As organizations increasingly seek Magnet^(R) recognition, professional development of nurses is becoming a primary focus.1 Peer review offers an opportunity for nurses to provide feedback about their colleagues, and it teaches nurses to give and receive constructive feedback. However, peer review is often misunderstood. Leaders confuse the review with the annual performance evaluation, nurses perceive peer feedback as a negative experience, and anonymous feedback makes the review a forum to complain about colleagues without fear of repercussion.2 The American Nurses Association (ANA) has advocated for peer evaluation since 1973, and it first published peer-review guidelines in 1988.3 Within the nursing profession, no one is better suited to evaluate and provide feedback on the performance of their peers than other professional nurses.

The paper age

Since the 1980s, peer reviews were conducted at the study facility using a paper-based survey. Domains of nursing competencies were assessed using a 5-point Likert scale for each item. Items included were:

* builds and maintains productive interpersonal relationships

* finds time to help others, either by answering their questions or providing assistance

* demonstrates a willingness to be flexible with coworkers

* identifies, understands, and responds to the appropriate needs of customers

* implements service recovery by recognizing problems, identifying underlying causes, and taking steps toward resolution

* respects others by communicating with confidentiality and consideration

* exhibits clinical competencies in his or her work area

* can be described as "a good listener"

* is a team player

* collaborates appropriately with other departments/units.

Respondents were then asked to rate their peer on overall qualities of teamwork, customer service, clinical skills, and interpersonal skills. Response choices for these items were: exceeds, meets, or needs improvement. The option unknown/not applicable or neutral was available for all items.

Paper-based peer-review forms were handed out before the annual evaluation. The nurse being evaluated gave the form to two colleagues and the nurse manager chose one peer to give an anonymous evaluation. These responses were presented at the annual evaluation discussion.

Surveying nurse leaders

A survey was created to assess the opinions of nurse managers in the organization about the usefulness of the evaluation. The survey was distributed electronically to the corporate e-mail group "nurse managers." Fifty-one contacts in this group included nurse managers, nursing directors, and executive nursing leadership.

Twenty leaders completed the survey for a response rate of 39.2%. (See Table 1.) The majority of respondents felt the current peer-review process wasn't effective in promoting staff development. Most felt that peer reviews should be performed during the annual evaluation, but this question wasn't presented in a way to indicate alternative time frames for reviews. Leaders claimed comments would be useful in coaching, and the majority agreed that a higher number of reviews would make the process more effective. The participants felt all staff should be involved in the peer evaluation process.

Table 1: Table 1: Nurse leaders' opinions of the paper-based peer evaluation process

One participant commented, "They would be helpful if peers were truthful and believed they were confidential." This comment indicates a deficiency in the current process. The low rate of participation provided by three peer surveys among 26 nurses on the study unit (11.5% response rate) minimizes confidentiality and lends selection bias to the sample. Any comments provided might easily be traced to the reviewer. Another manager commented, "Many times staff just circle the numbers in response to the questions without any constructive comments." It's important that reviews be validated with comments about the skill being evaluated. The ANA's peer-review guidelines call for nonanonymous comments from reviewers.3 This proposal, however, places a burden on the evaluator to maintain confidentiality.

An important aim in this study was to assure reviewers that their identity would only be known to the manager presenting the evaluation, not to the nurse being evaluated. This strategy allowed for clarification of comments by the manager, but avoided creating interpersonal conflicts during the study. Specific comments needing further discussion could be mediated by the manager, allowing adherence to the ANA guidelines. Instruction to reviewers on how to give constructive feedback would also be useful in the process.

Other comments included "Would staff possibly be more open to performing a peer review electronically to allow more anonymity and also allow a larger number of peer reviews to be done on each person?" The leaders surveyed weren't aware of the proposed intervention. This comment validated the study and gave encouraging insight that some leaders in the organization were open to a change in the process.

