INTRODUCTION
The American Nurses Association (ANA) published "Peer Review Guidelines" in 1988. Peer review was defined by the ANA as "a process by which nurses systematically evaluate and monitor the quality of nursing care provided by fellow nurses according to professional standards of practice" (Haag-Heitman et al., 2018).
The Texas Board of Nursing (2022) characterizes Peer Review in Nursing as a peer review of nursing services, the nurse's qualifications, the quality of patient care provided by the nurse. Peer review in nursing is according to Murphy et al. (2018) the process by which nurses systematically assess, monitor, and provide feedback to their colleagues about the quality of nursing care measured in accordance with professional standards of practice. It promotes self-regulation and a culture of responsibility. Nurses are mutually responsible for the high quality of nursing care provided. The authors emphasize that the manager does not participate in the peer review evaluation and it is not tied to the regular annual evaluation of the workers. Also the author collective Colella et al. (2021) characterize peer review in nursing as a process by which nurses systematically monitor and assess the quality of provided nursing care according to professional standards of practice, the nurse evaluates the nurse. Peer review in nursing increases professionalism, responsibility and supports self-regulation of practice. The organization must have a structured peer review process implemented, pre-established evaluation criteria that all nurses are familiar with. The evaluating nurse will also be evaluated by a colleague. It is necessary to educate nurses about peer review, evaluation ethics, procedures, methods, providing feedback. Peer review participants can learn from each other, gain insight into their professional development, especially in the areas of professional socialization, communication, collaboration, organization and leadership. Peer review assessment should be impartial, objective, fair; Conflicts of interest must be disclosed in advance. Garner (2015) emphasizes that peer review is a process that identifies problems in patient care. It is a recognized method for improving the quality and safety of nursing. Responsibility is an important manifestation of professionalism.
The implementation of a peer review assessment program is a means of improving the safety culture in healthcare facilities (Herrington & Hand, 2019). Davis, Capozzoli, Parks (2009) state other benefits of introducing the peer review process into professional nursing. The peer review process allows for systematic evaluation, monitoring, assessment and feedback to colleagues by comparing actual practice with established standards. A multigenerational workforce is involved in peer review. The benefit is also higher satisfaction and engagement of nurses. As part of an annual performance review, peer review can create positive relationships, foster a better work environment, and allow colleagues to increase individual and group accountability. According to the ANA, peer review must be peer-reviewed and practice-oriented. Each nurse is responsible for participating in the development of practice evaluation criteria and for using these criteria in peer and self-evaluation. Feedback should promote growth and professional development through continuous learning and take into account the nurse's level of expertise (Gnilka, 2018). Many authors (Haag-Heitman et al., 2018; Roberts, 2017; DuBose, 2021; Williams, 2022) agree that although the American Nurses Association published its recommendations for peer review in nursing in 1988, peer review is not currently fully implemented in nursing practice.
Peer review assessment was also defined by the American Association of Critical Care Nurses in 2012 as "a process by which professionals with similar knowledge, skills, and abilities assess the processes and/or outcomes of care" (Bergum, Canaan, Delemos et al. 2017).
Murdock (2018) states that it is the professional duty of nurses to define, implement and maintain standards of professional practice using control mechanisms such as peer review to protect both nurses and patients. Regulatory bodies, professional organizations, and the public expect nurses to provide safe, high-quality care to patients, and peer review plays an important role in maintaining professional autonomy. For nurses, the primary focus of peer review assessment is the quality of nursing practice assessed according to standards. Through peer review, nurses can assess the quality of nursing care in accordance with an established standard, identify strengths and weaknesses in practice, inform procedures for improving nursing care, and identify gaps in the knowledge of their colleagues.
Peer review is a method of evaluating the professional competence of nurses at all levels. The study by Roberts (2017) points to the need to update the peer review program, which was introduced by the ANA in 1988, and especially the need to revise and rework the peer review program not only for nurses, but also for nurse managers, as the competencies of nurses and managers have changed significantly since 1988. The aim of the ANA was to demonstrate to the public the self-regulation of the nursing profession through peer review and to increase the quality of care provided. Although the ANA guidelines have not yet been updated, the authors and medical facilities refer to them. Literature sources, current in 2020, continue to emphasize the need for the implementation of peer review of nurses as an important indicator in the culture of safety, but a standardized framework is lacking (Williams, 2022).
