Using Nursing Peer Review for Quality Improvement and Professional Development with Focus on Standards of Professional Performance

This article explains the pilot project and results of a peer review which, according to the data available, is the first such review carried out in the Croatian nursing practice. The goals of this project were to identify standards of professional performance which describe behaviour of competent professionals. Peer review is the evaluation of an individual’s professional performance for relevant competency categories by using multiple sources of data. Semi-structured interviews were carried out with all nursing staff (N=16) in St. Catherine Hospital. This system of peer feedback is generally acceptable to the participants. The experience suggests that the approach enhances understanding of roles and responsibilities and is supportive to inter professional team development. The peer review had positive outcomes, particularly in the planning of future development of education and staff training, as well as in general professional development of the nurses and the nurse leader.


Introduction
Peer review has been a part of the nursing profession for many years with varying concepts, processes, degrees of implementation and success. [5] The first principles and practice of nursing peer review were defined 25 years ago and hold nursing practice to the highest standards. [1]

Definition of Peer Review
The first definition of nursing peer review proposed by ANA in 1988 is still applicable today: "An organizational effort whereby practicing professionals review the quality and appropriateness of services ordered or performed by their professional peers. Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice….Peer review implies that the nursing care delivered by a group of nurses or an individual nurse is evaluated by individuals of the same rank or standing according to established standards of practice." [1] During the years, different authors provided many different definitions of peer review.
According to Diaz peer review process is the evaluation of the delivery of nursing care in an objective and non-judgmental manner when analysing causative factors involved in medical errors with potential untoward events. [10] On the other hand, Gopee's theory about peer review is related to the identification of appropriate and willing peers for obtaining feedback on performance on a particular activity. [14] Brooks, Olsen, Rieger-Kligys, and Mooney define peer review as a process for evaluating performance and strengthening group communication, which also helps to maintain the integrity and self-governance of the nursing unit. [4] All definitions focus on maintaining standards of nursing practice and upgrading nursing care in three contemporary focus areas for peer review-quality and safety, role actualization and practice advancement. [9] Peer review has beneficial effect on nursing practice as it reinforces the self-regulating nature of the nursing profession and has potential to create a culture of safety [10]; it can be a mechanism through which the profession acts to assure quality nursing care [1] and it can increase teamwork, creativity and a sense of ownership amongst nurses. [4] It meets the ANA's Peer Review Guidelines stating that 104 Using Nursing Peer Review for Quality Improvement and Professional Development with Focus on Standards of Professional Performance "Each nurse must participate with other nurses in the decision-making process for evaluating nursing care." [1] Peer review also helps to maintain standards of nursing care, provides evidence for change or needs for knowledge in practice protocols to improve care. It enhances transparency in nursing. [20]

Peer-review Practice Principles
Using the six peer-review practice principles below (which are based on the ANA Guidelines) helps ensure a consistent, evidence-based approach to peer review.  A peer is someone of the same rank.  Peer review is practice-focused.  Feedback is timely, routine, and a continuous expectation.  Peer review fosters a continuous learning culture of patient safety and best practice.  Feedback is not anonymous.  Feedback incorporates the nurse's developmental stage.

Dimensions of Contemporary Peer Review
Nursing peer review is a critical component to addressing the variations and inadequacies in the quality of nursing care. Nursing needs to be proactive in its response to quality and safety issues as these data are increasingly being reported publicly. [20] A typically reported peer review process consists of the nurse manager collecting peer input on direct-care nurses' performance from other direct-care nurses, summarizing and binding the results, and then delivering the peer evaluation at the time of the annual performance review. [15] The manager´s role is critical to helping facilitate the establishment of effective peer review structures and processes. To provide the transformational leadership necessary to support successful peer review implementation, each manager must be knowledgeable about the contemporary focuses of peer review and the associated evidence-based principles.
The three dimensions of peer review are: quality and safety, role actualization and practice advancement. [15] Peer review activities for each of the three areas can be targeted at the individual, unit, population, and organizational levels. Understanding the objectives and distinctions between the annual performance review and peer review is important to ensure that both processes achieve their intended purposes. The annual performance review focuses on employees` goal attainment and goal alignment to the organization, while peer review focuses on quality of the care and professional practice outcomes. [6] The annual performance review is within the scope of the manager role. [12] Peer review can be individualized to fit any type of unit or work culture. [9] The design and format of peer review programs can change and evolve as unit cultures shift on the basis of the goals and values of existing staff and the maturity of their programs. A variety of models are described in the literature, including peer review councils, anonymous or signed feedback forms, and one-to-one individual feedback. [19] In some cases, feedback tools are linked to reflect the unit standards for areas such as education, clinical practice, performance improvement, valuable strategy for teaching and learning, opportunity to develop nursing skills while growing in areas of professional socialization, communication, collaboration, organization, and leadership. [17] [13] [2] Methods for assessing other important domains of competence, such as interpersonal skills, humanism and teamwork skills, are less well developed.
In addition, development, implementation and results of peer assessment could be used as a measure of professional competence of medical students for formative purposes. [7]

