What should a nursing peer review include?

Purpose/objectives: Nursing peer review (NPR), a formal process by which nurses are referred for peer evaluation when patient care problems are identified, has gained acceptance as a method to improve nursing quality and safety. This article describes the development of a formal NPR program for acute care nurses, intended to validate and improve nursing practice.

Background: Nursing peer review is a systematic process of assessing and evaluating nursing care by peers against professional practice standards. The purpose of an NPR program is to provide a pathway whereby peers hold one another accountable for practice.

Rationale: Accountability is an important demonstrator of professionalism. Because nursing is a trusted profession, it is imperative that it demonstrate accountability.

Description: The NPR program was developed and implemented by a clinical nurse specialist. A literature review was conducted to assist program development including the processes of building an NPR committee and nurses for review. To trigger referrals to the NPR system, nursing indicators were identified. To diminish fear among nurses, education for staff members focused on the purpose and importance of the NPR process and the intent to strengthen practice. Nursing peer review committee members were also educated in the use of NPR principles including just culture, appreciative inquiry, and confidentiality.

Outcome: Upon implementation, nearly 200 referrals were received within the first 14 months; 85% met criteria for review. Nursing practice was identified as appropriate (ie, nursing actions were consistent with good practice) in 66% of the reviews. Trends in individual and system processes were identified for improvement.

Conclusion/implications: The clinical nurse specialist's role as NPR program coordinator provided an innovative way to impact nursing and organizational spheres of influence through program development and implementation. Future goals include sustaining/improving nursing awareness of the NPR process and identification of additional indicators to trigger review.

Peer reviews have long been valued in nursing to assess professional performance, with nurses and other caregivers submitting themselves to a panel of peers for appraisal. In 1988, the American Nurses Association (ANA) released peer review guidelines. Healthcare organizations are required to have systematic peer review practices to attain Magnet® designation. There are many benefits of the peer review process; but peer reviews are not without peril.

“In healthcare organizations, peer reviews are typically used to assure clinicians meet minimum clinical or professional ladder criteria, support ladder progression to the next level and provide a fuller picture of the previous year’s performance during the annual review,” says Sandra L. Siedlecki, PhD, RN, APRN-CNS, FAAN, Senior Nurse Scientist in the Office of Nursing Research and Innovation at Cleveland Clinic. “However, when using a peer review process for job performance assessments, there is a potential for ethical violations.”

In an article on the ethics of peer review in Nursing2015, Siedlecki delved into the possible pitfalls of peer review for appraising professional performance, but the pitfalls also apply to reviewing manuscripts, research proposals and grant submissions. Her assertions still hold true today.

Potential pitfalls of peer review

The peer review process should be fair, producing an unbiased evaluation of a person’s performance. Unfortunately, it doesn’t always meet this high standard. “Peer review is meant to improve the process rather than having a single person – your manager – deciding everything,” says Siedlecki. “But it’s not foolproof because we are dealing with people.”

Here are a few problems that may occur:

• Inappropriate reviewer – “Reviewers must hold at least the same position or higher than the people being reviewed,” says Siedlecki. “Somebody with a lower position can’t assess qualifications for a position they haven’t obtained.” For instance, a clinical nurse II cannot assess someone applying for or in a clinical nurse III position.
• Number of reviewers – Each clinician being reviewed needs to have more than one reviewer. Typically, when three reviewers are utilized, the person reviewing responses can consider aberrant reviews/comments in relation to the others.
• Conflict of interest – “If reviewers are applying for the same position or if they know the person well – whether they like or dislike the person – there is a high likelihood that the reviewer may be biased, reflecting a conflict of interest,” says Siedlecki. “The people who make decisions about the peer review feedback need to understand that bias in delivering feedback is common.” After all, most people who provide peer reviews base their feedback on clinical work practices and collaborations, not on written reports or curriculum vitae that have identifying information removed.
• Lack of review criteria – To maintain objectivity, reviewers should consider documents and other evidence submitted against established criteria, such as a rubric that says the candidate demonstrates X through completion of project Y.
• Haphazard reviews – “Nurse reviewers need to be diligent, be careful, pay attention to the details and make sure they have enough time to review the materials submitted,” says Siedlecki.
• Disregard of confidentiality – “The person who is being reviewed has a right to expect their materials are going to be handled carefully, confidentially and objectively by the people entrusted as reviewers,” says Siedlecki. “They can’t share materials verbally with colleagues or leave them on a desk where anybody might have access to them inadvertently. Paper materials must be destroyed when reviews are completed.”
• Inappropriate commentary – “The reviewer’s comments are meant to be accurate, helpful and kind. Gratuitous nastiness is not acceptable,” says Siedlecki.

Ways to avoid ethical miscues

One of the best ways to ensure that peer reviews for job performance appraisals are fair and unbiased is to educate nurses on the process. “Most nurses have never been taught the basic rules of performing meaningful peer reviews; they don’t understand the ethics involved,” says Siedlecki. There are many articles devoted to the peer review process in publications such as the Journal of Nursing Education and online content provided by the ANA. Numerous organizations also offer continuing education courses on peer review.

In addition, it’s critical to develop pre-established criteria for the review process. “Having set criteria helps maintain fairness and reinforces that it is not acceptable to compare people,” says Siedlecki. “Instead, each person who submits materials should stand alone against the predetermined criteria.”

Finally, although peer reviewers can appraise a person and make recommendations, they should not make the final decision; the peer review is simply one part or aspect of the review process. The final review should be completed by a nurse manager, director or other leader.

Although the peer review process can present challenges, it’s a practice worth committing to, says Siedlecki. “Don’t give up on it! The process provides a good opportunity to experience what it’s like to be peer reviewed and to review others,” she says. “It’s a big responsibility, but an opportunity to grow, too.”