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 benefitalbeit indirectlyfrom 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 nursesand 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 canbe 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 nurses 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 organizations 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 companys 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 weeks 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. f 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 Lewins change model can be effective in promoting evidence-based practices in health care. Lewins 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. Lewins (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 actionsand the boy would be shown running to and away from the sea. Lewins 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 Lewins 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 Lewins 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 changeand 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.