Dimensions of peer review assessment
Peer review can be categorized by type of activity, area and level of practice. Haag-Heitman & George (2011) and Murdock (2018) describe three dimensions for peer review: 1. quality and safety, 2. role update, 3. progress in practice.
The update of roles focuses on nurses' competencies and professional qualifications, critical thinking, expanding knowledge and skills, to support the professional development of graduate nurses to advanced practice nurses. "Advancement in practice centers on the use of peer review to update and improve nursing practice through new knowledge, innovation, and research. Achieving excellence in clinical outcomes often involves critically analyzing current ineffective practices and changing traditional practices to evidence-based approaches" (George & Haag-Heitman, 2011, p.257). The quality of care is measured according to the achievement of identified performance criteria.
Purpose of peer review
According to Murdock (2018), the purpose of nursing peer review is to assess the quality of nursing care in accordance with established standards, to identify strengths and weaknesses in practice and gaps in knowledge. Murphy et al. (2018) state that the purpose of nursing peer review is to ensure that patient care is provided according to clinical standards and to achieve an optimal level of quality. Williams (2022) holds a similar opinion, the purpose is to evaluate the quality of practice, increase professionalism and identify strengths and weaknesses in practice. Haag-Heitman et al. (2018) emphasize that the purpose of peer review is mainly:
- evaluate the quality of nursing care provided,
- determine the strengths and weaknesses of nursing care,
- support new procedures, standards, recommendations for improving nursing care,
- to identify areas in which practical training of nurses is needed.
The primary purpose of peer review is to ensure the quality and safety of nursing care through standards and the latest evidence-based practices. Nursing practice standards are a tool for measuring the quality of nursing care a patient receives. Every nurse is responsible for the implementation of standards of nursing practice and together with other nurses must participate in the decision-making process in the assessment of nursing care (George & Haag-Heitman, 2011).
Principles of peer review
Peer review in nursing must be ethical - mutual evaluation of work performance should be unbiased, impartial, fair, without conflict of interests. Nurses must know the evaluation criteria, each nurse is evaluated by only one nurse: peer-to-peer. ANA recommends educating nurses about peer review. The peer review process stimulates professionalism through increased accountability and promotes self-regulation of practice.
Principle No. 1: Nurses in the same positions evaluate each other. Nurses are evaluated by nurses and not managers, even though managers practice as direct care nurses. Principle No. 2: Peer assessment is focused on practice. Effective peer review includes evidence-based nursing practice, standards of nursing care, quality, and safety with a focus on outcomes. Principle No. 3: Providing feedback. Nurses achieve a high quality of care by continuously providing feedback to their colleagues. Principle No. 4: Peer review promotes a culture of patient safety and continuous learning. Peer review helps nurses feel safe. Early and continuous peer review provides the means for an effective systemic approach to error reduction along with the unlearning of inefficient or unsafe practices. A culture of continuous learning shifts the focus from individual learning to organizational learning and fosters a shared commitment to achieving and maintaining desired quality and safety outcomes. Principle No. 5: Feedback is not anonymous.
According to the ANA Code of Ethics, the nurse has an obligation to use respectful communication with an open exchange of views to maintain the integrity and safety of the practice. Face-to-face dialogue gives nurses the opportunity to give and receive feedback. Principle No. 6: Evaluation supports professional growth. Participation in peer evaluation supports the professional growth of nurses, as beginner nurses are evaluated together with nurses with many years of experience. Less experienced nurses have the opportunity to communicate with experienced nurses, be mentored by them, gain knowledge and a different perspective (Nursing peer review: Principles and practice. American Nurse. 2011; Haag-Heitman et al., 2018; Haag-Heitman & George, 2011).
Meaning of peer review
Peer review in nursing is a process by which nurses systematically monitor and assess the quality of nursing care provided by fellow nurses according to professional practice standards. Providing feedback in peer review will reveal and identify the most common errors, improve clinical outcomes, and increase the quality of care (George & Haag-Heitman, 2011). Peer review motivates nurses to further education and evidence-based practice; supports nurses' self-regulation; professional responsibility leading to increased autonomy and role updating (Gnilka, 2018). Participation in the peer review process increases nurses' responsibility, improves team functioning, and improves the quality of nursing care (Haag-Heitman et al., 2018). Peer review is a process in which nurses evaluate and judge their colleagues based on the nursing care provided with current professional standards Williams (2022). Peer review increases professional autonomy, nurses take responsibility, must be proactive, provide safe and effective patient care, practice at the highest possible level (DuBose, 2021).