Implementing a Peer Review Process
The following guidelines and recommendations are designed to assist managers and clinical staff with the implementation of a peer review process. They can also be used as a way to assess a current peer review process and assist with revisions. The implementation steps are divided into 5 phases describing the introduction of concepts and getting nurses engaged, implementation guidelines, piloting the process, staff education, and ongoing evaluation. [9] For most organizations, the implementation of peer review is not merely the addition of a new process or way to do performance appraisals, but rather a significant change in its culture, requiring a paradigm shift on the part of both the nursing staff and administration. [16] Designing the structure and process of a peer review program is a complex task. Decisions to be made include what aspects of performance will be included in the review and how the performance will be monitored and documented. [16] Implementation of the program on a pilot unit is also recommended. Likewise, in addition to evaluating the process itself, an evaluation of the expected outcomes is recommended. A successful peer review program is expected to develop a more cohesive team and promote professional growth and accountability. Metrics such as documentation compliance, errors, staff and patient satisfaction, and nurse retention may all be expected to improve as a result of a peer review program. [3] Essential elements in the development of a peer review process include: soliciting input from important stakeholders, determining the evaluation criteria or standards, developing the tool, and determining the reviewers. [3]

Determining the Standards and Developing a Tool
Multiple standards must be considered for inclusion in a tool developed for peer review.
Once the pertinent standards have been identified, they need to be operationalized. The final format of the tool might be as broad and unstructured as guidelines for a letter of support, or as specific as a checklist of items attached to a rating scale. Regardless of the design, the driving force should be capturing all the pertinent data in a readily usable format.
Other important considerations are the objectivity of the measures and the length and complexity of the document. Feedback that is considered to be too subjective might be dismissed by the individual being reviewed, especially if it contains criticisms. Tools that are too long or are very complex discourage user participation in the process. [3]

Objectives
The goals of this project were to identify standards of professional performance which describe behaviour of competent professionals. Every registered nurse is expected to meet each accompanying competency at certain level. Competencies are specified in the Croatian nurse law.

Materials and Methods
The participants were all nurses (N=16) from St Catherine hospital.
The pilot project of the peer review was used two times, in January 2013 and May 2014.
Approximately 1 hour per participant was needed for the peer review process. Generally, the mean time taken to review papers did not differ significantly between the years. The same nurses participated in the peer review in 2013 and 2014.
The differences in average scores between the years were examined.
The purpose and procedures of the project were fully explained to the nursing staff. The confidentiality of the participants was protected. The peer review contained a checklist and 6 semi-structured items. The check-list had 26 structured items based on a 5-point Likert-type scale. The results for the 26 structured items were based on the compromise between nursing staff Hospital Chief Nursing Officer views and experiences, while the answers to the 6 semi-structured items were remarks made by the nurse leader. Each peer review lasted approximately 60 minutes.

Procedure
St. Catherine hospital is a new small private hospital that deals with orthopedics and spinal surgery. The hospital and the nurse teams were established three years ago. The field management activities that were given priority were human resource management and professional development, with the aim to optimize each individual's capacities.
Peer review has been recognized as one of the possible tools, being an organised effort whereby people critically appraise, systematically assess, monitor, make judgements, determine their strengths and weaknesses and review the quality of their practice. [21] The culture of the organisation must be considered and positive, all staff must be clear about their role and making personal evaluation and have opportunity for career development.
It was an alternative process of peer review. In Croatia peer review is very new practice according to the data available. Education about peer review is insufficient. The major education of the process of peer review was done by AONE for nurse director during AIHA partnership and collaboration.
This is the first step and pilot project aiming towards the development of regular peer review process.
The essential elements in the development of the peer review process included: soliciting input from important contents of peer review checklists, determining the evaluation criteria and standards, and developing the tool. All items in this peer review reflect the level of the Standards of Professional Performance for nurses.
The peer review tool was developed in cooperation with the nurse leader manager, the head nurse of the ward and a professor at the nursing medical school. The researcher was familiar with the nursing culture in question and communication skills, which helped in understanding participants. [18] The peer review interview protected confidentiality of the nurse practitioner. During the peer review process both, nurse and nurse leaders had a questionnaire. Results for the 26 structured items were based on the compromise between nursing staff and the clinical nurse leader's views and experiences, while the answers to the 6 semi-structured items were remarks made by the nurse leader.
The interview was conducted as a discussion between nursing staff and nurse leader, explaining each other's views and trying to find common ground. In cases of disagreement, both views and the final score in the form of the average of the two ratings were written in the remark column.
Participants were more critical in their self-evaluation when compared to peer review nurse manager's ratings. [18] This could suggest that much more effort must be given to active encouragement of nurse staff to be more assertive in discussion with their peers.
Self-evaluation and peer review as evaluation methods helped the nursing staff to promote and internalize the concept of supporting development, the important factors being providing feedback and enhancing reflection.
Peer review tool had two parts. The first part included structured questionnaire about nursing care referring to Fundamental knowledge, Nursing skills, Orientation and Professionalism, the factors described in the Croatian National Curriculum.
Using Nursing Peer Review for Quality Improvement and Professional Development with Focus on Standards of Professional Performance

