The contribution of peer review assessment in nursing to increasing patient safety and preventing adverse events - a pilot study

INTRODUCTION

Peer review in nursing is defined as the process by which nurses systematically evaluate, monitor, and assess the quality of nursing care and provide feedback to colleagues by comparing actual practice with established standards (Murdock, 2018; George, Haag-Heitman, 2015; Goble et al., 2017; George, Haag-Heitman, 2012; Haag-Heitman, George, 2011; Roberts Holli, 2017; Murphy et al., 2018). Peer review assessment is a structured process in which nursing care is assessed by colleagues within a fair organizational culture, so that the highest possible quality of patient care is ensured (Grootendorst, Lawson 2015; Bergum et al., 2017). The author groups Colella et al. (2021) and Haag-Heitman et al. (2018) also describe peer review in nursing as a process by which nurses systematically monitor and assess the quality of nursing care according to professional practice standards; a nurse reviews a nurse. Introducing mutual evaluation in nursing allows care to be assessed according to nursing care standards in a constructive atmosphere (Harrington, Smith, 2008; Davis, Capozzoli, Parks, 2009). Nursing peer review provides an effective, systematic, nonpunitive way of addressing care quality. According to the American Association of Nurses, nurses are responsible for the quality of nursing care. Every nurse is responsible for implementing nursing practice standards and must participate with other nurses in the decision-making process when evaluating nursing care (Goos, 2021).

Regulatory authorities, professional organizations, and the public expect nurses to provide safe and high-quality care to patients. Mutual evaluation of nurses increases their professional autonomy. For nurses, the primary focus of mutual evaluation is the quality of nursing care compared to established standards (Murdock, 2018; George, Haag-Heitman, 2015). Mutual evaluation increases nurses' accountability, inspires them to improve the quality of their work, and enables nurses to monitor performance and compare each other (Goble et al., 2017). Mutual evaluation gives assurance that nurses provide safe, ethical, and evidence-based nursing care. Implementing mutual evaluation of nurses supports a culture of continuous learning in patient safety and best practices (George, Haag-Heitman, 2015).

Mutual evaluation enables nurses to monitor performance in a non-punitive environment, take control of their practice, identify opportunities to improve performance, and determine the educational needs of nurses (Harrington, Smith, 2015). Nursing peer review is an evaluation of the professional practice of individual nurses by other nurses. The authors emphasize that a peer is a person practicing the same profession; they have bed-side practice experience. It is an evaluation of individual nurses’ professional performance, including identification of opportunities to improve care by a person with the relevant expertise to perform this evaluation. Nursing peer review is a tool for improving nursing practice, enhancing patient safety, and supporting professional growth. For nurses, it is important to understand the purpose of mutual evaluation: it is about identifying areas for professional growth and sharing best practices, not searching for mistakes and punishing colleagues. Through mutual review of nursing work, nurses can identify potential mistakes or omissions, share best practices, learn from colleagues, and thereby improve overall care quality, develop team collaboration, and support a culture of continuous learning (Harrington, Smith, 2015).

An evidence-based nurse-led mutual review program supports nurses in critically reviewing their practice and addressing deviations from care standards that may lead to patient harm. Peer review increases accountability for professional practice and enables nurses to manage change within their organizations (Goss, 2021). The American Nurses Association has included safety, quality, risk management, clinical care delivery, promotion of a healthy working environment, and legal compliance among core accountable competencies of nurses (Roberts Holli, 2017).

One of the principles of peer review assessment is the promotion of a continuous learning culture in patient safety and best practices.

Mutual evaluation helps nurses feel safe; it provides means for an effective systemic approach to reducing errors, together with unlearning ineffective or unsafe practices. A culture of continuous learning shifts the focus from individual education to organizational learning and supports a shared commitment to achieving and sustaining desired outcomes in quality and safety. Current dimensions of mutual evaluation include quality and safety, role updating, and practice development (George, Haag-Heitman, 2012; Haag-Heitman, George, 2011).