GOAL
To verify the content relevance of the tool and the appropriateness of implementing peer review assessment into nursing practice in Slovakia.
FILE AND METHODOLOGY
As part of the pilot study, data were collected in the months of February-April 2023 using triangulation of methods: focus group method, semi-structured interviews and content analysis of the peer review evaluation checklist. A total of 43 nurses working in institutional health facilities and at the same time students of the FZ TnUAD, master's study program in Nursing, evaluated their colleagues. The average age of the evaluating nurses was 25.8 years. All evaluating nurses had completed university education I. st. and worked for an average of 3.5 years. None of the evaluating nurses had evaluated a colleague nurse during their practice. 43 nurses were evaluated. The average age of the evaluated nurses was 38 years, while the youngest nurse was 22 years old and the oldest 63 years old. The average length of practice was 15 years, the least worked by the evaluated nurse was 6 months, and the longest practice was performed by the nurse for 42 years. Eight participants had completed secondary education, two had higher professional education, 21 nurses had completed university education. and 12 nurses, university education II st. As with the evaluating nurses, none of the evaluated nurses had encountered a peer review evaluation in their practice. When creating the peer review checklist, we were inspired by foreign literary sources, especially Svetic Cisic & Frankovic (2015) and modified the assessed items with regard to the present, conditions of practice in the Slovak Republic, current competencies of nurses and other factors. The peer review check list contained 29 items based on a 5-point Likert-type scale. The nurse evaluated the assessed indicators: (1)-insufficient; (2)-adequate; (3)-average; (4)-very good; (5)-excellent.
Both the evaluated and the evaluating nurses indicated their age, education, and years of experience in the demographic items. In the open question, we found out whether they were evaluated by a nurse-colleague during their practice, or whether they evaluated their colleague during their practice. We wanted to test the applicability and applicability of peer review assessment in Slovak conditions. Check sheets were distributed to nurses who chose a colleague - nurse, whom they evaluated at their workplaces. Evaluating nurses were familiarized with the theory of peer evaluation within the subject Management in nursing, before the evaluation they were given instructions on peer evaluation of their colleagues. Another method used for data collection was three focus groups in order to reach data saturation, which was defined as the point when the participants' discussion no longer yielded new information. Focus groups were conducted with the intention of obtaining data on three areas of peer review: 1. quality and safety, 2. role updating, 3. progress in practice. The responses were coded and analyzed. We processed the data obtained from the peer review checklist statistically: arithmetic mean, standard deviation, median, minimum and maximum value, variance. The interpretation of the findings is presented in overview table No. 1.
RESULTS AND DISCUSSION
Peer review assessment in nursing in the Slovak Republic is an unknown concept not only for nurses, but also for many managers. Based on the study of foreign literary sources and the results of many studies (listed in the list of bibliographic references), it is clear that the implementation of peer review assessment would significantly contribute to strengthening the autonomy and professionalization of nursing even in our conditions.
20 nurses evaluated their peers and 23 nurses evaluated older colleagues. The largest age difference and difference in years of experience was observed in the 63-year-old evaluated nurse with 42 years of experience, who was evaluated by a 23-year-old colleague with one year of experience. The average value in all 29 peer evaluation indicators was for the evaluated nurse (x̄ = 2.96). The lowest rating - insufficient (1b on the Likert scale) was found in the following indicators: Acceptance of constructive criticism; Participation in the creation of guidelines and procedures; Initiative and IT knowledge. The data analysis showed that seven nurses evaluated their colleagues who had the same length of practice (2-4 years). The average values in all 29 peer evaluation indicators were from x̄ = 3.10 to x̄ = 4.65 for the seven evaluated nurses. High average values point to the bias and overestimation of some indicators due to the low number of years of experience.
