The Fundamentals of Nursing Peer Review (NPR)

If your hospital is currently on the Magnet journey, or has achieved Magnet status, you know that the ANCC Magnet Recognition Program® calls for a model of shared governance. The idea is to empower nurses by giving them the professional autonomy to manage their own practice – rather than having policies and workflows dictated by administrators who are not on the front lines of patient care. Empowered nurses can better serve as patient advocates and are in a better position to improve patient outcomes.

Nursing peer review (NPR) is a component of shared governance that is far too often misunderstood. It can be misperceived by nurses as a practice that is meant to be judgmental in nature or designed to punish mistakes. Nothing could be farther from the truth! Nursing peer review is actually 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.

So what is nursing peer review?
NPR 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 peer review may be a new concept for many nurses, physicians routinely collaborate this way, through a type of meeting known as a morbidity and mortality conference, or M&M. Doctors see these events as an opportunity to improve patient care by reviewing surgical and medical 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.

There are two basic types of nursing peer review: incident-related and routine. Incident-related reviews are triggered by an adverse event or poor outcome directly related to nursing care, like administering a medication to the wrong patient or failing to recognize a change in vital signs. In these cases, the incident is examined in detail, not to assign blame to the nurses involved, but to determine whether a breakdown in systems or processes contributed to the problem. The goal is to identify problems that might arise again, and to proactively prevent them from becoming threats to patient safety.

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 – for who can better review and improve nursing practice than nurses themselves?

The fundamentals of nursing peer review
Way back in 1988, the American Nurses Association (ANA) issued a set of six principles for nursing peer review. These principles are more relevant today than ever before, given our current focus on improving health care quality and patient safety. These six principles are outlined below.

1. A peer is someone of the same rank.The term “peer review” does not refer to an annual performance evaluation conducted by a manager. In true peer review, floor nurses review other floor nurses, advanced practice nurses review other APNs, and so forth.

2. Peer-review is practice-focused.
This means the process is concerned with patient outcomes. It’s a way to monitor the standards of care within a unit, as measured against professional standards and evidence-based nursing practice.

3. Feedback is timely, routine, and continuous.
When peer review happens in real-time – rather than as an annual evaluation – nurses can catch policy and process failures right away and correct them, before more harm occurs.

4. Peer review fosters a culture of continuous learning regarding patient safety and best practices.
Peer review is not a blame game. Its purpose is to gather evidence that can be used as the basis for policies and procedures that improve nursing care on an organizational basis.

5. Feedback is not anonymous.
In order for nurses to work together collaboratively, we need face-to-face, professional dialogue about nursing practice, rather than sharp criticisms or personal attacks.

6.  Feedback considers the developmental stage of each nurse.
Nursing skills develop along a continuum, from novice to expert. This brings into play another important consideration – 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.