Assessing RN-to-RN peer review on clinical units

Assessing RN-to-RN peer review on clinical units

JUDITH A. PFEIFFER P h D , R N , P M H C N S - B C , N E A - B C1, MARY A. WICKLINE M L I S , M E d

2, JILL DEETZ B S N , R N3

and ELISE S. BERRY M A4

1Director, Nursing Education, Development & Research and Psychiatric Services, UC San Diego Health System,2Librarian, UC San Diego Biomedical Library, 3Director, Professional Services and 4Senior Administrative Analyst,UC San Diego Health System, San Diego, CA, USA

Introduction

Excellent communication about the quality of nursing

care is vitally important to patient safety. One of the

most common reasons for errors and adverse outcomes

involving patient care is inadequate communication

(Boggs 2007). Peer review as a formal practice of

examining sentinel events is well-documented (Silver

et al. 2007). Another more informal type of peer

review – day-to-day discussion with one�s peers regard-

ing the quality of nursing care – is essential, yet not well-

researched. One challenge for nursing leadership is

ensuring excellent registered nurse (RN)-to-RN peer

review. For bedside nurses, one of the organisational

Correspondence

Judith A. Pfeiffer

UC San Diego Health System

200 West Arbor Drive

San Diego

CA 92103-8929

USA

E-mail: [email protected]

P F E I F F E R J . A . , W I C K L I N E M . A . , D E E T Z J . & B E R R Y E . S . (2012) Journal of Nursing Management

20, 390–400

Assessing RN-to-RN peer review on clinical units

Aim The primary purpose of this study was to measure informal registered nurse(RN)-to-RN peer review (defined as collegial communication about the quality of

nursing care) at the work-unit level.

Methods Survey design with cluster sampling of 28 hospital or ambulatory care

units (n = 541 respondents). Results were compared with existing patient safety and

satisfaction data. A chi-squared test was used to compare responses against nurse

characteristics.

Results Nurses agreed that RN-to-RN peer review takes place on their units, but no

correlation with patient safety and satisfaction data was found. Misunderstandings

about the meaning of peer review were evident. Open-ended comments revealed

barriers to peer review: fear of retribution, language barriers and lack of profes-

sionalism.

Conclusions Nurses need clarification of peer review. Issues with common language

in a professional environment need to be addressed and nurses can learn collabo-

ration from each other�s cultures.

Implications for nursing management Managers should support RN-to-RN peer

review on clinical units. Methods used here may be useful to assess current

departmental nurse peer review.

Keywords: health care, interprofessional relations, intraprofessional relations, nursing

staff, peer review, quality of nursing care

Accepted for publication: 5 September 2011

Journal of Nursing Management, 2012, 20, 390–400

DOI: 10.1111/j.1365-2834.2011.01321.x390 ª 2011 Blackwell Publishing Ltd

characteristics defining a Magnet hospital is, �Enough

time and opportunity to discuss patient care problems

with other nurses� (McClure & Hinshaw 2002, p. 68).

Regular, on-going, RN-to-RN peer review at the nursing

care unit level is necessary to RNs� collaborative work in

their daily practice.

In this study, we define peer review as RN-to-RN

professional communication between nurses of the

same rank, on a routine basis, about the quality of

nursing care on their unit (Haag-Heitman & George

2011). This is a distinct process different from the

management function of annual performance appraisal.

The primary purpose of this study was to discover the

extent and quality of informal peer review among

nurses within inpatient or ambulatory care units.

Literature review

Over the past decade, the American Nurses Creden-

tialing Center (ANCC) Magnet framework has repeat-

edly found that nurses value working with other

competent nurses. In multiple studies, the top-ranked

factor related to quality of nursing care is �working with

other nurses who are clinically competent� (McClure &

Hinshaw 2002, Schmalenberg & Kramer 2008a,b,

Schmalenberg et al. 2008). Nurses experience psycho-

logical or moral distress when they do not feel compe-

tent or when colleagues� nursing practice is perceived as

suboptimal (Rice et al. 2008).

The concepts of caring interaction (Hughes 1998,

Watson 2009, Burhans & Alligood 2010) and com-

munication about the quality of nursing care are sup-

ported by the American Nurses Association (2005) code

of ethics and the American Association of Critical-care

Nurses (AACN) (2005) Standards for Establishing and

Sustaining Healthy Work Environments. The intro-

duction to the AACN �Standards� opens with a moral

imperative from Martin Luther King Jr, �Our lives begin

to end the day we become silent about things that

matter�, and it lists skilled communication as standard

number one; specifically stating, �Nurses must be as

proficient in communication skills as they are in clinical

skills� (American Association of Critical-care Nurses

2005). The American Nurses Association Code of Eth-

ics for Nurses states, �The nurse is responsible and

accountable for individual nursing practice and deter-

mines the appropriate delegation of tasks consistent

with the nurse�s obligation to provide optimum patient

care� (Fowler 2008, American Nurses Association 2005,

provision 4). It further states, �Sound ethical decision-

making requires the respectful and open exchange of

views between and among all individuals with relevant

interests… [and] the nurse has a responsibility to ex-

press moral perspectives, even when they differ from

those of others, and even when they might not prevail�(American Nurses Association 2005, Provision 5.3).