Table 1 Peer review evaluation results
| Indicators | N | x̄ | Sd | xm | min. | max. | mod(x) | s2 |
|---|---|---|---|---|---|---|---|---|
| Basic knowledge about the provision of nursing care | 43 | 4.53 | 0.58 | 5 | 3 | 5 | 5 | 0.34 |
| Skills in providing nursing care | 43 | 4.67 | 0.51 | 5 | 3 | 5 | 5 | 0.266 |
| Competences for the performance of the profession | 43 | 4.34 | 0.8 | 5 | 2 | 5 | 5 | 0.64 |
| Professional approach | 43 | 4,395 | 0.78 | 5 | 2 | 5 | 5 | 0.61 |
| Education | 43 | 4 | 0.89 | 4 | 0 | 5 | 4 | 0.79 |
| Providing knowledge, experience and support to colleagues | 43 | 4,139 | 1.13 | 5 | 0 | 5 | 5 | 1.28 |
| Communication with colleagues | 43 | 4.32 | 0.79 | 5 | 2 | 5 | 5 | 0.63 |
| Communication with patients | 43 | 4.34 | 0.74 | 4 | 2 | 5 | 5 | 0.55 |
| Increasing the quality of work | 43 | 3.81 | 0.97 | 4 | 2 | 5 | 4 | 0.94 |
| Compliance with regulations, directives, standards | 43 | 3.86 | 0.9 | 4 | 1 | 5 | 4 | 0.817 |
| Creativity | 43 | 3.72 | 1.127 | 4 | 1 | 5 | 4, 5 | 1.27 |
| Adherence to time management | 43 | 4.11 | 0.97 | 4 | 1 | 5 | 5 | 0.94 |
| Participation in the creation of guidelines, procedures 43 | 2 | 1.46 | 2 | 0 | 5 | 1 | 2.13 | |
| Proactivity - taking responsibility for one's actions 43 | 4.18 | 1.1 | 5 | 1 | 5 | 5 | 1.25 | |
| Accuracy of tasks, compliance with deadlines | 43 | 4,186 | 1.06 | 5 | 1 | 5 | 5 | 1.128 |
| Accepting constructive criticism | 43 | 3.51 | 1.148 | 4 | 1 | 5 | 4 | 1,319 |
| Error detection | 43 | 3.86 | 0.878 | 4 | 1 | 5 | 4 | 0.77 |
| Enthusiasm | 43 | 3.58 | 1.1 | 3 | 1 | 5 | 3 | 1.22 |
| IT knowledge | 43 | 3,767 | 1.19 | 4 | 1 | 5 | 5 | 1.43 |
| Initiative | 43 | 4,069 | 1,169 | 4 | 1 | 5 | 5 | 1,367 |
| Order and cleanliness at the workplace | 43 | 4.51 | 0.817 | 5 | 1 | 5 | 5 | 0.66 |
| Reliability | 43 | 4.67 | 0.515 | 5 | 3 | 5 | 5 | 0.266 |
| Quality of provided nursing care | 43 | 4,325 | 0.95 | 5 | 0 | 5 | 5 | 0.91 |
| Patient identification | 43 | 4,465 | 0.78 | 5 | 2 | 5 | 5 | 0.62 |
| Prevention of nosocomial infections | 43 | 4,186 | 0.92 | 4 | 2 | 5 | 5 | 0.95 |
| Prevention of pressure ulcers | 43 | 4,023 | 1,248 | 4 | 0 | 5 | 5 | 1.55 |
| Fall prevention | 43 | 3.93 | 1,246 | 4 | 0 | 5 | 5 | 1.55 |
| Respect for patient privacy | 43 | 4,162 | 1.03 | 5 | 2 | 5 | 5 | 1.06 |
| Respecting the confidentiality of information | 43 | 4,325 | 0.93 | 5 | 1 | 5 | 5 | 0.87 |
Legend: n – number of respondents, x̄ – arithmetic mean, sd – standard deviation, xm – median, min. – minimum value, max. – maximum value, mod(x) – mode, s2 – variance.
Table 1 shows the results of the peer review assessment, which shows that nurses achieved the highest value in the indicators: Skills in providing nursing care and Reliability (x̄ = 4.67). The result reflects the fact that the assessment nurses have been working in the profession for an average of 3.5 years and value the practical skills acquired over the years the most in their older colleagues. Only one nurse was rated with a score of 3-average skills. The skills of 30 nurses were evaluated by their colleagues as excellent (5b on the Likert scale). The weakest indicator was participation in the creation of guidelines and procedures (x̄ = 2.00). The five evaluated nurses do not participate in the creation of procedures and/or guidelines at all, the evaluating nurses wrote the evaluation (0) in the check sheet - table no. 2. Insufficient involvement (1b on the Likert scale) was assessed in 16 evaluated nurses.
