Nurses want to work in clinically superior practice environments, places that demonstrate adherence to professional standards of practice, quality, and safety. Who better than nurses to assess through peer review whether the workplace and colleagues measure up?
This fall, ONE/NJ and the American Nurses Credentialing Center hosted an all-day conference, "Peer Review: Growth and Development, A Program for Nurses," at the New Jersey Hospital Association, Princeton.
Peer review, says the ANA, is the process by which practicing RNs systematically assess, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice. It means that each nurse must participate with other nurses in the decision-making process of evaluating nursing care.
"Although the ANA published its first peer review guidelines on quality in 1988, they have not yet been fully translated into practice," says Barbara Haag-Heitman, RN, PhD, PHCNS, workshop presenter and a national and international consultant specializing in organizational innovation, shared leadership, conflict, and peer review.
It's Not Pal Review
Peer review is often seen as a managerial process in which the manager gives feedback at the annual review. Peers may be asked to give input, often anonymously. Instead of being associated with specific nursing practice, peer review has sometimes been related to the citizenship of nurses — whether they are pleasant to work with or whether their work is of good quality (without saying what quality means), says Haag-Heitman. When this happens, peer review becomes 'pal' review, she says.
Too often, peer review is seen as being punitive in nature, especially when performed at the same time as the annual review. Rather than being seen as disciplinary, peer review should be considered educational and developmental, and feedback should be timely and foster continuous learning cultures of patient safety and best practice, Haag-Heitman says.
"The attitude toward peer review depends on the organization," says Maria Brennan, RN, MSN, CPHQ, CNO/CEO, St. Joseph's Regional Medical Center, Paterson. "Nurses unfamiliar with peer review may be fearful or reluctant at the peer level to tell colleagues what they are not doing well and where they need to improve or change."
Ongoing and Objective
On the positive side, peer review identifies not only areas that need improvement but areas for praise, says Brennan. "Managers can't be everywhere, so peer review often results in kudos for nurses who otherwise might have been overlooked," she says.
Haag-Heitman suggests that peer review be ongoing and performed in a variety of ways, at all levels of the organization, beginning with staff members as the primary peer review givers looking to enhance quality around defined nursing standards.
The well-defined guidelines for ventilator-associated pneumonia, for example, make VAP a good example for use in peer review during handoffs. Here the discussion centers on what should be done for patients to prevent VAP. When RNs began looking at these standards around handoffs, there was a decrease in VAP, according to Haag-Heitman.
[caption id="attachment_" align="alignright" width="195"] Peer Review Conference speaker Barbara Haig-Heitman (second from right) with (from far left) ONE/NJ president-elect Deanna Sperling, Vice President Nursing, Kimball Medical Center/Saint Barnabas Behavioral Health; Mary Golway, Education and Consultative Specialist, ANCC; and current ONE/NJ president Edna Cadmus, senior vice president, Patient Care Services, Englewood Hospital Medical Center.[/caption]
SBIR and How It Works
"This is a real-time application of peer review: Identify the quality standard, train people to give feedback, and measure the impact, so that you have a structure, process, and outcomes," Haag-Heitman says.
Making peer review relevant may mean updating communication training within the organization. Haag-Heitman suggested an adapted version of the Situation-Background-Assessment-Recommendation communication technique, or SBAR, from the Institute for Healthcare Improvement. The adapted SBIR version is an acronym that translates into the following steps:
? State the situation
? Describe the behavior
? State the impact on the individual, team, patient, or family and take a pause
? Make a recommendation for change in behavior or practice
"As with SBAR, SBIR feedback is specific, straightforward, and nonjudgmental, using firsthand information," says Haag-Heitman. "The SBIR method targets feedback without hurting the relationship," she says.
Practice Makes Perfect
As part of its Magnet status, Englewood Hospital and Medical Center has various components of peer/practice review in place. Edna Cadmus, RN, PhD, NEA-BC, senior vice president, Patient Care Services, says peer review is not just an evaluation process, as previously believed, but can be identified in many things done by staff on a regular basis. For example, competency validation — checking someone on a new skill — is a form of peer review; in fact, it is a review of practice.
A team at EHMC is creating a work plan that redefines peer review for the organization, so that staff can better connect their current activities with peer/practice review.
At St. Joseph's Regional Medical Center, a three-time Magnet recipient, peer review has been used for the last 12 years. Brennan says that some units have elected to have a panel while others ask a few nurses to perform peer review.
"The more you use it, the more comfortable you become with the process," says Brennan. "It's an art that needs to be learned."