While this generally refers to communication with

physicians and other health-care professionals, it is also

relevant among nurse peers.

The AACN recognizes that �Relationship issues are

real obstacles to the development of work environments

where patients and their families can receive safe, even

excellent, care. Inattention to work relationships creates

obstacles that may become the root cause of medical

errors, hospital-acquired infections and other compli-

cations, patient readmission and nurse turnover�(American Association of Critical-care Nurses 2005).

The AACN Standards for Establishing and Sustaining a

Healthy Work Environment standard 2 is, �True Col-

laboration: Nurses must be relentless in pursuing and

fostering true collaboration� (American Association of

Critical-care Nurses 2005). The AACN Standards also

explicitly state the interdependence of all six standards

and the importance of a healthy work environment to

optimal patient outcomes and clinical excellence.

Effective decision-making in a healthy clinical envi-

ronment is dependent upon skilled communication and

collaboration.

Nurses must negotiate relationships with patients,

doctors, allied health providers, and each other, in an

environment that is frequently stressful. A good deal of

the research literature addresses issues of nurses� com-

munication with doctors (Zangaro & Soeken 2007,

Miller et al. 2008, Vogwill & Reeves 2008) or with

patients, (Charlton et al. 2008, Finke et al. 2008, Flei-

scher et al. 2009) but daily informal peer review among

nurses themselves is equally important. �Strong positive

organisational cultures are built on group cohesiveness

in which members insist on high levels of performance

and each individual is encouraged to do his or her best�(Heath et al. 2004). Good communication skills and

on-going peer review with nurse colleagues – feedback

pertaining to the nursing process and quality of nursing

care – is an essential element of excellent clinical care

and patient safety. One aspect of transformational

leadership focuses on helping each nurse to do his or her

best. The AACN Standards state, �It is ethical to

request, encourage and deliver feedback on all facets of

individual and organisational performance. It is uneth-

ical to ignore, discourage or fail to give feedback�(American Association of Critical-care Nurses 2005).

International literature on peer review, as in the USA,

frequently uses the term peer review to refer to

performance appraisal or annual evaluations (see, for

Assessing RN peer review on clinical units

ª 2011 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 390–400 391

example, Lofman et al. 2007). Roberts et al. (2010) in

the UK used a form of peer review to evaluate large-

scale clinical service across hospitals. However, we

found very few recent studies that examined RN-to-RN

peer review. Hogston (1995), in an early grounded

theory study in England, found that nurses use ad hoc

dialogue and sharing in addition to more formal

methods to assess quality of care. Welch (2001) in

Canada found that peer review �enables individuals to

become more responsible for their performance and the

performance of the unit.� Engels et al. (2003) from the

Netherlands found peer review to be an effective tool in

continuous quality improvement among midwives, as

did Hyrkas et al. (2003) among nurse managers using

peer supervision in Finland. Rout and Roberts (2008),

from the UK, did a recent and valuable systematic

review on peer review that found �there is a lack of high

quality, published evidence [of peer review in nursing

and midwifery] upon which to base good practice�.This study focuses on the gap in the literature about

informal, staff nurse peer review on the nursing unit.

The primary aim was to measure RN-to-RN peer

review at the unit level. We also explored, through

secondary analysis of Culture of Safety and Press Ganey

questions, potential relationships with nurse-assessed

patient safety and patient-assessed satisfaction with

quality of nursing care.

Methodology

A mixed-methods, cross-sectional, survey design was

used to obtain a descriptive baseline of RN-to-RN

informal peer review on nursing units in an academic

medical centre with two hospitals and multiple ambu-

latory care clinics. The primary instrument was Hugh-

es�s (1998) Peer Group Caring Interaction Scale

(PGCIS) modified to fit clinical nurses. Qualitative data

was also gathered through the inclusion of open-ended

questions and optional comment boxes.