Mutual evaluation among nurses is a tool for developing nursing practice and increasing patient safety (Ohmart, 2013). The purpose of the assessment, according to the author, is not for nurses to criticize or blame each other, but to allow them to grow professionally through collaboration and knowledge sharing. One form of peer review is incident-related nursing peer review. The trigger is an adverse event directly related to nursing care. In such cases, the incident is examined in detail, not with the aim of assigning blame to the nurses involved, but to determine whether care standards were met. If standard procedures were not followed, identify which processes contributed to the adverse event. The author emphasizes that only nurses themselves can monitor and improve nursing practice.

The implementation of peer review in nursing is a means of improving safety culture in healthcare facilities (Herrington, Hand, 2019).

AIM

To assess the contribution of peer review assessment in nursing in key attributes of quality and safety.

SAMPLE AND METHODOLOGY

We used a modified assessment form by Svetić Čišić, Frankovic (2015), with the consent of R. Svetić Čišić, BsN, MN, Ph.D., adapted to comply with legal requirements regarding the scope of nursing practice provided by a nurse in the Slovak Republic, for peer review. The peer review assessment form contained 29 items based on a 5-point Likert scale. Nurses assessed criteria as follows: (1) insufficient; (2) adequate; (3) average; (4) very good; (5) excellent. The peer assessments were completed by 43 evaluated nurses working in institutional healthcare facilities and 43 assessing nurses. Both assessed and assessing nurses reported their age, education, and years of practice in demographic items. In an open question, we examined whether during their practice they had been assessed by a colleague-nurse or had assessed their colleague. For both groups of respondents, peer review was a first experience. The average age of assessed nurses was 38 years; the youngest nurse was 22 years old and the oldest 63 years old. The average length of their practice was 15 years; the shortest practice was six months and the longest was 42 years. Eight nurses had completed secondary education, two had higher vocational education, 21 nurses had completed first-cycle higher education, and 12 had second-cycle higher education. The average age of assessing nurses was 25.8 years. All assessing nurses had completed first-cycle higher education and had worked for an average of 3.5 years.

Data obtained from peer review assessments in 2023 were processed using InStat®, Version 3.02 32 bit for Win95/NT, GraphPad Software, Inc., USA, and findings are interpreted in tables.

RESULTS

Introducing mutual peer review in nursing helps nurses take responsibility for their performance, increase the quality and safety of nursing care, and implement standards (Shogren, 2016). Patient safety is the highest priority in all healthcare facilities. It is essential to support organizational commitment that values a culture of safety through error reporting and analysis of adverse events (Kilíková et al., 2020; Sovariová Soosová, Zamboriová, Murgová, 2017; Dimunová, 2017).

Mutual evaluation in nursing facilitates the creation of a culture of safety because it aims to analyze errors and eliminate repeated adverse events (Diaz, 2008).

In our study, we focused on peer review criteria in the quality and safety dimension (Table 1). Of the peer review criteria assessed in the quality and safety dimension, the evaluated nurses considered the following to be most important: patient identification (x̄ = 4,465); quality of provided nursing care (x̄ = 4,325); prevention of nosocomial infections (x̄ = 4,186); prevention of pressure ulcers (x̄ = 4,023); fall prevention (x̄ = 3,93); error recognition (x̄ = 3,86); adherence to regulations, guidelines, and standards (x̄ = 3,86); and quality improvement (x̄ = 3,81).

Table 1. Peer review assessment criteria in the quality and safety dimension, ordered by importance

Legend: x̄ – arithmetic mean, sd – standard deviation, xm – median, min. – minimum value, max. – maximum value, mod(x) – mode, s2 – variance; Q1, Q2, Q3 – quartiles

The average value of mutual assessment across all peer review criteria among the 43 assessed nurses was (x̄ = 4,06), which represents a very good assessment; the lowest value was (x̄ = 2,79) and the highest was (x̄ = 4,96).