Testing electronic peer evaluation

The study site was a 28-bed inpatient unit employing 26 RNs, located within a 461-bed suburban hospital currently pursuing Magnet recognition. Institutional Review Board approval was obtained. The existing review format was converted into an electronic survey and distributed to all nurses on the unit. Due to varying work schedules, respondents were given 1 week to complete the survey.

Following completion of the survey period, responses were tabulated and calculated by assigning points to each response, then creating a composite score for the average points. Individual responses weren't provided to the employee. This method ensured confidentiality for evaluators and prevented small numbers of extreme scores from having a large impact on the composite score.

During the annual evaluation, the composite scores were presented in a bar chart format. The x-axis was rounded to the lowest composite minus 1 and the highest composite plus 1 to demonstrate gaps in scores. The second set of domains was presented as individual responses. However, during the evaluation, the nurses were encouraged to look at the frequency of responses.

During the study period of March 1 to May 31, 2012, eight nurses participated in the revised peer evaluation process. None refused to participate. However, bias may have existed because the investigator was also the nurses' direct supervisor. In an attempt to control for this bias, a nurse on the unit serving as co-investigator approached the nurses before the evaluation to assess their willingness to participate.

The survey included a free-text comment box that instructed users to enter their names with any comments, but anonymous comments were frequently given. Positive anonymous comments were provided to the nurses for encouragement. In some instances, three or more negative anonymous comments with similar themes were used as feedback. Otherwise, they weren't used.

Response rates to the peer evaluations ranged from 30.8% to 50% of the 26 nurses who received the survey. For the eight nurses evaluated during the study, an average of 11.1 nurses completed a peer review on each. This was a significant improvement over three evaluations (11.5% response) obtained during the previous evaluation method. A co-investigator solicited feedback from the staff members after evaluations and found that most appreciated the insight. A few were angry or surprised at negative comments. All agreed that the new process was an improvement.

Positive reviews reinforced strong evaluations and indicated nurses who could take on advanced responsibilities. The peer evaluations were most useful when themes could be identified. These themes were highly effective in correcting undesired performance.

Implications for future research

The sample in this research was small and homogenous. The nurses being evaluated were generally white women, and further research is needed to assess reactions of other groups. The peer review can reveal performance issues with which nurses haven't been confronted, and delivery of results and development of action plans requires sensitivity on the part of the evaluator.

The domains on the review tool were copied from the institution's review form. An examination of current research to validate or revise the tool is recommended. Also, use of the peer evaluation for unlicensed assistive personnel would likely yield similar benefits. The co-investigator revealed that some nurses felt a peer review done 6 months before the annual evaluation would allow them to set goals and have those goals evaluated during their performance review. This suggestion warrants further research and development of tools to assist with performance improvement.

The benefits of peer evaluation

The ANA recommends using peers of the same rank, focusing on practice instead of personalities, considering the experience level of the nurse, and avoiding anonymity in responses. The guidelines call for peer review to be a routine process that focuses on best practices and patient safety.4

Nurses participating in the online peer-review process felt that it was much more effective than the previous method. The review provided opportunities to explore expanded responsibilities on the unit, and it opened up discussions about performance issues that otherwise may have gone unexplored.

As nurses are tasked with continuous quality improvement in their workplace, it seems logical that they should also play a part in improving the performance of their peers. These nurses have insight into positive or negative behaviors that may not be apparent to managers. As leaders, we must efficiently tap this valuable resource to empower and develop the nurses we lead.

REFERENCES

1. Luzinski C. An innovative environment where empowered nurses flourish. J Nurs Adm. 2012;42(1):3-4. [Context Link]

2. Pfeiffer JA, Wickline MA, Deetz J, Berry ES. Assessing RN-to-RN peer review on clinical units. J Nurs Manag. 2012;20(3):390-400. [Context Link]

3. American Nurses Association. Peer Review Guidelines. Kansas City, MO: American Nurses Association; 1988. [Context Link]

4. Haag-Heitman B, George V. Nursing peer review: the manager's role. J Nurs Manag. 2011;19(2):254-259. [Context Link]