Sample and setting

A cluster-sample was created with data from 28 clinical

units in an academic medical centre in southern Cali-

fornia with two hospitals (a total of 492 beds) and

several ambulatory care units. Inclusion criteria were:

being a registered nurse working in an inpatient unit,

emergency department, or a procedural or outpatient

clinic. Travellers and per diem nurses were included

because their use is common and their time on the unit

is extensive. Exclusion criteria included float nurses and

nurse leaders (manager, charge, lead, or any advanced

practice nurses). We excluded nurse leaders because we

are interested specifically in peer review and did not

wish to address in this research any hierarchical or

management issues. Float nurses were excluded because

their time on any one unit is minimal. Demographic

information collected included age group, race or eth-

nicity, nursing education, years of experience as a nurse,

and years of experience on their current nursing unit.

Gender was not asked as the low number of male nurses

could have potentially identified an individual.

Instrument

Linda Hughes (1998) developed the PGCIS with nurs-

ing students (n = 873) enrolled in 87 Bachelor pro-

grammes to examine the climate or atmosphere among

nursing students. The instrument uses a six-point,

forced-choice Likert scale to indicate degree of

disagreement or agreement with 16 items on two sub-

scales related to: (1) modelling behaviours of suppor-

tiveness, willingness to help, and sensitivity, and (2)

giving assistance, characterized by sharing information,

sharing ideas and sharing aspects of self. We chose this

instrument, not to measure nurse competence, but to

measure nurses� peer review (collaboration and

communication) about nursing care on their unit. With

Hughes�s permission, �Students at this school� was

changed to �RNs on my unit� in each question.

Three nursing directors examined our modified

questions for content validity, and two staff nurses

evaluated the instrument for clarity before implemen-

tation. All items on the revised scale relate to peer col-

laboration and communication about nursing practice

and offer a valid and reliable scale for measuring

RN-to-RN peer review in an academic medical centre.

Cronbach�s a-test on our data showed high reliability

among item-total (a = 0.998), while inter-item correla-

tions for subscales showed mean = 0.468, indicating a

minimum of redundancy.

Along with the modified PGCIS, we asked questions

about the nurse�s experience of the quality of profes-

sional communication with RN peers on the unit.

These questions generally related to generational, gen-

der and race or ethnicity differences, as well as to the

value of the information given or received and the

nurses� perception of respectfulness in communication

between themselves and other RNs. We asked three

open-ended questions about peer communication and

the quality of nursing practice. We also allowed for

optional free-form comments on all questions if the

nurse wished to further explain or offer additional

information that we may not have specifically

J. A. Pfeiffer et al.

ª 2011 Blackwell Publishing Ltd392 Journal of Nursing Management, 2012, 20, 390–400

requested. We wanted to hear in the nurses own words

their experience of peer review on the unit, and open

comments provided the nurses with an anonymous

voice where he or she could �speak� freely, and we –

having it in writing – could �listen� more closely and

carefully to this detailed response.

Procedure

The instrument was electronically formatted and dis-

tributed via email to 1406 registered nurses. The email

was sent from the librarian (a person who does not

supervise the staff nurses in any way) in order to elim-

inate any hierarchical influence or perceived pressure to

participate. The electronic document opened with a

click-through informed consent that defined peer re-

view, explained the research and explicitly assured

confidentiality. Nurses were reminded on each page to

answer questions with RN peers on their unit in mind.

Data collection took place over a 2-month period from

mid-August to mid-October 2009 following receipt of

an exemption letter by the institutional review board at

the participating institution.

Announcement of the survey was published in a

weekly newsletter distributed at the hospitals, and flyers

were posted in each nursing unit and in public areas.

After initial distribution, two staff nurses and the

librarian went to units with a copy of the flyer to raise

awareness and encourage participation in the research.

Four reminder notices were sent out over the 2-month

period in e-mails from the librarian.

Measures of association with patient safety andsatisfaction

We used regularly collected existing data from Culture

of Safety and Press Ganey reports to examine unit-based

correlations with nurse-assessed patient safety and

patient-assessed satisfaction with nursing care during

the same time period. An analyst from the Continuous

Quality Improvement office worked with our statisti-

cian to retrieve staff RN data that excluded nurse

managers or licenced vocational nurses (LVNs). As a

measure indicating whether or not the nurses felt their

unit provided good patient safety, we examined the

percentage of nurses on each unit who responded

positively to the statement �I would feel safe being

treated here as a patient� from the Culture of Safety

survey during the same time period. To determine pa-

tient satisfaction with the quality of nursing care during

our study period, we extracted Press Ganey questions

about patients� satisfaction with their overall nursing

care (an average of monthly scores received in August,

September and October 2009).

