1. Lamonica, Nancy MHA, MSN, RN, PCCN
  2. Cama, Melanie BSN, RN, CHPCA
  3. Dennehy, Nancy MHA, BSN, RN-BC
  4. Duncan, Pam BSN, RN-BC
  5. McDonald, Amanda BSN, RNC
  6. Mohrlein, Cheryl MSN, RN, NE-BC, OCN
  7. Norton, Karen BSN, RN, CAPA
  8. Potticary, Deborah BSN, RN, CHPN

Article Content

Development of true peer review can provide the necessary substance to support and grow 21st century nursing leaders. However, there's often limited formal recognition and support for nurses who choose management. At Middlesex Hospital, our nursing leadership team launched an initiative to promote the recognition, assessment, and competency development of nurses in leadership positions. Our CNO propelled us into action by establishing a nursing management peer review taskforce.

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Proposal development

The taskforce was a composite of leadership roles within our nursing management team, including nurse managers, assistant nurse managers, and program directors from diverse areas, which ensured full organizational representation, collaboration, and potential buy-in. The purpose of the taskforce was to assess our current leadership practices, extract data, and establish a more deliberate, meaningful peer review process for managers. The group's action plan was to research, develop, and design a peer review process that supports leadership growth; encompasses achievable goal setting both organizationally and personally; and includes tracking input, developing a coaching concept, and evaluating successes, barriers, and outcomes after 1 year.


The taskforce began its work at an educational retreat reflecting on our current management peer review and determining the need for a value-based process. We evaluated two existing internal processes for peer review. The first involved a peer review committee that evaluated organizational best practices and adverse events. The second was a concept integrating peer review with evaluation compensation. Both of these processes can contribute to professional growth; however, they didn't specifically reflect individualized leadership growth or goal setting.


Literature review

We conducted an assessment of the literature on leadership peer review. The literature resulted in limited findings; however, the American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE) support growth from the peer review practice. Each reference offered some leadership tools and guidelines without a clear structural process. The 1988 ANA Peer Review Guidelines was the most current resource, which was somewhat concerning, but it helped us focus our discussions and decision making regarding professional grouping.1 The AONE Nurse Executive Competencies Assessment Tool gave definition to the development of core competencies for goals and leadership growth.2


One book defined ANA's peer review as practicing professionals reviewing services or quality of work.3 However, this seems to address global nursing without leadership delineation. This definition did provide clarity that the process should be a formal one and leadership-specific standards need to be integrated as part of peer review criteria. One article inspired us to integrate a peer coaching element early in this phase.4 By expanding our vision of peer review and integrating peer coaching, we suggested enhancement of leadership support throughout the process to increase our chances of a successful outcome.


Design and goal setting

Our first goal was to integrate and enhance a collaborative peer review process. The following criteria were the starting point for the design:


* the peer is of the same rank


* review is practice-focused


* feedback is timely, routine, and continuous


* review fosters continuous learning


* feedback isn't anonymous


* feedback incorporates the leader's developmental stage.3



The taskforce shifted focus from peer review evaluation to collaborative peer review, with a coaching process emphasizing mutual support for skill building and goals. This process needed to be nonthreatening and collegial in nature, focused on organizational leadership skills and goals, and applicable to individual needs at any phase of the leader's career. Because this initiative was dependent on mutual peer coaching for achieving growth and development, the group defined "peer" with inclusion and exclusion criteria to ensure participants shared a common role within the organization.


Participants were nurse managers, assistant nurse managers, and program managers with direct reports. The participants shared similar roles and responsibilities with staff and upper-level management. New nurse leaders with less than 6 months' experience were exempt because they were already participating in an orientation process with mentorship, so the focus for new leaders was more on orientation versus leadership growth. Clinical nurse leaders were exempt because their role focuses primarily on quality and continuum of care. APRNs in management roles didn't seem to fit the criteria because their roles have more of an independent practice focus.


