses to coordinate and organize more effectively ensuring that positive feedback from peers will facilitate the development of quality care processes over time (Roberts & Cronin, 2017). In order to develop the NPR process, nursing indicators have to be indentified: these are events involving patient care problems that trigger the implementation of the NPR process (Garner, 2015). Identifying what indicators should trigger the process is the first step.

Identification of Stakeholders

Stakeholders in the development of the NPR process include: RNs, patients, physicians, and the hospital administration and management.

Discussion of stakeholders.

Nurses at the hospital have the power to implement the NPR process and to initiate it routinely. They also have the main interest in the process, as they are the ones who stand to benefit immediately from it. Their influence is also the one to be most felt, as they are the individuals who will be relied upon to ensure its effective implementation.

Patients stand to have power in this process in the sense that they, ultimately, will be the ones whose satisfaction is at stake. If they continue to express dissatisfaction with services, nurses will have to undergo further review. Thus, their influence is equal to their power in this regard, and as for their interest, they are the ones who ultimately stand to benefit—albeit indirectly—from the nurses’ improvement in quality care.

Physicians will have power in this process to a limited degree, as the peer review will be conducted by the nurses. Their influence, however, may be felt in that they communicate with nurses and can serve as indicators for review, just as patients can. Additionally, their interest in the NPR process development is considerable for though they are not on the receiving end of quality care, they are on the giving end and when nurses are better trained and equipped to help physicians deliver quality care, doctors can be more confident that their treatment care will be satisfactory for patients.

Hospital administrators and nurses also have power in this process as they will be the ones to oversee its development and implementation. Their influence will be equally significant as they can make recommendations and insert changes along the way. Likewise, their interest in the process is also equal to their power and influence as they, ultimately, like the patients (though in a different manner), stand to benefit from the process, as better nurses equals to more satisfied patients, which is likely to mean that the organization will continue to be able to provide care to them and maintain or even increase revenues.

Explanation of Project

The purpose of this project is to develop an NPR process for Cypress Fairbanks Medical Center. The NPR process will allow nurses to review themselves so that they can better provide quality care to patients. The process is a response to indicators or triggers (such as patient care problems) that arise during the course of nursing care. When a problem arises, the NPR process is engaged, and nurses receive feedback from their peers to help them overcome issues that resulted in the initial care problem. However, in order for the NPR process to be engaged, the NPR must first be developed, and that is what this evidence-based project aims to accomplish.

Proposed Solution

RNs alone are involved in the NPR process, as “peer” refers to those individuals who are in the same role as the nurse being reviewed. Peer review can thus only be accomplished by the other nurses who are working in the same ward or department as the nurse subject for review. Therefore the development of the NPR process should include feedback from RNs about what types of communication and feedback should be included in the peer review and how reviews should be written. A knowledge of the job, therefore, is required in order for the review process to be effectively employed. The focus of the review is on the work not on the personality of the nurse. Its aim is collegial not confrontational. The review is also not anonymous. One of the purposes of the review is to facilitate the growth of respect among RNs. The tone of the review should also be professional. Professionalism is expected among nurses—and that is the reason for the NPR. Thus, the NPR itself should maintain a professional tone. And the main purpose of the review is to enable nurses to assist one another so the quality care can be delivered routinely by all. Nursing managers and administrators will only be required in terms of providing oversight in the development of the review process. Their expertise will be helpful in ensuring that the NPR provides a framework for addressing key characteristics of the job. As the project will take place at Cypress Fairbanks Medical Center, the nurses at the Center and select managers and administrators will be used to facilitate the development of the NPR.

Evidence Summary

The NPR process is an effective way to help nurses achieve quality care and safe practice with respect to patients and to promote a positive workplace culture. By highlighting areas of concern for nurses who have shown signs of having difficulty in certain patient care areas, the NPR reduces the risk of nurse error by allowing nursing peers to inform nurses in a professional manner of what the individual is doing correct and incorrectly (Roberts & Cronin, 2017). In this manner, the NPR is most helpful because it ensures that education is continuous and ongoing while nurses are on the job and not something that stops with the last class in nursing school (Bergum et al., 2017). Highlighting the educative aspects of the NPR supports the concept of it being used as a professional development tool rather than as it being misperceived as a tool for personal attack. Conducting the NPR also helps nurse managers plan for the future development of training and education procedures in the facility (Cisic & Frankovic, 2015). This in turn facilitates the development of the workplace culture and supports communication, collaboration and professional development.

Developing the NPR is something that nurse administrators and managers should consider carefully. When developing the NPR, it is important to consider indicators or patient care problems that should trigger the process (Whitney et al., 2016). It is also important to educate staff on the purpose of NPRs so that they are not fearful about engaging in the process (Garner, 2015). One way to assuage fears is to show that peer review is practice focused not person focused (Saver, 2016). This helps nurses to feel more comfortable about being honest regarding what they see their peers do effectively or ineffectively and where the raising of some awareness could be beneficial.