Table 2 Demographic characteristics of five nurses - non-participation in the creation of guidelines, procedures
| ID Rated Nurse | Age | Education | Years of experience |
|---|---|---|---|
| 11 | 42 | university 1st century | 23 |
| 15 | 52 | sš | 33 |
| 17 | 56 | sš | 38 |
| 18 | 47 | sš | 19 |
| 37 | 35 | university 1st century | 11 |
From the data in table no. 2, it is clear that participation in the creation of nursing procedures is mostly ignored by older nurses, while their long-term practical experience in the creation of new procedures would be very valuable.
Haag-Heitman & George have conducted extensive research and published several articles on peer review in nursing (George & Haag-Heitman, 2015; George & Haag-Heitman, 2012; George & Haag-Heitman, 2011; Haag-Heitman & George, 2011a Haag-Heitman & George, 2011b; Whitney, Haag-Heitman, Chisholm, & Gale, 2016). They have developed a contemporary focus on peer review to maintain standards of nursing practice and care in three areas: quality and safety, role updating, and practice advancement (Haag-Heitman & George, 2011; Roberts, 2017).
Svetic Cisic & Frankovic (2015) describe a pilot project and the results of a peer review evaluation, which, according to available data, is the first such evaluation conducted in Croatian nursing practice. The aim of the authors' study was to evaluate the quality of nursing care. The findings confirmed that peer review increases responsibility, supports teamwork and positively affects the professional development of nurses. During the peer review evaluation, they came to the conclusion that the five-point Likert scale is not accurate enough, so it should be expanded. It is also necessary to introduce new variables that will help create a more accurate way of measuring relevant indicators. The authors emphasize that peer review assessment creates a culture of safety, increases transparency in nursing, and proactiveness in connection with the increase in published errors and mistakes. In Croatia, as well as in the Slovak Republic, peer review is, according to available data, a completely new practice, and nurses' knowledge of this evaluation is insufficient. The results of the study by Haag-Heitman et al. (2018) confirmed the importance of implementing a structured peer review process at the organizational level. Foreign research and studies on peer review focus primarily on nurses' attitudes and knowledge about evaluation and barriers to peer review implementation (Murdock, 2018). Obstacles to the successful implementation of peer review assessment can be insufficient acceptance by nurses, unprofessional practice, fear of retribution, of the impact on work relationships, non-transparency, the need for further education, misunderstanding of the value and meaning of peer review assessment (Murdock, 2018; Pfeiffer et al., 2012). Also Haag-Heitman et al. (2018) confirmed that many nurses stated that they did not know what peer review is, why they should be evaluated, participation in the evaluation caused them feelings of anxiety, uncertainty and fear of failure.
Key areas of the pilot study were findings related to the quality and safety of nursing care. LeClair-Smith et al. (2016) and Gnilka (2018) found that the peer review process had a significant impact on two quality indicators: falls and pressure ulcers. In our study, the quality and safety indicators were evaluated as follows: Patient identification (x̄ = 4.465); Quality of provided nursing care (x̄ = 4.325); Prevention of nosocomial infections (x̄ = 4.186) and Prevention of falls (x̄ = 3.93). Communication with patients (x̄ = 4.34) and Communication with colleagues (x̄ = 4.32) were rated with the same high point score, which we relate to the fact that the evaluating nurses are generation cohort Z and prefer personal communication and good interpersonal relationships in the work team. They require guidance, mentoring and feedback from their older and more experienced colleagues and superiors. George & Haag-Heitman (2011) state that the purpose of peer review is to ensure the quality of nursing care. Nursing must be proactive in its response to quality and safety issues as these data are publicized. Also Gnilka (2018), based on a literature review from 2007-2017 in CINHAL, PubMed and Medline databases, confirmed the agreement of several authors that peer review in nursing is necessary to support safe, autonomous and high-quality nursing care. The aim of the Zadeh (2018) study was to investigate the impact of the peer review process on the quality of nurse performance and patient satisfaction in selected hospitals in Iran. The results of the study showed that the peer review process has an impact on the quality of the nurse's performance and patient satisfaction. Given the key role of the nurse in the health care team, it is the manager's responsibility to plan for increasing the knowledge and practical skills of nurses. The peer review process is seen as a managerial delegation approach to quality assurance in nursing.
