Nursing Peer Review

Nurses play an important role as patient advocates anytime they work to resolve workplace and professional issues that potentially affect patient care.

A model of shared governance can empower nurses to take a more active role in advocacy and even improve patient outcomes, by giving them the professional autonomy to manage their own practice.

One strategy for shared governance is nursing peer review, which is too often misunderstood by nurses to be judgmental in nature or designed to punish mistakes.

It’s important for nurses to understand that peer review is a tool for advancing nursing practice and promoting patient safety.

It’s very much related to the new focus on evidence-based nursing practice, and can help the profession to implement new evidence-based interventions as they are identified.

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Defining Peer Review

So what is nursing peer review?

It is a method of examining the quality of nursing care within a unit, in terms of structure, process and outcome. The goal is not for nurses to criticize or assign blame to each other, but to allow them to grow professionally through collaboration and shared insights.

While it may be a new concept for many nurses, physicians have been collaborating this way since the early 1900s.

The “morbidity and mortality conference,” commonly known as an M&M, is essentially a medical or surgical peer review, i.e., a chance to improve patient care by reviewing specific complications to determine whether or not they were preventable. It’s time for nursing to adopt peer review as a quality-of-care initiative as well.

Triggered vs. Routine

There are two basic types of nursing peer review: incident-related and routine.

Incident-related reviews are triggered by an adverse event or outcome directly related to nursing care, like the failure to recognize a change in patient status or to initiate a timely response to that change.

In these cases, the incident is examined in detail, not to assign blame to the nurses involved, but to determine if standards of care had been met: and if not, to identify which systems or processes contributed to the adverse event.

Incident-related reviews can identify issues that are likely to happen again, and allows nursing staff to proactively create policies that keep patients safe going forward, which is an important facet of our role in patient advocacy.

In most hospitals, routine nursing peer review is either non-existent or done infrequently, perhaps as part of an annual employee evaluation.

The exception is Magnet hospitals, which must have an ongoing peer review process in place to maintain the designation.

According to the American Nurses Credentialing Center the peer review process stimulates professionalism through increased accountability and promotes self-regulation of the practice.

For this reason alone, nursing peer review should become a more widespread practice.It should take place on a regular basis with a focus on quality and safety, not only to promote patient advocacy but also to advance the entire nursing profession, for who can better review and improve nursing practice than nurses themselves?

The Fundamentals of Nursing Peer Review

The American Nurses Association issued a set of six principles for nursing peer review way back in 1988. Even though peer review has not yet become standard practice in most hospitals, these principles are more relevant today than ever before, given our current focus on improving healthcare quality and patient safety. These six principles are outlined below.

1. A peer is someone of the same rank.
The term “peer review” is too often mistakenly applied to an annual performance evaluation conducted by a manager. When a review is a managerial function, it’s more likely to be seen as punitive or judgmental, and it simply doesn’t meet the definition or goals of peer review, which is truly performed among colleagues who are peers – so floor nurses review other floor nurses, advanced practice nurses review other APNs, etc. In a hospital, peer review is most effectively done by unit, where nurses have similar competencies and can take into consideration the scope of nursing practice there, including specific contributing factors like documentation systems and availability of supplies.

2. Peer-review is practice-focused.
This means the process is concerned with patient outcomes, which is what makes it so important to patient advocacy. Peer review should not be about personality conflicts within a unit, but about keeping patients safe and comfortable during a hospitalization. It’s a way to monitor the standards of care within a unit, as measured against professional standards and evidence-based nursing practice. And let’s face it, nursing practice grows more complicated all the time, as nurses are being called upon to contribute to quality initiatives like preventing hospital-acquired infections. As nursing practice integrates new forms of interventions – like nurse-directed catheter removal, for example – we can all benefit from a system that ensures we’re meeting protocols.

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3. Feedback is timely, routine, and continuous.
When nursing peer review only happens once a year in conjunction with an annual performance evaluation, it simply cannot make a real impact on patient care. Only a systematic and ongoing review process can contribute to patient safety initiatives. When peer review happens in real-time, nurses can catch policy and process failures right away and correct them, before more harm occurs. Ideally, nursing should move to dynamic feedback loops that originate at the point of care. An example would be implementing elements of peer review into the patient handoffs that occur at shift changes. Nurses from both shifts can then become jointly responsible for monitoring adherence to evidence-based practice, whether noting that a ventilated patient did not receive appropriate oral care or that an intervention to prevent falls has been successful.

4. Peer review fosters a culture of continuous learning regarding patient safety and best practices.
Again, patient advocacy comes into play here in an important way. Peer review is not about finger-pointing or whistle-blowing – because the focus is not on individual improvement so much as organizational improvement. Its purpose is to gather evidence that can be used as the basis for policies and procedures that improve nursing care. In this way, it collectively expands the clinical knowledge and skills of an entire nursing unit. When an adverse event or near-miss occurs, nurses can work together in a culture of safety – rather than a culture of blame – to analyze the relevant information and make critical decisions about standards of care.

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5. Feedback is not anonymous.
In order for nurses to work together collaboratively, we need skillful, professional dialogue about nursing practice, rather than sharp criticisms or personal attacks. Each nurse must have a chance both to give and to receive feedback, fostering a collegial atmosphere. This can best be achieved through face-to-face communication and honest discussion about nursing theory, hospital protocols, and ethics. Nursing programs today teach leadership skills for this very reason – to help nurses become grounded in evidence, with a broader base of knowledge that helps them question current practices that can be improved upon.

6. Feedback considers the developmental stage of each nurse.
Nursing skills develop along a continuum, from novice to expert, particularly in specialized settings like the ICU where nurses need specific competencies. This brings into play another important consideration in nursing peer review – the chance for experienced nurses to act as informal mentors to younger nurses, by sharing supportive insights or practical ways to apply critical thinking skills. In this way, peer review contributes to patient outcomes by supporting the professional development of newer nurses or those adjusting to a new specialty area.

Good Reviews

Nursing peer review is an effective way to hold nursing practice to the highest professional standards. It can be a very positive experience for all the nurses involved, allowing them to take ownership of their own unit in order to improve the quality of care and effectively advocate for their patients.

Gloria Ohmart is the associate dean of undergraduate nursing programs at American Sentinel University.

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