Plan of Action

This project will be initialized with the consent, support and oversight of the head nurse at Cypress Fairbanks Medical Center. The head nurse and the writer of this capstone will convene a panel of volunteer RNs at the Center, consisting of six total nurses to identify triggers that will serve as prompts for initiating the peer review process. With these triggers identified, the development of the NPR process will move onto the preparatory stage.

The preparatory stage will consist of gathering information on NPR best practices. The development of the NPR will be based on evidence obtained by conducting a literature review of relevant studies that provide ideas on how to approach the process and what principles to follow. These principles will serve to guide the development process from beginning to end.

Cisic and Frankovic (2015) provide six principles that should be used to guide the NPR development process:

· A peer is someone of the same rank.

· Peer review is practice-focused.

· Feedback is timely, routine, and a continuous expectation.

· Peer review fosters a continuous learning culture of patient safety and best practice.

· Feedback is not anonymous.

· Feedback incorporates the nurse’s developmental stage.

These six principles are important to follow because each reinforces the concept of the review being open, honest, professional, and practice- rather than person-oriented. Observations made in the peer review should be disinterested and objective and should serve to show the extent to which the subject nurse is performing in accordance with the organization’s expectations.

Bakker and Schaufeli (2008) note that “employee engagement is conceived in terms of commitment and extra-role behavior, for instance, as a psychological state where employees feel a vested interest in the company’s success and perform to a high standard that may exceed the stated requirements of the job” (p. 151). From this perspective, it is completely advisable that nurses take part in NPRs because it can produce a “psychological state where employees feel a vested interest” in one another and in the healthcare organization itself.

The development plan is to proceed in five basic steps:

· First, the project will be given permission to proceed by the head nurse at the facility and the panel of six nurses will determine a broad scope for the NPR and the basic topics it should include.

· Second, the literature review will be conducted.

· Third, the main recommendations for constructing an NPR obtained through the literature review will be presented to the panel for confirmation and so that further comments or recommendations can be obtained.

· Fourth, the NPR will be constructed in accordance with the principles and standards recommended by researchers in the field and within the framework desired by the panel.

· Fifth, the NPR will be reviewed with stakeholders and the panel to ensure that it conforms to the needs of the facility.

The end product will be a complete NPR that can also be used for self-appraisal. It will allow nurses to evaluate the extent to which core competencies, practice, knowledge and skill are evident in the nurse subject. It will allow nurses to provide both quantitative data (using the five-point Likert scale) and qualitative data (such as additional comments or recommendations). Post-delivery discussions with stakeholders will involve evaluating the NPR and standardizing its application in the facility.

Timeline

Week 1 will involve discussing the project with the head nurse and selecting nurses for the panel to obtain insight into what they would like to see in an NPR. The nurses on the panel will include the researcher, the head nurse, and four other nurses who volunteer to meet for the panel discussion. The nurses will be workers at Cypress Fairbanks Medical Center. The panel will meet twice: once on the Monday of the first week and once on the Friday of the first week. The first meeting will be held to introduce the topic and explain its significance and to discuss possible triggers that could be used as a call to conduct the NPR once it is developed. The panel will also be asked to provide input on ideas or thoughts about what to include in the NPR. The second meeting will be held to share these thoughts and ideas so that the researcher can include them in following week’s research.

Week 2 will involve conducting the literature review. Key word searches will be conducted using ideas presented during the panel from the prior week. Searches will be performed using online databases such as PubMed and Google Scholar. Inclusion criteria will be based on panel discussions about what to include in the NPR and articles for inclusion in the literature review will be decided based on abstract.

Week 3 will involve reconvening with the panel to share evidence obtained through the literature. The meeting will be held on the Monday of the week so that if there is need for further meetings to discuss the evidence obtained, there will be time throughout the rest of the week. If the panel is satisfied with the evidence obtained from the literature review and presented by the researcher, the project will move forward with the fourth step.

Week 3 into Week 4 will involve constructing the NPR based on the evidence obtained from the literature review and the inputs received from the panel. The aim of the construction of the NPR will be to include the areas for review that are pertinent to the triggers discussed at the panel and the areas that are highlighted in the literature review.

Week 5 will involve presenting the completed NPR to the panel to discuss it and to receive feedback. Any revisions to the NPR will be conducted during this week and presented in the final meeting with the panel.

Resources and Personnel

The panel will require the use of one meeting room with a table large enough to seat six. At Cypress Fairbanks Medical Center there are numerous meeting rooms available for this purpose and obtaining one at will presents no problem or difficulty.

The personnel who will serve on the panel will include the researcher, the head nurse and four nurses who volunteer their time. They will be chosen on a first come, first serve basis: an announcement will be made among the nursing staff at Cyprus Fairbanks in the week prior to Week 1. The first four nurses to come forward and express interest in assisting with the panel to share ideas about NPR will be included.