Leadership pairing was designed to span across the organization, allowing for diversity in peer review. Each pairing needed to establish meeting times for self-reflection and goal setting strategies. Additional structural foundation for peer review was added by adapting key competencies published by the Healthcare Leadership Alliance (HLA).5 The following five competency domains were determined to be fundamental for all healthcare managers:


* communication and relationship management


* professionalism


* leadership


* knowledge of the healthcare system


* business skills and knowledge.



These domains fit well with our objectives of promoting professionalism and nursing leadership as a specialty.


Next, the taskforce adopted the AONE Nurse Executive Competencies Assessment Tool, which was developed simultaneously but independently of the HLA competency framework. Our initial vision was to support nursing management by transferring knowledge, expertise, and experience. The taskforce expanded on this vision by providing developmental tools and processes that offered ongoing growth along with transparency. The leader's individualized goal was derived from a self-assessment and reflection using the AONE tool. Each leader's responsibility was to outline a self-developed goal. The strategic goal for the entire group came from our leadership's strategic vision for the current year.


An electronic tool was needed to provide structure, oversight, and transparency for all managers. The tool needed to allow for easy importation of managers' names; peer matching; and effective tracking of peer meetings, goal setting, and achievements. It also needed to contain all necessary documents for peer review steps and self-assessment guidelines. These documents defined the plan, timelines, and any resources needed for participation. All participants were given access to the tool, allowing for transparency and accountability among peers. Nursing management owned every aspect of the peer review process.


The basic steps of the electronic process were to:


* perform a self-assessment using the AONE Nurse Executive Assessment Tool


* meet with the assigned peer coach three times a year


* document a strategic goal and assessment toward the goal


* develop and document a personal goal and individual work done in meeting the goal.




Always a question with any new process, we asked "does it work?" To address this question, the taskforce put two structures in place. First, two nurse managers were designated to oversee the process. The oversight managers provided quarterly updates at leadership meetings promoting transparency in nursing management at the executive level. The leader's responsibilities were to monitor, coach, and encourage the team. Second, the team devised a way to measure outcomes and monitor feedback specific to process design and implementation. By doing this, areas of concern were identified for ongoing improvement and change.


Each leadership participant received an evaluation at the end of the peer review cycle. This peer review assessment and feedback form was completed at the end of the coaching cycle. The first part of the survey assessed whether the process met the criteria set forth in the ANA Peer Review Guidelines. This allowed all participants to rank themselves and their peer on knowledge of the process, organization and consistency, reliability and availability, and professional feedback.1 The second part was a self-reflection on individual goal setting. For consistency purposes, the tool used a 0 to 5 scoring range.


The leadership surveys at the end of the cycle showed positive outcomes. One recommendation for change was to develop a way to provide structured meeting times for all leaders to pursue peer review.


Positive outcomes

Peer coaching at the leadership level must take into account the complexities and time restraints of today's healthcare leaders. The continued expectation is that nursing management participation will encourage individual growth and improvement of overall leadership skills, supporting the healthcare structure. True peer review can lead to increased personal fulfillment, thereby improving the overall retention of nursing leadership.


The focus of management peer review is one of the contemporary tenets of our profession, including quality, safety, role actualization, and practice advancement. In the pursuit of perfection for our peer review process, we need to evaluate, review, and change often to meet the demands of our leadership roles. Assessing expertise and stimulating growth adequately nurture our advancement. Nurse leaders need to work collaboratively to translate values, competence, and managerial strategies into professional practice. Continuous growth and self-improvement can only be achieved through ongoing review and redesign. Processes and programs are only as good as their latest evaluation. The nurse leader peer review process implemented at Middlesex Hospital is one of the first steps in supporting continuous peer-to-peer professional growth within our nursing management team.




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


2. American Organization of Nurse Executives. Nurse executive competencies. [Context Link]


3. George V, Haag-Heitman B. Peer Review In Nursing: Principles for Successful Practice. Sudbury, MA: Jones & Bartlett; 2010. [Context Link]


4. Robbins P. How to plan and implement a peer coaching program. Int J Nurs Studies. 2010;47(3):363-385. [Context Link]


5. Stefl ME. Common competencies for all healthcare managers: the Healthcare Leadership Alliance model. J Healthc Manag. 2008;53(6):360-374. [Context Link]