Analysis

For satisfaction and safety relationships to peer review,

we charted each unit�s responses (to a Press Ganey

patient satisfaction question and a Culture of Safety

patient safety question) against the PGCIS summative

scores for the unit. Statistical Package for the Social

Sciences (SPSS v.17.0 for Windows; SPSS, Chicago, IL,

USA) was used to perform chi-squared tests for signifi-

cance of whether the PGCIS responses differed signifi-

cantly from the null (P < 0.05) across nurses� age,

ethnicity, unit type, years of experience on the unit,

years of experience in nursing and highest nursing

degree. Frequency distributions were tabulated from raw

data and analysed as follows: if the survey response was

1, 2 or 3 (varying degrees of disagreement) response was

scored as �0� and if the response was 4, 5 or 6 (varying

degrees of agreement), the response was scored as �1�.Two of the researchers independently reviewed open-

ended questions and optional comments for common

themes reported by the respondents. Our goal was

descriptive rather than theory development; however,

we borrowed analysis technique from a grounded the-

ory approach (Strauss & Corbin 1990). We also sought

to use an element of inter-rater reliability by having

them do the same work separately before comparing

notes. Each researcher conducted an open coding

analysis of the qualitative data to extract provisional

concepts from the raw data, primarily using in vivo

codes (respondents� actual words). They used multiple

readings of the responses in a constant comparative

analysis to identify similarities to, or differences from,

their initial concepts (Corbin & Strauss 2008). The

researchers then traded transcripts and notes. Together,

they compared concepts and developed higher-order

abstract categories and integrated them into core

themes (Corbin & Strauss 2008).

Results

Overall response rate was 38% (541/1406). Seventy-

five per cent of respondents (405/541) answered all

questions. Units with fewer than four respondents were

eliminated to ensure confidentiality of individual nurses.

Characteristics of the sample

Comparison with characteristics of the hospitals� popu-

lation of nurses confirmed the sample representativeness



in terms of level of education, years as a nurse, age and

ethnicity. Overall, nurses in this sample were well-

educated, middle-aged, and the majority were Cauca-

sian with fairly extensive experience as a nurse but less

than a decade on their current unit (Table 1).

Over 65% (328/501) of our sample had a BSN or

higher educational level. �Years of experience as a nurse�was bimodal. The largest group, 34% (169/495), had

more than 20 years of experience as a nurse. The second

largest group, 20% (101/495), had 5 years or less of

experience.

Nurses were asked their age by age-group. Two per

cent were <25 years old. Eleven per cent (55/495) were

between 25 and 30 years old. Thirty per cent (148/495)

were between 31 and 40 years old. Twenty-seven per

cent (131/495) were between 41 and 50 years old.

Twenty-six per cent (127/495) were 51–60 years old.

Four per cent (22/495) were 61–70 years old.

Experience on current unit showed 49% (244/495)

with 5 years or fewer of experience on their current unit.

Twenty-five per cent (122/495) had 6–10 years of expe-

rience on the unit. Twenty-six per cent (129/495) had

more than 10 years of experience on their current unit.

Fifty-four per cent (267/493) of the sample was Cau-

casian. The next highest ethnicity was Filipino at 27%

(134/493), then Asian at 7% (34/493), Latino/Hispanic

at 5% (24/493), African-American at 2% (11/493). The

remaining respondents self-identified as Other at 2%

(12/493), Pacific Islander at 1% (7/493), African at <1%

(3/493), and American Indian at <1% (1/493).

RN-to-RN peer review

Across all units, nurses reported that RN-to-RN peer

review takes place on their unit. Eighty-five per cent

(366/432) agreed with the statement: �I regularly give

my peers feedback related to the quality of nursing care

that they deliver on our unit�. Seventy-seven per cent

(334/432) reported that their peers gave them feedback

related to the quality of nursing care on the unit. Ninety

per cent (388/432) agreed with the statement that �The

quality of the information I receive from my peers

(related to MY delivery of nursing care) is valuable�.Eighty-eight per cent (382/432) reported that their peers

�appear to value the information I give them (related to

the nursing care THEY deliver)�. The high percentage of

affirmative responses to these direct statements indi-

cates that these nurses value peer review. However, on

every unit, nurses reported giving more peer feedback

than they received. They identified that they valued

information received from peers more than their peers

appeared to value the information given.

The PGCIS scores also reflected giving assistance and

modelling professional collaboration across all units.

However, summated PGCIS scores charted against

patient satisfaction or patient safety questions showed

no clear correlation on each unit (Figure 1). The PGCIS

scores across the units were generally lower than the

patient satisfaction and perception of patient safety

scores. This was unexpected. Higher PGCIS scores

indicate better peer review on the unit. We expected

units with the highest scores to have stronger reporting

of nurse-assessed patient safety and patient-assessed

satisfaction with overall nursing care.

From the chi-squared analysis, we determined whether

the number of nurses who disagreed with each question

vs. those who agreed with each question was significantly

different than the null we would expect, across educa-

tion, age, experience, and ethnicity. The chi-squared

analysis showed no significant differences (P < 0.05) for

the nurse�s age or number of years of experience on the

unit for each survey question. However, there were sig-

nificant differences among responses by other nurse

characteristics (Table 2).