Proposed Change Theory

Manchester, Gray-Miceli, Metcalf et al. (2014) show that Lewin’s change model can be effective in promoting evidence-based practices in health care. Lewin’s change model is the basis of what in recent years has become known as “sensitivity training,” because it focuses on how personalities are involved in the process of creating a culture and impacting the stability of an environment. Lewin’s (1935) theory originated in A Dynamic Theory of Personality, in which he used empirical evidence to develop a theory for how personality evolves over time, essentially from childhood into adulthood. In an early documentary film, Lewin (1925) recorded images of children playing. He analyzed the film and saw a variety of personality forces at work. In instance, he showed a boy displaying “simultaneous attraction and repulsion (a positive and a negative valence)” for the sea, which “in the same place leads in this case to oscillation of the actions”—and the boy would be shown running to and away from the sea. Lewin’s change theory developed out of this insight. It showed how in human systems there is a level of resistance to change that is to be expected based on these variety of forces within the human personality. To address these forces, Lewin proposed a three-stage model that is also called the unfreezing-change-refreeze model, which is based on the idea that old habits and ideas have to be “unfrozen” within the minds of participants so that a change can be implemented. Once the change is implemented, the system must “freeze” the habits so that they are conditioned to continue to follow the changes. The change theory proposed by Lewin recognizes that there needs to be “a dynamic balance of forces working in opposing directions” (Kritsonis, 2005).

There are three forces that need to be considered when using Lewin’s change model: driving forces, restraining forces and the equilibrium force. Driving forces push for change. Restraining forces oppose change. Equilibrium occurs when driving and restraining forces are equal and no change is happening. To implement a change, a driving force has to overcome the restraining force and once the change has occurred, equilibrium can be restored. This process occurs in three stages according to Lewin’s model.

Stage 1 is the act of unfreezing in which old patterns of behavior are let go. In the case of this project, the old pattern of behavior will be not having an NPR to use. Stage 2 is Movement process in which the change is implemented. In this case, the change is the development of the NPR. Stage 3 is the refreezing process, in which the change becomes standard operating procedure. In order for the change to be successful, driving and restraining forces must be analyzed prior to the change—and that is one of the purposes of the panel in this project: by sharing ideas about the NPR, driving and restraining forces can be identified, discussed, and clarified to ensure that the change will be able to be implemented once the NPR has been developed.

Barriers to Implementation

Resistance to change is not likely to be a large issue for this project as it is focusing mainly on the development of the NPR and not on the implementation of the NPR, which is beyond the scope of this project. The development process will be facilitated by the guidance of a head nurse and the assistance of a panel of nurses. Restraining and driving forces may become evident during the panel, but it is expected that the panel will mainly be constructive and supportive of the change since it is to be formed of nurses who volunteer to share thoughts and ideas about the NPR and what triggers should be identified to start the process.

Time should also not be a major barrier and may only come into play with regard to scheduling meetings for the panel to convene throughout the 5 week project. If some nurses on the panel are not able to meet due to scheduling conflicts, the panel may have to reconvene at a later time or proceed without the missing nurses. With regard to researching the NPR development process and constructing it, the time set aside for achieving these aims is judged to be sufficient.

The organizational culture at Cyprus Fairbanks is also not expected to be a problem as the facility is very supportive overall and has a good workplace culture and environment where nurses communicate well, are professional, and treat patients and peers with respect. Because of this culture, it is expected that nurses will be willing to step forward and volunteer to be part of the panel for supporting this project. If no nurses choose to volunteer, it will be left to the head nurse to decide whether it is necessary to appoint nurses or if the project may proceed with simply the head nurse and the researcher acting as the facilitators.

References

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Wiens, K. (2017). Implementation and evaluation of a peer review process for advanced practice nurses in a university hospital setting. Journal of the American Association of Nurse Practitioners, 29(7), 369-374. doi: 10.1002/2327-6924.12471

Cisic, R. S., & Frankovic, S. (2015). Using nursing peer review for quality improvement

and professional development with focus on standards of professional performance. Nursing and Health, 3(5), 103-109. doi: 10.13189/nh.2015.030501 

Garner, J. K. (2015). Implementation of a nursing peer-review program in the hospital

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Horkan, A. M. (2014). Alarm fatigue and patient safety. Nephrology Nursing Journal,

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Management, Business, and Administration, 8(1), 1-6.

Lewin, K. (1925). The child and the field forces. Retrieved from

https://www.youtube.com/watch?v=eK8HEQfjY-E

Lewin, K. (1935). A dynamic theory of personality. New York, NY: McGraw-Hill.

Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle,

C. L., & Owens, M. G. (2014). Facilitating Lewin’s change model with collaborative evaluation in promoting evidence based practices of health professionals. Eval Program Planning, 47, 82-90. doi:10.1016/j.evalprogplan.2014.08.007

Roberts, H., & Cronin, S. N. (2017). A descriptive study of nursing peer-review

programs in US Magnet® hospitals. Journal of Nursing Administration, 47(4), 226-231. doi: 10.1097/NNA.0000000000000469

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perceptions and practices: a survey of chief nurse executives. Journal of Nursing Administration, 46(10), 541-548. doi: 10.1097/NNA.0000000000000399

Task 2: Introduction and Literature Review

Chapter 1: Introduction

Background

Cypress Fairbanks Medical Center is an advanced-care facility in Houston, Texas, that maintains 180 beds and employs approximately 500 physicians, staff members and continuum of care providers. Since 1983, the facility has provided a wide range of health care services to patients in the community, offering 24-hour emergency care, a Primary Stroke Center, a Chest Pain Center, pediatric care, bariatrics, ob-gyn services among other specialties. Even though the facility has achieved great success in its more than three decades of service, it has as of now no nursing peer review process to help nurses obtain feedback from their peers when patient care problems arise. Nursing peer review (NPR) can be an effective means of communicating to nurses with regard to the professional issues and problems in nursing care that might otherwise go unaddressed (Roberts & Cronin, 2017). NPR has been recognized as a tool within the shared governance approach that nurses can utilize to boost accountability, improve nursing quality and better ensure patient safety (Siller, Dolansky, Clavelle and Fitzpatrick (2016; Whitney, Haag-Heitman, Chisholm & Gale, 2016). Because of the various benefits it can bring to the culture and professional practice at Cypress Fairbanks Medical Center, an NPR process should be developed.

The need for establishing a nursing peer review process has already been identified by a number of researchers in the healthcare industry (Garner, 2015; Bergum, Canaan, Delemos et al., 2017). As Cypress Fairbanks Medical Center currently has no NPR process in place and thus has no means by which nurses can receive peer evaluation when a patient care problem has been identified, it is imperative that the NPR be developed. As Garner (2015) notes, NPR is an accepted method that facilities can utilize in order to “improve nursing quality and safety” (p. 271). NPR does more than provide support for nurses; it also can be used to help to improve the workplace culture in the healthcare organization by creating an environment of open communication, honesty, respect and professionalism (Cisic & Frankovic, 2015). Though the Cypress Fairbanks Medical Center has always had a good workplace culture, improving it should always be an option.

Problem Statement

The problem of how to improve quality care is one that has numerous factors that must be analyzed. For example, patient wait times may be excessive, causing low patient satisfaction (Institute for Healthcare Improvement, 2018). Or nurses may be overworked or experience alarm fatigue (Horkan, 2014). A lack of good leadership could be contributing to a poor workplace culture (Schyns & Schilling, 2013). All of this can have a negative effect on quality care. One way that researchers have identified as having a positive effect on improving quality care, however, is the NPR process (Garner, 2015).

However, underlying all of these symptoms of poor quality care may be that there is no nursing peer review process that will support improved nursing care development (Garner, 2015; Bergum et al., 2017). When nurses are not subject to routine peer review, their patient care can slide through lack of education, negligence or any of the other factors described above. Engaging in peer review can help professionals to ensure that top quality care is being delivered, just as peer review among academics who publish their work in journals helps to ensure that research is produced and routinely checked for quality.

The NPR process enables nurses to coordinate and organize more effectively ensuring that positive feedback from peers will facilitate the development of quality care processes over time (Roberts & Cronin, 2017). In order to develop the NPR process, nursing indicators have to be indentified: these are events involving patient care problems that trigger the implementation of the NPR process (Garner, 2015). Identifying what indicators should trigger the process is the first step.

Scope

Quality Improvement

The goal of quality improvement for this project is to be achieved by the development of an NPR process for Cypress Fairbanks Medical Center. The NPR process will allow nurses to review themselves so that they can better provide quality care to patients. The process is a response to indicators or triggers (such as patient care problems) that arise during the course of nursing care. When a problem arises, the NPR process is engaged, and nurses receive feedback from their peers to help them overcome issues that resulted in the initial care problem. However, in order for the NPR process to be engaged, the NPR must first be developed, and that is what this evidence-based project aims to accomplish.

RNs alone are involved in the NPR process, as “peer” refers to those individuals who are in the same role as the nurse being reviewed. Peer review can thus only be accomplished by the other nurses who are working in the same ward or department as the nurse subject for review. Therefore the development of the NPR process should include feedback from RNs about what types of communication and feedback should be included in the peer review and how reviews should be written. A knowledge of the job, therefore, is required in order for the review process to be effectively employed. The focus of the review is on the work not on the personality of the nurse. Its aim is collegial not confrontational. The review is also not anonymous. One of the purposes of the review is to facilitate the growth of respect among RNs. The tone of the review should also be professional. Professionalism is expected among nurses—and that is the reason for the NPR. Thus, the NPR itself should maintain a professional tone. And the main purpose of the review is to enable nurses to assist one another so the quality care can be delivered routinely by all. Nursing managers and administrators will only be required in terms of providing oversight in the development of the review process. Their expertise will be helpful in ensuring that the NPR provides a framework for addressing key characteristics of the job. As the project will take place at Cypress Fairbanks Medical Center, the nurses at the Center and select managers and administrators will be used to facilitate the development of the NPR.

