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Nurse Performance Appraisals

What purpose do they serve?

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In any top-notch organization, not just in healthcare, performance appraisals are essential if the company is going to achieve its mission and ensure a competent staff and safe environment, for its external and internal customers.

Additionally today, nurses must be held accountable for fiscal responsibility if the hospital is going to remain solvent.

Many hospital policies, as well as standards set by the American Nurses Association and the American Nursing Credentialing Center Magnet Recognition Program for Nursing Excellence, require nurses to prepare a self-evaluation that becomes part of the annual evaluation.

Self-Evaluation Basics

The self-evaluation should be submitted to the manager prior to the annual review. It is important the nurse being evaluated uses the same criteria or evaluation tool as the nursing department's standardized format. At the evaluation conference, there should be no surprises.

If the nurse had a deficiency within the past year, she should have been counseled at the time, and a plan for improvement and a re-evaluation time scheduled by the manager. If the deficiency has been remedied, this may or may not be included in the evaluation. Conversely, if the nurse had a problem with the manager throughout the year, she should have met with her at the time and not discussed her dissatisfaction with the manager for a year.

A primary objective of the evaluation conference is to build trust between the nurse and the manager/evaluator. This helps to facilitate and maintain a professional, working relationship. Achieving this objective sets the stage for mutual goal setting and interpersonal growth between the nurse and manager.

Off-the-Shelf

Meanwhile, with cost accounting in healthcare a top priority, many hospitals administrators need more quantitative data on how their employees are meeting business goals.

Some facilities have a computerized system that evaluates nurses and other personnel according to specific business metrics the hospital chooses to use. For example, if the hospital wants information on how much money it is losing annually on infection rates, the evaluation tool would be developed by a software company to measure this indicator. In hospitals using the metrics-evaluation model, nurse managers are evaluated not on how the hospital unit she manages met the goal, but simply was it met. A numerical score is then attached to each indicator.

Peer Review: A Continuous Process

Using peer review as an evaluation process is quite popular in nursing, but it's not new to the industry.

In 1998, the ANA defined peer review "as the process by which practicing registered nurses systematically assess, monitor and make judgments about the quality of nursing care as measured against professional standards of practice."

The peer-review process has been used as part of nursing performance appraisal since the 1980s. Hospitals that received early designation by the ANCC Magnet program incorporated peer review into their shared-governance models early on, and it remains mandatory for all Magnet-designated hospitals.

In nursing departments where peer review has been retained, nurses report the outcomes generally have been positive and similar. These include: increased professionalism, accountability, autonomy, nurse retention and improved communication skills.

Many nurses involved in peer-review activities report they believe appraisals, "from multiple sources, such as peers, will be more complete, less subjective, and more reliable and valid," according to Karen Kent, MSN, RN, director of patient care services, Bayfront Medical Center, St. Petersburg, FL.

In an article published in this magazine in 2005, Kent pointed out there has been substantial anecdotal reporting supporting the positive outcomes from using peer review. However, the nurse administrator noted there has not been a substantial body of research to document evidence of the outcomes cited by nursing staff to serve as the framework for a professional practice model.

Currently, there seems to be a resurgence of more non-Magnet-designated nursing departments implementing peer-review models, according to Kent. The reason for this change may be administrators' expectations that nurses need to be more accountable and self-directed, in light of the public's concern about increased medical errors, she said.

Overcoming Pitfalls

In some hospitals where peer-review programs were attempted, the effort was halted when pitfalls became too many. For example, if hospital administration didn't support the change, peer review was doomed from the beginning.

In other hospitals, nurses who tried to adopt the peer-review process didn't realize it was not just a different evaluation method they were initiating, but rather a major change in the nursing. When they accepted this reality, it was too late to regain support to continue on.

In contrast, at Sarasota Memorial Hospital (SMH), Sarasota, FL, the peer-review program is alive and well, according to Janet Steves, MBA, BSN, RN, director of nursing resources; Jennifer Rheingans, PhD, RN, AHN-BC, education, professional development and research department; and Kelle Brooks, MBA, BS, RN, PACU nurse and research council chairman.

Designated a Magnet hospital in 2003 and re-designated in 2008, SMH's Professional Peer Review Policy and Procedure can be viewed online at [http://home.smh.com/sections/services-procedures/medlib/nursing/NursPandP/126_004_Professional_063008.pdf].

Steves noted the online policy and procedure, adopted in 2008, can help other nurses see SMH's program includes "every nurse, in every position, at every level."

The administrator added, "Since we began the program we have always been transparent about sharing what we are doing." The Career Ladder program at SMH can also be accessed online at [http://home.smh.com/sections/services-procedures/medlib/nursing/Continuing_education/Career%20Ladder/Profesional_practice_Presentation_career_ladder.pdf].

Peer Review 101

Steves, Rheingans and Brooks are proud of the 1,200 RNs who have embraced the peer-review program at SMH. A major reason for the program's success is the pre-planning involved.

"With the management team and the Magnet champions, we started with Peer Review Workshops 101. The group defined broadly what was essential to include in the peer review process. Then we had 'aha' moments, as we began to tailor the program to our hospital and define the process more narrowly," Brooks reported.

"When the change was introduced to the staff, they had a lot of fear and trepidation," admitted Steves. "We were successful because we stayed one step ahead of the game," added Brooks and Rheingans.

After 9 months and classes on peer review concepts and communication strategies, the staff felt braver and bolder, according to the managers.

"Nurses complete peer reviews on each other with each RN receiving at least three peer reviews annually. The nurse manager incorporates this into the development plan for each RN, which is formed, discussed and re-evaluated at the annual performance evaluation," Steves explained.

It's important to recognize peer review is not limited to only providing feedback to performance appraisals. SMH developed an innovative tool, "From Pal to Peer," an attractive poster that reinforces the essentials of peer review. For example, the purposes, benefits and types of peer-review activities are listed, as well as self-evaluation questions on how to ensure success in the peer-review process. There is even a photo of a nurse and her testimonial about the process.

The SMH peer-review team is excited about guiding the nurses to the next tier of peer review that includes nurse involvement in quality improvement, nursing indicators and professional role actualization - using Benner's "From Novice to Expert Model."

The managers noted one of their benchmarks for peer review at SMH is when nurses deliver a face-to face performance appraisal to a peer.

Nurse Accountability

At Main Line Health System (MLHS) in suburban Philadelphia, three of the acute care hospitals - Bryn Mawr, Lankenau and Paoli - received Magnet designation in 2005 and again in 2010. Riddle Memorial Hospital, another acute care hospital in the system, is currently on the Magnet journey.

Martha Lyman, MPH, RN, director of nursing systems and special projects, pointed out since Magnet principles and guidelines were introduced to the MLHS nurses almost a decade ago, the Magnet culture is strongly embedded into the system, which uses peer review in nurse performance appraisals.

"Peer review is not just about providing feedback to peers in performance appraisals, although this is done routinely," Lyman said. "Peer review by MLHS nurses is evident in all areas of the hospitals, as the nurses work collaboratively with all disciplines, including physicians."

Lyman provided an example of peer review in action at MLHS that aptly demonstrates nurse accountability. At the facility's monthly Nursing Process and Outcomes Review Committee, a branch of the Nursing Quality Council at SMH, nurses present a patient care situation to discuss about how the nursing care provided to a specific patient on a specific unit could have been delivered differently.

"This is shared decision-making," she explained. "The nurses examine the situation and determine if this is a compliance or systems issue, and then decide if it needs further study and action."

Kay Bensing is senior nurse consultant at ADVANCE.


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