Highest nursing degree

Nurses with a bachelor�s degree were more likely

(40%) than diploma- (30%), Associate�s- (28%), or

Master�s-prepared (20%) nurses to agree that it should be

Table 1Nurse characteristics

Characteristic Sample

Education (%)*Diploma 6.6Associate�s 31.0BS in Nursing 65.4Master�s in Nursing 6.2

Age (years), mean (SD) 43.4 (10.9)Race/ethnicity (%)

Caucasian 54Filipino 27Asian 7Latino/Hispanic 5African American 2Other 2Pacific Islander 1African 2American Indian 0

Years as nurse %5 or fewer 20 (100/494)6–10 15 (76/494)11–15 13 (65/494)15–20 17 (84/494)>20 34 (169/494)

Years on unit, mean (SD) 8.1 (6.4)

*Education exceeds 100% because we did not ask for highestnursing degree, but asked �Please check degrees you hold inNursing�. Some nurses responded with multiple degrees.



left to the nurse manager(s) to work with RNs who need

additional help related to patient care (v2 = 9.4, df = 3,

P = 0.025). Diploma-prepared nurses (70%) were least

likely to agree with the statement that �RNs on my unit

get support from their fellow RNs when they are

uncomfortable providing patient care� compared with

Associate- (86%), Bachelor- (91%), or Master�s-prepared (90%) nurses (v2 = 9.6, df = 3, P = 0.022).

Years of experience as a nurse

There was a significant difference in responses by �years

of experience as a nurse� for PGCIS question 10: �RNs

on my unit can count on other RNs for help�. Nurses

with 5 years or fewer of experience (94%), 6–10 years

of experience (95%), or nurses with more than 20 years

of experience (90%) agreed more with the statement

than mid-career nurses with either 11–15 years of

experience (82%) or 15–20 years of experience (84%)

(v2 = 9.9, df = 4, P = 0.042).

Ethnicity

There were significant differences in responses by eth-

nicity for six questions related to the nurse�s qualitative

experience of professional communication and 10

questions on the PGCIS. Only the most significant dif-

ferences (with P-values <0.01) are reported here. More

Filipino (95%) or Latino (96%) nurses than Caucasian

(86%) nurses agreed with the statement �My peers who

are of a different gender speak to me respectfully and

communicate well when giving feedback� (v2 = 24.4,

df = 8, P = 0.002). A significantly higher percentage of

Filipino nurses (93%) agreed with the statement that

�RNs on my unit are a source of encouragement to each

other� than did their Caucasian (84%) or Latino (70%)

peers (v2 = 25.7, df = 8, P = 0.001). A much higher

percentage of Filipino nurses (92%) than Caucasian

(77%) or Latino (65%) nurses agreed with the state-

ment that �RNs on my unit help each other by sharing

information sources, research articles or evidence re-

Figure 1Patient safety & satisfaction correlations with RN-to-RN peer review August–October 2009, by unit. (1) The safety survey question displayed ingraph is �I would feel safe being treated here as a patient.� (2) The Press Ganey patient satisfaction question displayed in the graph is for �OverallNursing�. (3) Peer review is the summative score of the Peer Group Caring Interaction Scale. *Patient Satisfaction data is not available for unitnos. 11, 13 & 28. Safety Survey data is not available for unit nos. 24–27.



lated to our patient care� (v2 = 21.2, df = 8, P = 0.007).

However, more Filipino nurses (46%) than Caucasian

(25%) or Latino (26%) nurses also agreed with the

statement that �RNs on my unit will help another RN

only when it is their own best interest to do so�(v2 = 22.4, df = 8, P = 0.004).

Themes from open-ended questions and comments

For the open-ended questions, there were 303 re-

sponses to �What, if anything, do you think would help

improve peer communication on your unit?�. There

were 450 responses to �When you see an RN on your

unit doing something in nursing practice that you be-

lieve is incorrect, what do you do?�. The final question

elicited 113 responses to �Is there anything else you

would like us to know related to PEER REVIEW

(professional communication among RNs on your

unit)?�.Two of the researchers independently reviewed open-

ended questions and optional comments for common

themes reported by the respondents. Four clear themes

emerged as the main barriers to effective peer commu-

nication. They were: (1) lack of clarity around what

constitutes peer review; (2) fear of peer retribution; (3)

concerns with language and cultural barriers; and (4)

Table 2Chi-squared analysis was used to determine whether there was an association between demographic characteristics and agreement or dis-agreement with PGCIS & PR questions. Statistically significant differences by education, experience, and ethnicity were found and are reportedhere. The p value represents how likely this result would be if there was no real underlying effect. Effect sizes were small-to-moderate (rangingfrom 0.15 to 0.24) using Pearson�s contingency coefficient and a standard of 0.10 = small, 0.30 = moderate, 0.50 = large effect. Practicalsignificance is discussed in the text