Rationale

The NPR process is an effective way to help nurses achieve quality care and safe practice with respect to patients and to promote a positive workplace culture. By highlighting areas of concern for nurses who have shown signs of having difficulty in certain patient care areas, the NPR reduces the risk of nurse error by allowing nursing peers to inform nurses in a professional manner of what the individual is doing correct and incorrectly (Roberts & Cronin, 2017). In this manner, the NPR is most helpful because it ensures that education is continuous and ongoing while nurses are on the job and not something that stops with the last class in nursing school (Bergum et al., 2017). Highlighting the educative aspects of the NPR supports the concept of it being used as a professional development tool rather than as it being misperceived as a tool for personal attack. Conducting the NPR also helps nurse managers plan for the future development of training and education procedures in the facility (Cisic & Frankovic, 2015). This in turn facilitates the development of the workplace culture and supports communication, collaboration and professional development.

Chapter 2 will provide an examination of evidence-based practice data found among the literature related to the issue of NPR tools, development and implementation. It will also discuss best practices and recommendations for quality improvement at Cyprus Fairbanks.

Chapter 2: Literature Review

Literature Review

Garner (2015) describes the NPR as a formal process that nurses can use to conduct peer evaluation when a trigger has been pulled relating to patient care. The purpose of the NPR is to help nurses ensure quality and safety and in the study, Garner (2015) discusses how the NPR can be developed. Because the NPR is a systematic method of evaluation, it should consist of a standardized format that nurses can use simply but effectively. The standards that should be included in the NPR can be gone through much like a checklist, with nurses providing a score of the subject nurse in terms of the extent to which each professional standard is met in the nurse’s practice. The aim is to ensure that every nurse is held accountable, and since the profession is a serious one in which trust is built-in, nurses should routinely be open to peer evaluation as it helps to validate the trust that patients have for nurses (Garner, 2015).

This same concept has been expressed by Bergum, Canaan, Delemos et al. (2017) in their study on how to develop an appropriate NPR. The standardization of the NPR, in their study, is shown to best be effected through the use of the Likert scale which is used to measure the extent to which nurses meet their professional standards. The Likert scale is commonly utilized in a five-point format in which 1 is used to indicate the absolute minimum score and 5 is used to indicate a maximum score. If a nurse is reaching all of the standards of the profession, the nurse would be evaluated in the NPR with scores of 5 across the board. This method of reviewing and evaluating can be very helpful in keeping the NPR process simple but effective at the same time. Measuring sores using the Likert scale is an efficient way to show the extent to which nurses are performing at a professional level, as Bergum et al. (2017) show.

In spite of the usefulness and utility of NPR, its prevalence continues to remain low in the nursing industry. Whitney, Haag-Heitman, Chisholm and Gale (2016) show that this is because there is still a lack of education among nurses regarding the positive effects that NPRs can have: nurses are unfamiliar with the purpose and the outcomes of the peer review method. The findings of Whitney et al. (2016) indicate that more education needs to be provided among nurses as to how NPRs can help to support professional development and workplace culture, improve nursing quality and ensure safety for patients. In the course of developing the NPR, therefore, it is important to consider steps that may be taken to help nurses deal with restraining forces that might compel some nurses to resist its implementation. These restraining forces, as Manchester, Gray-Miceli, Metcalf et al. (2014) indicate should be resolved through the use of educational steps provided by the operatives engaged in the driving force of change. When constructing the NPR, therefore, a view to applying standards in the process should be aligned with the expectations nurses have among themselves as to how they should execute their practice. This will help to mitigate the risk of restraining forces acting equally to driving forces and negating the change process.

To help formulate the NPR, Cisic and Frankovic (2015) provide six principles that should be used when engaging in the NPR development process:

1) The NPR developer must remember that a peer is someone of the same rank as the nurse—not a lower level or higher level employee or nurse.

2) The NPR is practice-focused—not person-focused. This means that the NPR should be developed with standards that are wholly reflective of the professional standards and expectations of the nursing unit rather than standards of personality.

3) The NPR should be quick to conduct, as feedback should be timely, a matter of routine and something that the subject of the NPR can expect within a reasonable amount of the trigger for the NPR process being pulled.

4) The NPR should help to support a culture of continuous learning, patient safety, and best practice development.

5) The NPR must not be anonymous: all nurses should know who is conducting the review so that it is above-board, the process is transparent, and honesty, professionalism and respect are appreciated and maintained.

6) The NPR should include identification of the developmental stage of the nurse—i.e., what year of practice the nurse is in, how far the nurse has progressed in practice and education, etc.

These six principles are important to follow because each reinforces the concept that the review process should be open, honest, professional, and practice- rather than person-oriented. Observations made in the peer review should be disinterested and objective and should serve to show the extent to which the subject nurse is performing in accordance with the organization’s expectations.

