Developing a Nursing Peer Review Process: A Project Proposal

Introduction and Clinical Problem

The facility discussed in this project is an advanced-care hospital 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 healthcare 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, and other specialties. Although the facility has achieved great success in its more than three decades of service, it currently has no nursing peer review (NPR) 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 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 & Fitzpatrick, 2016; Whitney, Haag-Heitman, Chisholm & Gale, 2016). The need for establishing an NPR process has already been identified by a number of researchers in the healthcare industry (Garner, 2015; Bergum, Canaan, Delemos et al., 2017). As Garner (2015) notes, NPR is an accepted method that facilities can utilize to "improve nursing quality and safety" (p. 271). NPR does more than provide support for nurses; it can also help improve workplace culture in a healthcare organization by creating an environment of open communication, honesty, respect, and professionalism (Cisic & Frankovic, 2015).

The problem of how to improve quality care has numerous factors. For example, patient wait times may be excessive, 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 these factors can negatively affect quality care. One way that researchers have identified as having a positive effect on improving quality care, however, is the NPR process (Garner, 2015).

Underlying all of these symptoms of poor quality care may be the absence of a nursing peer review process that supports improved nursing care development (Garner, 2015; Bergum et al., 2017). When nurses are not subject to routine peer review, their patient care can decline through lack of education, negligence, or any of the other factors described above. Engaging in peer review can help professionals ensure that top-quality care is being delivered, much as peer review among academics who publish their work in journals helps ensure that research is 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 must be identified: these are events involving patient care problems that trigger the implementation of the NPR process (Garner, 2015). Identifying which indicators should trigger the process is the first step.

Stakeholders and Proposed Solution

Stakeholders in the development of the NPR process include registered nurses (RNs), patients, physicians, and hospital administration and management.

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

Patients stand to have power in this process in the sense that their satisfaction is ultimately at stake. If they continue to express dissatisfaction with services, nurses will be subject to further review. Their interest is equally significant: they are the ones who ultimately stand to benefit — albeit indirectly — from nurses' improvement in quality care.

Physicians will have power in this process to a limited degree, as the peer review will be conducted by nurses. Their influence may be felt in that they communicate with nurses and can serve as sources of indicators for review, just as patients can. Their interest in the NPR development is also considerable: though they are not on the receiving end of quality care, they are on the giving end. When nurses are better trained and equipped to assist physicians in delivering quality care, doctors can be more confident that treatment outcomes will satisfy patients.

Hospital administrators also have power in this process, as they will oversee its development and implementation. Their influence will be equally significant, as they can make recommendations and insert changes along the way. Their interest in the process is also substantial: better-performing nurses produce more satisfied patients, which supports the organization's ability to continue providing care and maintain or increase revenues.

RNs alone are involved in the NPR process, since "peer" refers to individuals in the same role as the nurse being reviewed. Peer review can thus only be accomplished by nurses working in the same ward or department as the nurse subject to review. Therefore, the development of the NPR process should include feedback from RNs about what types of communication and feedback should be included and how reviews should be written. The focus of the review is on practice, not on the personality of the nurse. Its aim is collegial, not confrontational. The review is also not anonymous; one of its purposes is to facilitate the growth of respect among RNs. The tone of the review should be professional, and its main purpose is to enable nurses to assist one another so that quality care can be delivered routinely by all. Nursing managers and administrators will be required only in terms of providing oversight during the development of the review process.

The NPR process is an effective way to help nurses achieve quality care and safe practice while promoting a positive workplace culture. By highlighting areas of concern for nurses who have shown difficulty in certain patient care areas, the NPR reduces the risk of nurse error by allowing nursing peers to inform a nurse professionally of what the individual is doing correctly 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 — 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 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), facilitating the development of workplace culture and supporting communication, collaboration, and professional development.

Plan of Action and Timeline

This project will be initialized with the consent, support, and oversight of the head nurse at the facility. The head nurse and the project researcher will convene a panel of six volunteer RNs 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 into 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 through a literature review of relevant studies that provide ideas on how to approach the process and which principles to follow. These principles will guide the development process from beginning to end.

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

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, serving 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 entirely advisable that nurses take part in NPRs, because doing so can produce a psychological state in which employees feel a vested interest in one another and in the healthcare organization itself.

The development plan proceeds in five basic steps:

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 a 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.

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 panel will include the researcher, the head nurse, and four other volunteer nurses. The panel will meet twice: once on Monday of the first week and once on Friday of the first week. The first meeting will introduce the topic, explain its significance, and discuss possible triggers for the NPR. The panel will also provide input on what to include in the NPR. The second meeting will be held to share those thoughts so that the researcher can incorporate them into the following week's research.