Factor/questions with statistically significant difference df n v2 P

Highest degreePGCIS Q6: RNs on my unit think it should be left up to the nurse manager(s) to work withRNs who need extra help related to patient care

3 430 9.36 0.025

PGCIS Q15: RNs on my unit talk with fellow RNs (on the same unit) about how it feels tocare for patients who they are uncomfortable with

3 430 9.61 0.022

Years of experience as a nursePGCIS Q10: RNs on my unit can count on other RNs on the unit for help 4 430 9.92 0.042

EthnicityPR Q2: My peers regularly give me feedback related to the quality of nursing care I deliveron our unit

8 430 16.04 0.042

PR Q3: The quality of the information I receive from my peers (related to MY deliveryof nursing care) is valuable

8 430 15.63 0.048

PR Q4: The quality of the information I give to my peers (related to the nursing care THEYdeliver) appears to be valuable to them

8 430 16.17 0.040

PR Q6: I deliver feedback to my peers in a way that they appear to be comfortablereceiving (listening to with an open mind)

8 430 17.43 0.026

PR Q7: My peers who are of a different gender speak to me respectfully and communicatewell when giving feedback

8 430 24.42 0.002

PR Q9: My peers who are of a different ethnicity or race are respectful and communicatewell when giving feedback

8 430 17.61 0.024

PGCIS Q2: RNs on my unit talk with each other about their problems and concerns relatedto nursing practice on the unit

8 430 15.79 0.046

PGCIS Q4: RNs on my unit talk with each other about things they wish they had donebetter while caring for a particular patient

8 430 16.92 0.031

PGCIS Q5: RNs on my unit will help another RN only when it is in their own best interestto do so

8 430 22.39 0.004

PGCIS Q6: RNs on my unit think it should be left up to the nurse manager(s) to work withRNs who need extra help related to patient care

8 430 16.37 0.037

PGCIS Q7: There is a lot of positive personal interaction among the RNs on my unit 8 430 20.77 0.008PGCIS Q9: RNs on my unit get advice and suggestions from other RNs on the unit relatedto patient care

8 430 16.37 0.037

PGCIS Q10: RNs on my unit can count on other RNs on the unit for help 8 430 15.91 0.044PGCIS Q12: RNs on my unit are a source of encouragement to each other 8 430 25.66 0.001PGCIS Q13: RNs on my unit help each other by sharing information sources, researcharticles, or evidence related to our patient care

8 430 21.20 0.007

PGCIS Q15: RNs on my unit talk with fellow RNs (on the same unit) about how it feels tocare for patients who they are uncomfortable with

8 430 16.56 0.035

PGCIS, Peer Group Caring Interaction Scale; PR, Peer Review (questions about the nurses� experience of the quality of professionalcommunication with RN peers on their unit).



concerns regarding lack of mutual respect and profes-

sionalism.

Clarity

A common theme in our respondents� comments cen-

tred around lack of clarity or a clear definition of peer

review. Despite defining peer review as �professional

communication among RNs about the quality of nurs-

ing care on the unit,� many respondents asked for

additional educational opportunities on the subject to

raise awareness, and they seemed uncertain of the def-

inition themselves. Comments such as, �I am unclear

about what peer communication includes� and �I do not

perceive a problem with peer communication, but I am

not sure what it is� were identified. Despite using the

term �peer communication,� our nurses were unsure of

exactly how to put peer review into practice.

Peer retribution

Some nurses reported that unless it would cause harm to

their patient, it was not worth �rocking the boat� with

their peers. Fear of disrupting the perceived smooth

workflow with their peers was reason enough not to

pursue giving feedback to a peer. Comments illustrating

this include: �Some nurses do not take comments. So

unless it�s detrimental to the patient, I keep my mouth

shut�; �Truthfully, I keep quiet if it�s not harmful to the

patient�; �Nurse to nurse criticism isn�t well received in

general�; �We must dispel the concept that peer review is

akin to fault-finding about your colleagues�; and �If it

would be more trouble than it is worth to let the person

know that it�s incorrect, I would hold my tongue�.

Language and culture

Cultural and language concerns were cited frequently as

barriers to effective peer communication. Fifty-four per

cent of our sample identified themselves as Caucasian

and 27% identified themselves as Filipino. Some com-

ments illustrated language as a communication issue

related to ethnicity: �Filipino nurses tend to speak in their

dialect in the unit when they don�t want other nurses to

know what they�re talking about, which makes me feel

that they are talking about me�; �I believe our cultural

differences inhibit the way we give and receive feedback

from each other�; �We communicate well – we all speak

Tagalog�; �We are all Filipinos, so we really don�t have

any problem communicating�; �When they speak in their

language, it keeps others from communicating with

them�. When nurses offered ideas to improve peer com-

munication, comments such as, �Always speaking Eng-

lish not Tagalog�, �good grasp of the English language�and �Everyone speaking fluent English� were identified.