Another problem that we want to point out in managerial practice in nursing is the absence of a peer review tool for nurse managers, with the help of which managers at the same levels of management will evaluate each other. Foreign literary sources emphasize the need to develop an up-to-date standardized evaluation tool in view of the changed competencies of nurse managers and the need for greater involvement of managers in the implementation of the peer review program in nursing. In 2011, the authors George & Haag-Heitman, based on the analysis of the literature review, concluded that peer review evaluation is lacking in nursing practice and emphasize the role of managers in the implementation of mutual evaluation of nurses. Also the author collective Goble et al. (2017) states that despite recommendations to improve nursing practice and quality of care through the implementation of peer review, many managers use peer review only once a year and often do not follow ANA guidelines. The aim of the study by Whitney et al. (2016) was to find out how nursing managers perceive the peer evaluation of nurses. Nursing peer review is a key component of professional nursing practice focused on self-regulation, quality improvement, and safety. Despite its advantages, it is not widespread, it is not understood, the prevalence is low, and the assessment procedures are not in accordance with the American Nurses Association guidelines. The results indicated that nurses do not understand the purpose of peer review and have knowledge gaps. The paper by Davis, Capozzoli, Parks (2009) describes the implementation of a peer review evaluation program in nursing practice. The implementation steps are divided into five phases that describe the introduction of the peer review concept and nurse involvement, implementation guidelines, piloting the process, staff education, and ongoing evaluation. The involvement of nurses is the most important aspect to a successful peer review process.
Peer review assessment in nursing is also important for the career growth of nurses, and the results of peer assessment are a valuable source of data for educators who teach the subjects Management in Nursing and Communication in Nursing at universities and colleges in the Nursing study program.
The aim of the study by Vuorinen et al. (2000) was to clarify the importance of peer review assessment with regard to the career development of nurses and the connection with the introduction of a career development program for nurses in a Finnish teaching hospital. The research concept was created based on the literature analysis. Participants (n = 24) answered five open-ended questions in the form of an essay. The responses were analyzed using qualitative content analysis. Peer review enables nurses to provide and receive professional and personal support supporting professional development. Assessment is a means of supporting the professional development of nurses.
Boehm & Bonnel (2010) argue that peer assessment is an effective tool that educators can use to develop the professional skills of nursing students. Feedback from peer review can be used to identify clinical education needs to improve the safety and quality of patient care.
Regular peer review in nursing assures the public that nurses are competent to practice. Therefore, it should be in the interest of the management of medical facilities to implement a reliable way to evaluate the performance of individual workers. The results pointed to different levels of the evaluated indicators. The sample of nurses in this study found no major barriers to implementing peer review. Although the results from this selected sample cannot be generalized, the use of peer review to evaluate female colleagues appears to be feasible and acceptable. Nurses were willing to undergo this type of assessment.
The assessment of female colleagues using a formally accepted and standardized tool is a shift in the thinking, competences and interpersonal communication skills of nurses. Through their assessment, the nurses demonstrate their assumption of responsibility, their willingness to undergo the process to assess your clinical practice. Peer review will arouse nurses' interest in education, advancement, and career growth.
Recommendations for practice
Based on the results of the pilot study, we propose to develop a Slovak version of the national standardized tool for peer review assessment in nursing; develop a guideline/methodology for mutual evaluation; developing a handbook - a manual for peer review for nurses, would be a suitable tool that would offer nurses guidance for mutual evaluation necessary for the successful implementation of peer review in nursing practice. Educate nurses and nursing managers about peer review assessment in nursing.
CONCLUSION
Nursing peer assessment increases responsibility, a sense of teamwork, promotes better work results and creativity. Peer review provides nurses with many opportunities for growth and development, allowing them to develop communication, evaluation and presentation skills. By improving their communication skills, nurses will demonstrate greater comfort in providing feedback to colleagues. Peer assessment in a clinical setting can facilitate the sharing of best practices, personal and professional growth, as it allows nurses to learn from each other and gain insight into their professional development, including communication, socialization, and collaboration (Svetic Cisic & Frankovic, 2015). The result of the mutual evaluation depends on the motivation and values of the nurses, the format of the evaluation, and the involvement and participation of the nurses in the evaluation. Peer review can reveal gaps in practice, identify topics for further education and risk management programs (Sheahan et al., 2005).
Limits
The sample size and the use of an unvalidated instrument limit the generalizability of the study results. Another weak link is the training of assessment nurses and their age structure - the average age is 26 years. This fact probably influenced the evaluation results.
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Author: doc. PhDr. Viera Hulková, PhD., MPH Department of Nursing, Faculty of Health Sciences, Alexander Dubček University of Trenčín ORCID 0000-0003-2631-1803