We were interested in whether nurses’ length of practice influenced the assessment of safety and quality criteria of provided nursing care. Results were processed using nonparametric Spearman correlation coefficient calculations between nurses’ length of practice and the peer review criteria of nursing peer assessment regarding nursing care safety. Spearman’s R was chosen because the normality of data distribution could not be assumed. The strength and direction of the relationship between pairs of variables were assessed based on the magnitude and sign of R, and we considered the significance of its difference from zero (p); if p was less than 0,05, we treated R as statistically significantly different from zero. Table 2 shows that there is no relevant correlation between nurses’ length of practice and the peer review criteria regarding nursing care safety (p˃0,05), with one exception: adherence to guidelines (R=0,38; p=0,01), where a weaker positive correlation was observed between increased nursing practice length and increased numeric response value regarding guideline adherence.

Table 2. Relationship between nurses’ length of practice and assessed criteria

Legend: R – Spearman correlation coefficient, IS – two-sided 95% confidence interval of the correlation coefficient position, p – statistical significance of the difference between the obtained value of R and zero.

DISCUSSION

The implementation of a nursing peer review assessment program is a means of improving safety culture in healthcare facilities (Herrington, Hand, 2019). Garner (2015) emphasizes that peer review assessment is the process through which problems in patient care are identified. It is a recognized method for improving nursing quality and safety. It is important that nurses understand that peer review assessment is a tool for developing evidence-based nursing practice and improving safe nursing care. For many nurses, this is a new concept whose purpose is not to have nurses criticize or blame each other, but to share knowledge and grow professionally. Mutual peer review assessment in nursing is focused on the quality of nursing care.

According to the American Nurses Credentialing Center, peer review assessment stimulates professionalism through increased accountability and supports self-regulation of practice. Assessment should be conducted regularly, focusing on quality and safety, because only nurses are best positioned to control and improve nursing practice (Ohmart, 2013). According to Murphy et al. (2018), nurses are mutually responsible for the high quality of nursing care provided.

In our study, nurses considered the most important quality and safety criteria in nursing to be safe patient identification, quality of provided nursing care, prevention of nosocomial infections, and prevention of pressure ulcers. Monitoring and assessing these indicators is also embedded in legal requirements in Slovakia: Government Decree No. 752/2004 Z. z., which issues quality indicators for evaluating the provision of healthcare in the wording of NV SR 61/2013 Z.z.; Decree of the Ministry of Health of the Slovak Republic No. 444/2029 Z.z. on minimum requirements for internal systems for assessing patient safety, and the Bulletin of the Ministry of Health of the Slovak Republic, vol. 61, items 15–26, 15 October 2013 - Methodological Guideline of the Ministry of Health of the Slovak Republic for collecting quality indicators for assessing healthcare provision. Gnilka (2018) also states that the peer review process had a significant impact on two quality indicators: falls and pressure ulcers. In her literature review of 2007–2017 in the CINAHL, PubMed, and Medline databases, she confirmed that several authors agreed that peer review in nursing is needed to support safe, autonomous, and high-quality nursing care. In light of the public attention to errors in healthcare and nursing care, George and Haag-Heitman (2015) state that nursing must be proactive in responding to quality and safety issues. Svetić Čišić, Frankovic (2015) focused on assessing nursing care quality in Croatia. The authors emphasize that peer review assessment creates a safety culture, increases transparency in nursing, and increases proactivity in response to increasing publicity of errors and mistakes. In Croatia, as in the Slovak Republic, peer review according to available data is a completely new practice and nurses’ knowledge of this assessment remains insufficient. According to Shogren (2016), implementation of a professional peer review program in a monitored hospital in Texas reduced pressure ulcer incidence by 85% over 18 months. In Goss’ studies (2021), fourteen nurses participated in a four-month pilot Nursing Peer Review Program. The author evaluated the structure, process, and outcomes of program implementation and how participants perceived responsibility within assessment. Evidence-based nursing peer review by nurses supports nurses in critically assessing their practice and pointing out deviations in care that can harm patients. Based on pilot results, the program showed a benefit for improving patient care and preventing adverse events related to nursing care. Mutual evaluation is a tool for improving quality and safety in healthcare facilities, increasing accountability for practice, and reducing costs. Goss (2021) notes findings that healthcare organizations focused on a safety culture have standardized mutual evaluation procedures in place; voluntary reporting of safety incidents and accidents; systemic assessment of practice deviations; mentoring; aligned quality and safety processes; and integrated communication of system-level improvements arising from peer review into internal regulations and policies. A just culture ensures employees will not be persecuted or punished for mistakes, creating a trustworthy environment that encourages sharing important safety-related information (Hughes, 2008; WHO, 2021; Sovariová Soosová, Zamboriová, Murgová, 2017; Dimunová, 2017). Diaz (2008) also emphasizes that mutual assessment should not be understood as punitive but as a mentoring tool. Mutual review is an effective method of education and quality improvement. In their study, Herrington and Hand (2019) compared survey results before and after implementation of a nursing peer review program and found that it supports a culture of safety in healthcare facilities, improves feedback, and initiates nursing education.