Respect

Another common set of comments centred around the

theme of respect and professionalism. For example: �Ifind that people do not want constructive feedback�;�Our unit does not foster peer review. The nurses would

rather talk behind your back than to your face�; �Some

nurses are not respectful with their colleagues�; �I find it

difficult to give constructive criticism; most do not want

it�; �If it is a person who has no desire to hear any

suggestions, I may not discuss it at all�; �I tell the RN

that on this unit, this is how we do it�; �The problem is

that half of the staff that I work with eat their young�.

Discussion

We used the modified PGCIS as a measure of peer

review because the questions specifically address peers

at the same level, peer group climate and the types of

interactions among peers that reflect collegiality, sup-

port, and sharing of professional knowledge (Hughes

1998, Watson 2009). The fact that PGCIS scores

showed no clear correlation with patient safety and

satisfaction may be because all scores were high on

PGCIS and on nurse-assessed patient safety and patient-

assessed satisfaction. The Culture of Safety data�ssuperiority over PGCIS scores across all units appears to

indicate that although we �would feel safe being treated

here as a patient�, we perceive ourselves as less caring

toward each other. The Press Ganey patient satisfaction

score�s superiority over PGCIS scores similarly reflects

that the problem is not communication with patients

but with each other.

In the seven units that scored at 90% or higher on

patients� satisfaction with overall nursing care on Press

Ganey reports, the PGCIS score remained significantly

lower. These findings support an independent practice

model more than a collaborative team model. Collab-

orative team models are essential to ensure a profes-

sional work environment, to foster peer review, and to

improve decision-making and higher quality outcomes

(Kalisch et al. 2009, Orchard 2010).

Differences in responses related to some nurse char-

acteristics may reflect cross-cultural differences, as this

nursing workforce is 54% Caucasian and 39% Filipino,

Asian or Latino. Filipino nurses overall scored higher

than other ethnic groups on items related to positive peer

interactions and caring factors. The Filipino culture,

which stresses group orientation rather than individual

focus, may be an influencing factor (Purnell 2009).

As nurses with the least years of nursing experience

overall ( £ 5 years) and those with the most (>20 years)

agreed that they could count on each other for help,



perhaps more attention needs to be focused on nurses in

the middle range of experience. The least experienced

nurses have special programmes designed for them

while the most senior receive recognition for their lon-

gevity. Everyone needs to be recognized to foster col-

laboration, which comes partly from valuing each

other.

Open-ended comments largely did not mirror the

affirmation that peer review was taking place on the

units. To some, communication or feedback from peers

was apparently not perceived as peer review even

though peer review was defined as such in the consent

and within the survey. Some comments reflected �peer

review� as having a negative connotation.

This key area – understanding the meaning of peer

review – indicates a need to better define this term for

staff nurses. George and Haag-Heitman (2011) empha-

size that peer review is not the same as annual perfor-

mance review; it is not a managerial process and

managers should only support the process and remove

organisational barriers to peer review. Peer review

should never be anonymous because �anonymous staff

input has tarnished the notion of peer review for many�(Haag-Heitman & George 2011) and effectively repre-

sents an invitation to �talk behind a colleague�s back�.This statement was confirmed in open-ended comments

in our research. Peer feedback should not be confronta-

tional, yet we received a number of responses to an open-

ended question indicating that nurses would �confront� a

peer if they encountered a practice issue needing to be

addressed. Nurses need to have peer review defined for

them as, literally, �direct, professional, caring communi-

cation between RNs working at the same level�.In order to protect the dignity and autonomy of nurses

in the workplace, the ANA Bill of Rights (Wiseman

2001) clearly states that �nurses have the right to freely

and openly advocate for themselves and their patients,

without fear of retribution�. However, translation of this

concept to the bedside, is challenging at best. In our

study, it was apparent that cultural and language barri-

ers led to some perceptions of retribution, whether or not

they were based in fact. Nurses had difficulty commu-

nicating with a perceived unreceptive nurse. A common

method used to manage this situation was avoidance.

Methods of communicating information regarding a

patient�s condition need to be freely given regardless of

the recipient�s response. Role modelling, coaching and

mentoring more adaptive coping skills may reduce a

nurse�s reluctance to provide peer review in these situa-

tions. The intent behind communication ties with the

respect theme, as demonstrated by the comments re-

ceived. Development of collegial bonds would allow the

intent to come across, even when the style differs or

actual communication is less than perfect. Nurses who

effectively bracket their personal issues can provide their

professional colleagues with effective peer review.