Ethical Consideration
This project did not need the permission from the ethics committee. The process was carried out with the permission of the hospital management.

Results
Analysis of the results for nursing care and standards of professional performance, as well as total scores for the years 2013 and 2014 is shown in table 3. (see table 3) The objects used for evaluation and the themes in both evaluation tools were identical. The responses to every statement are presented in a table, as well as the average value of answers in each statement for each year.
Individual results by category are shown in table 4. (see  table 4) According to the results shown in the table 1 and 2 the following could be concluded:  The average was slightly higher in year 2014 in majority of categories.  The results reported in nurse care are higher for 2014, which was expected because the continuing education and more practice yielded the expected results. Knowledge and skills have been enhanced, nurses' orientation in the hospital has improved, which resulted in greater professionalism and expertise expressed in daily practice.
The overall results of the standards of professional practice are also visible higher values.
The highest results in standards of professional practice have been achieved in the following categories: reliability, tidiness, which is to be expected as the hospital is privately owned.  Education in the areas of communication yielded the expected results in relation to communication with patients and colleagues, as well as accepting criticism.  Continuing education in the field of security contributed to better results.  The initiative and proactive approach in work was prompted by the employees during work hours because teamwork provided conditions for this. The main idea of the peer review process is having possibility and ability to influence the work area situation because it is important for motivation and positive work place environment. In addition, it enables developing personal innovation in establishment of new modern nursing through cooperation and personal professional growth. [18] The average results were lower in a few categories:  Proactivity  Participation In The Development Of Work Guidelines  Improving The Quality Of Work This can be interpreted in such a way that nurses think that these three categories of the quality control of everyday nursing practice are not to be assessed continuously and, once they did it in the past, they do not give them special consideration.

Discussion
The process of peer review in Croatia is a completely new and undeveloped area in nursing.
There is no work culture of supervision among the professionals of the same rank. The idea was to start with a pilot process of peer review in the categories related to the standards of professional practice. The primary objective of the peer review was to evaluate the quality of nursing care services provided within the Health Care Providers care. It is planned to estimate work annually with the aim of establishing peer review as a regular process. In the future, it will be necessary to change the approach and have peer review organized following all the principles and recommendations of the ANA.
The advantages and limitations of the various formats used in the process of peer review should be also considered. During the peer review process it was concluded that the five-level Likert Scala is not precise enough, so it should be expanded. Also, there is a need of introducing new variables to help create a more precise way of measuring relevant indicators. That is why we have decided that next time we will carry out our peer review with an updated checklist.
The philosophy of this peer review process implied being fair, open, constant and providing positive and confidential feedback. The results of the research indicate that peer review could be useful for staff evaluation and professional development and that its application can enable positive motivation, and benefits for nurses' staff, the hospital development, as well as the satisfaction of the patient. [21]

Limitation
This research has confirmed the limitations of peer review due to the small number of participants and non-validated instrument.

Conclusions
The peer review conducted at St. Catherine Hospital had beneficial effects, particularly in the area of planning of future development of education and staff training, as well as in general professional development of the nurses and the nurse leader. It confirmed our assumption that peer review in clinical settings can facilitate the sharing of good practice and personal and professional growth as it allows participants to learn from each other and gain insight into their professional development, particularly in professional socialization, communication, collaboration, organization and leadership. We believe that our updated peer review will yield a better understanding of professional practice of nurses and nurse leaders.

Implications for Nursing
Peer review can facilitate the sharing of best practices and personal and professional growth in clinical settings. It allows participants to learn from each other and gain insight into their professional development, particularly in professional socialization, communication, collaboration, organization and leadership.

Future Challenges of the Research
An important area of future research is to identify and describe more specific activities to bridge gaps in achieving better determination of nursing practice in nursing care in this peer review tool. The big challenge for the future is empowering nurses to be responsible for peer review among nursing staff and to be more open for two way conversation in open positive atmosphere with the support of the nurse leader.
Also, in order to use this peer review as the valid basis for future activities for development it should be necessary to make it more sensitive, possibly by using Likert scale 1-10.
Hospital and nurse management have to clearly state that implementing peer review as a regular annual activity should become a standard practice for the benefit of all parties involved.