Week 2 will involve conducting the literature review. Keyword searches will be conducted using ideas presented during the panel 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 will be selected based on their abstracts.

Week 3 will involve reconvening with the panel to share evidence obtained through the literature. The meeting will be held on Monday of that week so that there is time for further discussion if needed. If the panel is satisfied with the evidence obtained from the literature review, the project will move forward to 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 will be to include areas for review that are pertinent to the triggers discussed at the panel and the areas highlighted in the literature.

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

The panel will require one meeting room with a table large enough to seat six. The personnel who will serve on the panel will include the researcher, the head nurse, and four volunteer nurses. They will be chosen on a first-come, first-served basis: an announcement will be made among the nursing staff in the week prior to Week 1, and the first four nurses to express interest in assisting will be included.

Literature Review: NPR Tools and Best Practices

Garner (2015) describes the NPR as a formal process that nurses can use to conduct peer evaluation when a trigger related to patient care has been identified. The purpose of the NPR is to help nurses ensure quality and safety. 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 included in the NPR can be worked through much like a checklist, with nurses scoring the subject nurse in terms of the extent to which each professional standard is met in practice. The aim is to ensure that every nurse is held accountable; since the profession is one in which patient trust is foundational, nurses should routinely be open to peer evaluation as it helps to validate that trust (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 be best achieved through use of the Likert scale, which measures the extent to which nurses meet their professional standards. The Likert scale is commonly used in a five-point format in which 1 indicates the lowest score and 5 indicates the highest. If a nurse is meeting all professional standards, the nurse would receive scores of 5 across the board. This method is very helpful in keeping the NPR process simple yet effective. Measuring scores using the Likert scale is an efficient way to show the extent to which nurses are performing at a professional level (Bergum et al., 2017).

In spite of the usefulness 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 outcomes of peer review. The findings of Whitney et al. (2016) indicate that more education needs to be provided so that nurses understand how NPRs can support professional development and workplace culture, improve nursing quality, and ensure patient safety. When constructing the NPR, therefore, standards applied in the process should be aligned with the expectations nurses hold among themselves about how to execute their practice. This alignment 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 to use in the NPR development process:

These six principles reinforce 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, serving to show the extent to which the subject nurse is performing in accordance with organizational expectations.

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 and an option for leaving a remark, they 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, and reliability. In the second portion of their NPR, the researchers developed a semi-structured questionnaire peer review tool focused on the nurse's professional development.

In the study conducted by Kim, Jung, Min et al. (2017), the peer review process is shown to work within a career development framework that has nursing professionalism as its goal. At the base of the framework are five 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. Kim et al. (2017) also provide a model NPR set of standards based upon these five factors, along with questions relating to patient care, human resources development, and leadership. These questions include:

These questions are thought-provoking and may be somewhat difficult to answer on a Likert scale, but there is no requirement that the Likert scale be used in every NPR. An open-ended approach to questioning, as in the tool designed by Kim et al. (2017), could reveal deeper levels of analysis — though it could also make the process too slow and cumbersome.

The MGH Institute of Health Professions (2018) developed an NPR tool to 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. 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). When developing the NPR, it is therefore important to allow it to be easily adaptable so that whenever new standards are implemented, the NPR can reflect those standards in the evaluation tool.

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

This approach is concise and somewhat different from other NPR tools. Rather than covering numerous nursing standards to provide a complete overview, it looks at only one particular standard and requires the reviewer to identify one strength and one opportunity for development. This approach is far less threatening: the term opportunity is used instead of deficient area, and the review must highlight a strong suit as well. It also ensures that the NPR is not overwhelming and can be completed over the course of a single shift. Importantly, there is no need to wait for a 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 undergo annually. This approach helps to decrease the chances of a nurse taking personal offense at being reviewed, since the review is routine and part of the workplace culture's focus on positivity and professional growth.

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

Writing for the Joint Commission, Wise (2013) states that the Ongoing Professional Practice Evaluation (OPPE) is a peer review tool 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. While an NPR tool could conceivably be developed for either approach, the more positive assessment practice falls in line with the majority of research on the subject showing how the NPR process can be used to support professional development, workplace culture, and communication (Cisic & Frankovic, 2015; Garner, 2015; Bergum et al., 2017). Sagin (2015) of the National Association Medical Staff Services (NAMSS) notes that in an OPPE-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.

The MGH Institute recommends that the process be more systematized and routine — and, above all, non-discriminatory. The goal is to maintain positivity and a spirit of supportive development in the nursing environment rather than to introduce criticism and anxiety. As Hellum (2016) concludes, different nurses will find different approaches to peer review appealing, and the degree to which an NPR is implemented successfully will depend upon the driving forces in the change management process and the restraining forces in the nursing workplace, as described by the Lewin change model.