The principles outlined by Cisic and Frankovic (2015) can also be analyzed in the context of the study conducted by Bakker and Schaufeli (2008), in which it is found that “employee engagement is conceived in terms of commitment and extra-role behavior, for instance, as a psychological state where employees feel a vested interest in the company’s success and perform to a high standard that may exceed the stated requirements of the job” (p. 151). From this perspective, it is completely advisable that nurses take part in NPRs because it can produce a “psychological state where employees feel a vested interest” in one another and in the healthcare organization itself. Nurses who respect the principles applied through the NPR can expect to help develop their workplace culture through respect, appreciation, support and professional development. Positive attitudes are more likely to be the fruit of an NPR process that is conducted by nurses who understand the process, as Whitney et al. (2016) point out, but the educative aspect of implementing the NPR is one that can be addressed once the NPR itself has already been developed.

The concept of shared governance plus nursing review is what allows for patient quality care to improve in the long run. Kutney-Lee, Germack, Hatfield et al. (2016) show that in hospitals where there is a substantial sense of shared governance among nurses, the outcomes for patients is much higher than in facilities where is less sense of shared governance. As NPR helps to build a sense of shared governance, its application has a positive effect for patient outcomes. Ott and Ross (2014) and Brann (2015) confirm this finding in their review of how nurses can increase quality care for patients by partaking in shared governance. And Siller, Dolansky, Clavelle and Fitzpatrick (2016) also highlight the positive effects of shared governance among nurses in emergency room settings. The overall findings thus support the concept of nurses working together to share in the oversight and direction of one another’s professional training, engagement and development.

Saver (2016) shows that the NPR process can have very effective results among nurses but only so long as they ensure that the process is in no way communicated as a personal one. The professional nature of the NPR should be felt by all nurses so that they are not hurt or offended by the review, either its contents the need for one. When patient care issues arise, the NPR simply gives nurses an opportunity to reinforce the understanding that they must continuously strive to maintain professional standards (Saver, 2016; Bergum et al., 2017; Roberts & Cronin, 2017). To that end, the NPR can be seen as a friendly exercise that helps nurses to address patient care issues among themselves instead of having to resort to outsider or administrative intervention. In this sense, it can be seen as a tool for empowering nurses and giving them the means to look after themselves and their own professional development in a systematized and standardized method.

In the study conducted by Kim, Jung, Min et al. (2017), it is shown how the peer review process works within a career development framework that has nursing professionalism as its goal. At the base of the framework are the various factors that must be part of standard practice: scientific knowledge, technical skill, ethical practice, aesthetic approaches, and existential awareness. From these five factors flows clinical competence. Peer review extends from clinical competence as part of the development of nursing professionalism and coincides with face-to-face interviews in the process of building one’s nursing career. Without peer review, career development can lack a very helpful component.

Figure 1. NPR as a variable in the career development framework.

Source: Kim et al. (2017)

Kim et al. (2017) also provide a model NPR set of standards based upon the five factors needed for clinical competence as well as questions relating to patient care, human resources development and leadership. These questions include:

· Does the nurse utilize knowledge effectively?

· Does the nurse analyze critical situations satisfactorily?

· Can the nurse operate equipment in the appropriate manner?

· Does the nurse support the growth and development of colleagues and juniors?

· Does the nurse actively join in discussions and demonstrate accountability and responsibility within the nursing unit?

These questions are certainly thought-provoking and may be somewhat difficult to answer on a Likert scale—but there is no need for the Likert scale to be used in every NPR. In a peer review such as the one designed by Kim et al. (2017) an open-ended approach to question asking could reveal deeper thoughts and levels of analysis. At the same time, they could cause the process to become too slow and cumbersome.

Another approach to developing the NPR is provided by Cisic and Frankovic (2015). Using a structured questionnaire format with a Likert scale system of measurement, along with an option for leaving a remark, Cisic and Frankovic (2015) focus their NPR on assessing nursing care knowledge, skills, orientation and professionalism. The NPR also focuses on specific professional standards, such as education, communication with peers and patients, quality, creativity, safety, respect, collaboration, initiative, IT knowledge, reliability, and so on. In the second portion of their NPR, the researchers developed a semi-structure questionnaire peer review tool that focused on the nurse’s professional development. Tables 1 and 2 illustrate the NPR tools developed by Cisic and Frankovic (2015) and how the NPR tools are scored.

Table 1. NPR—structured questionnaire tool.

Source: Cisic & Frankovic (2015)

Table 2. Second NPR—semi-structured peer review tool.

Source: Cisic & Frankovic (2015)

Because NPRs are not very proliferated in the U.S., an example of how the NPR might be developed in other countries can also be beneficial. The Australian Nursing and Midwifery Association (2015) developed a Nursing Peer Appraisal Tool for nurses in general practice. The standard is described at the top of the first column and extending out from that same row are the options to be checked by the reviewer: these options include a box for checking if the standard has been met, not met, or needs further development. There is also a box for “not applicable” in case the standardized NPR contains standards that are not pursued by a particular ward in the facility. A box for comments is retained at the end. Beneath the first standard are the various sub-standards that break the standard down into more detail. For example, in Table 3, it can be seen that the first standard of the NPR is labeled “Standard 1: Demonstrates an understanding of primary health care principles and nursing in general practice.” This standard is then divided into sub-standards down the page. These include: “1.1: Identifies the core principles of primary health care.” “1.2: Integrates the principles of primary health care into practice.” “1.3: Understands current national health priorities.” “1.4: Recognizes the impact of social determinants of health on consumers and integrates this understanding in the planning and delivery of nursing care.” “1.5: Identifies the broad health and social needs of the Practice community.” “1.6: Articulates the various roles and responsibilities of the general practice team, in particular the RN and EN scopes of practice and EN supervision requirements.”