The American Nurses Association has supported the peer review process for 37 years. Although mutual evaluation is becoming part of nursing practice and education, it has not been universally accepted. If nurses fear peer evaluation, this will hinder its implementation in practice (Morby, Skalla, 2010). Similarly, Ohmart (2013) reports that according to several international authors (DuBose, 2021; Roberts, 2017; Williams, 2022), nurse peer review has not become standard practice in most hospitals, although six principles for peer review in nursing are more relevant today than ever before.

Recommendations for practice

For successful implementation of nursing peer review in nursing in Slovakia, it is necessary to develop a Slovak version of a standardized tool for peer review assessment in nursing, verify its content validity with an expert team, and develop a methodology for peer review assessment of nurses. Education of nurses in nursing peer review assessment should also be emphasized. The expected benefit of the VEGA project is the creation of a functional model of assessment in nursing with emphasis on increasing the quality of provided nursing care and patient safety. At the same time, it will positively impact the development of nurses’ clinical and managerial competencies, increase opportunities for their career growth, and support their engagement.

CONCLUSION

Nursing peer review is an effective way to keep nursing practice at the highest professional level. For all participating nurses, it is a very positive experience that enables them to improve care quality (Ohmart, 2013). Williams (2022) adds that additional benefits of introducing nursing peer review include reduced nurse turnover in healthcare facilities and systemic improvements. Mutual evaluation in nursing is a stable indicator of safety culture. George and Haag-Heitman (2015) divide the benefits of mutual review in nursing into those for organizations (increased care quality and work efficiency) and for nurses (professional development).

Limitations

Sample size and use of an unvalidated tool limit the generalizability of study findings. Results are valid only for the nurses who participated in the study. Further research should focus on assessing the effect/impact of nurse peer review on nursing care quality, patient safety, and other selected indicators, and on nurses’ perception of peer review. The literature sources provided empirical support for our findings. Even with the stated limitations, we believe the results are acceptable and can be used to initiate practical solutions.

Authors: doc. PhDr. Viera Hulková, PhD., MPH Fakulta zdravotníctva, Trenčianska univerzita Alexandra Dubčeka v Trenčíne ORCID 0000-0003-2631-1803 prof. PhDr. Mária Kilíková, PhD., MPH VŠ sv. Alžbety, Bratislava, detašované pracovisko Rožňava doc. Ing. Magdaléna Tupá, PhD. Fakulta sociálno-ekonomických vzťahov, Trenčianska univerzita Alexandra Dubčeka v Trenčíne

Acknowledgement This article was produced with support from VEGA project No. 1/0440/25 “Hodnotenie pracovného výkonu sestier prostredníctvom peer review v kontexte nových trendov v riadení ľudských zdrojov.”

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