Filipino nurses scored significantly higher than other

groups on items related to positive peer interactions and

caring factors. Nurses from this cultural background

may be able to inspire other nurses by sharing their

cultural beliefs in this area. Integrating diverse views

enhances each nurse�s ability to relate and communicate

more effectively.

Peer review is a complicated process with seemingly

unlimited factors. Good communication skills are

teachable. We may not solve all RN-to-RN peer review

issues because communication among peers inevitably

involves the personalities of individuals; however,

effective teamwork begins with effective peer review.

Limitations and future research

Because this was a non-probability sample at one

institution, readers may potentially transfer results only

to institutions with similar context and characteristics

among nurses. We hope to have provided enough detail

about our sample to enable replication. Our methods

may be useful to other senior nursing leadership in

identifying their own unit-based nurse peer review.

Only 75% of those who began the survey completed it.

Dropout may have resulted from survey length in a busy

clinical environment or from nurses not wishing to an-

swer certain questions. Larger studies across multiple

institutions with randomized samples are needed, and

perhaps the use of only Hughes�s instrument (adapted for

clinical nurses) would solve the problem of length.

In all survey-based research there is the risk of bias in

self-selected samples (in terms of responders vs. non-

responders), and in self-report (which in this case might

include a lack of awareness about one�s own commu-

nication skills or a lack of recognition of others� skills).

It is possible that units with poor communication were

also those that did not have enough responses to eval-

uate. In future studies, observers on the unit would be

needed to determine whether or not communication is

happening as reported.

Further evaluation and assessment is needed in

identifying barriers to peer review and in prioritising

mentoring professional communication and a collabo-

rative practice model. Effective communication skills

provide the cornerstone of peer-to-peer exchange. This

study raised the question: Is the lack of effective com-

munication an essential skill that is missing and conse-

quently, a deal-breaker to peer review?



Conclusion and implications for nursingmanagement

This study demonstrated one method of measuring

informal peer review among nurses at the unit level that

could potentially be implemented in hospital systems in

different cultures and countries. We identified educa-

tion, engagement and participation of nurses at the unit

level as critical to moving forward with acceptance and

practice of informal peer review. Nurses� outcome

measures are reaching new levels of excellence, which

demonstrate to other health professionals and con-

sumers the value nursing provides. Increasing knowl-

edge and skills in peer review will encourage nurses

themselves to own the valuable contributions nursing

makes every day.

This study also indicated the need to ensure English

fluency. As diversity increases in our nursing popula-

tion, it raises questions that managers must address: Are

nurses from diverse backgrounds able to communicate

their expertise in English as well as they do in their

native language? How can nurse leaders assess this

factor and develop methods to improve fluency if nee-

ded? With the need for nurses increasing globally

(Oulton 2006), the nursing pipeline is becoming more

international. While this has benefits, it also presents

challenges. Our findings around language used on the

unit may prove true in other countries.

In order to have effective peer review on the unit,

nurses need to speak the same language. Communica-

tion is affected by language preferences and cultural

expectations within the workplace. Speaking a language

other than English while in the break room or cafeteria

is obviously normal and acceptable, but in a hospital

work environment it is essential that other nurses, other

co-workers and the patients are able to understand

what is spoken. Just as translators are necessary for

some patients, a common language is necessary for

nurses working together.

Professional, respectful communication is a founda-

tional skill in peer review. There is a fundamental need

to raise awareness about the importance of nurse peer

review on the unit and to redefine it as a caring inter-

action among colleagues as opposed to the confronta-

tional or judgmental connotation it apparently currently

carries. Nursing leadership can create an organisational

climate that encourages direct peer review as a practice

separate from annual evaluations. Unit managers,

through mentoring and modelling, can reinforce this

climate with their nursing staff and inspire its use.

We also recommend clarifying the language used

around peer review. Hospital leadership should provide

education to clearly explain peer review. It should be

defined separately from feedback received from peers

during annual performance reviews. As a profession, we

need to make peer review a positive, caring interaction

that ensures patient safety through the support of a

professional practice culture embracing positive, daily

RN-to-RN communication.

Source of funding

This study was self-funded by the authors.

Ethical approval

This study (Project No. 090750) was reviewed by the

University of California, San Diego Human Research

Protections Program and certified as exempt.

Conflict of interest

The authors report no conflict of interest.

Acknowledgement

The authors appreciate our fellow researchers: Mary

Hackim for early planning and coding themes work,

Daniel Patiag and Edita Petil for walking the floors to

encourage participation and all three for their input

regarding instrument validity.

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Assessing RN-to-RN peer review on clinical units