Table 3. Australian Nursing and Midwifery Association NPR.

Source: Australian Nursing and Midwifery Association (2015)

The manner in which this NPR identifies numerous sub-standards helps to make the NPR process much simpler and less time consuming for nurses conducting the peer-review, as it is just a matter of going down the checklist and checking the appropriate box in each row. It is far more detailed, too, than the NPR tool developed by Cisic and Frankovic (2015) shown in Tables 1 and 2. Their NPR tool lists a variety of standards but does not break them down into numerous sub-standards for a more detailed and thorough evaluation. In this regard, the NPR tool developed by Cisic and Frankovic (2015) allows more time and opportunity for the nurse peer reviewer to leave written remarks that might help the subject nurse to better see where issues are occurring.

The MGH Institute of Health Professions (2018) developed an NPR tool to help stimulate professional development by providing feedback for nurses and assisting in establishing goals. MGH recommends that the NPR process be conducted for all nurses at least once a year. The NPR process is viewed as part of a larger process of performance evaluation and goal setting. Peer review is ranked alongside manager assessment and self-assessment as one of three important tools for professional development in nursing and is described as “the annual Nursing Peer Review process [that focuses on] identifying an aspect of a nurse colleague’s practice that could/should be developed further for the benefit of the nurse and for the practice setting” (p. 2). Likewise, Haag-Heitman and George (2011) point out that the NPR process also “provides a mechanism to ensure that new nursing standards of care are addressed” (p. 51). In this sense, the NPR does not have to be used just when a practice issue is triggered or to evaluate a nurse’s competency and professionalism. It can also be used to help nurses evaluate their own understanding of new nursing standards. When developing the NPR it is therefore important to allow it to be easily adaptable so that whenever new standards are implemented into the nursing industry, the NPR can reflect these standards in the evaluation tool. This is in line with the American Nurses Association (ANA, 1988) guidance in the ANA’s Code of Ethics, which identifies peer review as a very valuable method of ensuring that all nurses hold themselves and one another to the industry’s top standards. Though nearly three decades have gone by since the ANA (1988) established its guidelines for peer review, the process is still as timely today as it ever was and has been adopted as an important part of criteria for hospitals earning credentialization.

The ANA’s affiliate, the American Nurses’ Credentialing Center (ANCC, 2017) awards Magnet status to hospitals that meet the criteria needed to evaluate the quality and safety of their nursing practice. Developing a NPR process so that nurses can provide peer review is among the set of criteria. Reich, Smith and Del Guidice (2016) show that hospitals that pursue the Magnet award are aware of the value that credentialing brings both to nursing practice and to patient safety, and Haig-Heitman and George (2011) also point this out: “to attain Magnet recognition, an organization must establish formalized, systematic peer-review nursing practices to evaluate nursing care” (p. 48). One of the aims identified by the ANCC (2017) is that peer review leads to self-regulation among nurses, which is a type of self-actualization recognized by Maslow (1943) in his hierarchy of needs as the very top level of development. Figure 2 of the MGH Institute shows how peer assessment plays a part in the self-actualization process of professional nurses.

Figure 2. MGH professional development and goal setting process.

Source: MGH Institute of Health Professions (2018)

The MGH Institute’s recommendations for developing an NPR tool include the following:

1) Choose one staff nurse peer (of the same rank as the subject) to observe the colleague’s regular practice. The nurse conducting the peer review will act as a shadow of the nurse for an appointed amount of time.

2) The NPR should have a theme or focus. One theme should focus on one particular standard and one theme should focus on one opportunity for development or growth. These can include areas such as: the nurse-patient relationship, collaborative care, clinical knowledge and so on. The nurse conducting the peer review will focus on these specific areas.

3) The nurse conducting the review should provide a short summary of one of the colleague’s strengths on the NPR tool, and should provide one example of this strength in the colleague’s practice

4) The nurse conducting the review should provide a short summary of one area where there is opportunity for development, and should give one example of this opportunity from the colleagues’ practice

5) The two nurses (the subject and the reviewer) should meet face-to-face to share feedback and to guarantee that the nurse’s practice is discussed on both points.

6) The completed NPR tool should be turned into the nurse manager, who will save it in the records so that the review can be included in the annual development of goals related to professional growth.

7) The NPR process should be conducted for every nurse at least once a year.

These recommendations are very concise and helpful—and somewhat different from the other approaches to developing an NPR tool that have already been seen. For example, this NPR tool, instead of focusing on several nursing standards so as to give a complete overview of a nurse’s qualifications and professionalism, looks at only one particular standard and requires the reviewer to identify one strength and one opportunity for development. This approach is also far less threatening and intimidating in terms of one nurse coming across as negative or critical by focusing on numerous problem areas. The NPR is situated in a context of positive terms: the term opportunity is used instead of deficient area, and the review also has to highlight a strong suit of the nurse. This approach also ensures that the NPR is not overwhelming and can be completed over the course of a single shift. It also allows the NPR to be formalized and systematic in the sense that there is no need to wait for a possible trigger—such as a patient care issue—for the NPR process to be initiated. Instead, the NPR is part of a formal, systematic approach to professional development that every nurse must take part in over the course of a year. This approach helps to decrease the chances of a nurse taking personal offense at being reviewed, since there is no basis of “a problem” being the reason for the review but rather the review is routine and part of the workplace culture’s focus on maintaining positivity and professional growth.

The Canterbury District Health Board (2018) provides a similar approach to the NPR tool but broadens the scope of the tool to include a variety of standards that are more in line with the NPR tools developed by Cisic and Frankovic (2015) and others. The ANCC (2013) does not provide any formal guidance in terms of what the NPR tool should utilize in terms of standards or approach to the peer review process but rather simply acknowledges that Magnet hospitals must have some form of peer review process implemented on a routine basis. By leaving it open to the individual hospitals, the ANCC allows room for creativity and accountability to be employed as the various facilities see fit.

Writing for the Joint Commission, Wise (2013) states that the Ongoing Professional Practice Evaluation (OPPE) is a peer review tool that is more in line with the use of the NPR as a means of evaluating problem areas. The MGH Institute on the other hand views the NPR in a more positive light, seeing it as a means of reinforcing growth without isolating nurses based on poor performance. The former is more critical in its approach to nursing practice, while the latter is more supportive and vision-oriented—i.e., it focuses on a specific area of practice that the nurse should strive to develop so that it is more in line with accepted professional standards. While conceivably, an NPR tool could be developed to assist nursing staffs to employ a tool for either approach, the more positive assessment practice falls in line with the majority of research on the subject devoted to showing how the NPR process can be used to support professional development, workplace culture, communication and a variety of other characteristics that a healthcare organization should seek to promote (Cisic and Frankovic, 2015; Garner, 2015; Bergum et al., 2017). Sagin (2015) of the National Association Medical Staff Services (NAMSS) notes that in an OPEE-oriented peer review, indicators, triggers or patient care issues should be clearly identified by the facility so that nurses know when to implement the review process.

However, MGH Institute recommends that the process be more systematized and routine—and, above all, non-discriminatory—i.e., not based on any indicator factor at all. The goal of the MGH Institute’s approach is to maintain positivity and a spirit of supportive development in the nursing environment rather than to introduce a spirit of criticism and paranoia. As Hellum (2016) concludes, different nurses will find different approaches to the issue of peer review appealing, and the degree to which they are implemented successfully will depend upon the driving forces in the change management process and the restraining forces in the nursing workplace, according to the Lewin change model.

Resistance to change can become an issue if the NPR process is not acceptable to nurses. Manchester et al. (2014) state that Lewin’s change model can be effective in promoting evidence-based practices in health care so long as those implementing the change identify factors that might lead to resistance—i.e., are the source of restraining forces. To address these forces, Lewin proposed a three-stage model that is also known as the unfreezing-change-refreeze model, which is based on the idea that old habits and ideas have to be “unfrozen” within the minds of participants so that a change can be implemented (Schalock, Lee, Verdugo et al., 2014; Hussain, Lei, Akram et al., 2016). Once the change is implemented, the system must “freeze” the habits so that they are conditioned to continue to follow the changes. The change theory proposed by Lewin recognizes that there needs to be “a dynamic balance of forces working in opposing directions” (Kritsonis, 2005). In order for the NPR tool to be received well by nurses within an organization it is important that it is developed with a view towards promoting the common goals and aims of the nurses so that their own professional desires are first and foremost evident in the process.

To ensure a successful development of the NPR tool, there are three forces that need to be considered when using Lewin’s change model: driving forces, restraining forces and the equilibrium force. Driving forces push for change. Restraining forces oppose change. Equilibrium occurs when driving and restraining forces are equal and no change is happening (Shirey, 2013; Mahmood, Idris, Samah & Omar, 2017). To implement a change, a driving force has to overcome the restraining force and once the change has occurred, equilibrium can be restored. This process occurs in three stages according to Lewin’s model.

Stage 1 is the act of unfreezing in which old patterns of behavior are let go. In the case of this project, the old pattern of behavior will be not having an NPR to use. Stage 2 is Movement process in which the change is implemented. In this case, the change is the development of the NPR. Stage 3 is the refreezing process, in which the change becomes standard operating procedure (Sutherland, 2013; Cummings, Bridgman & Brown, 2016). In order for the change to be successful, driving and restraining forces must be analyzed prior to the change—and that is one of the purposes of the panel in this project: by sharing ideas about the NPR, driving and restraining forces can be identified, discussed, and clarified to ensure that the change will be able to be implemented once the NPR has been developed.