Integrating Nursing Peer Review and a Restorative Just Culture for a Healthy Work Environment

Sunday, 19 March 2017: 10:00 AM

Jane Braaten, PhD, MS
Centura Health, Highlands Ranch, CO, USA
Cynthia A. Oster, PhD, MBA
Performance Practice and Innovation, Porter Adventist Hospital, Denver, CO, USA


Healthy work environments empower staff and foster effective interpersonal relationships and collaboration (American Association of Critical Care Nurses, 2016). A structure to integrate these characteristics into the workflow is necessary for change (Huddleston & Gray, 2016). Nursing peer review is an integral structure to ensure a healthy work environment and positive clinical outcomes. However, the implementation of peer review is still limited and can seem punitive due to a narrow focus on the person being reviewed (George & Haag-Heitman, 2015). This often leads to weak interventions that have a limited impact on patient outcomes and often are isolated to an individual rather than the system. This type of review often is damaging to the recipient and does not foster a healthy work environment. A healthy work environment calls for a restorative review that not only values the person who was harmed, but also the person being reviewed.

Sidney Dekker (2012) describes the difference between a retributive just culture in which there is blame and payment for harm and a restorative just culture as one that focuses on harm that needs healing and the community obligation to collectively find a solution to that harm considering not only the person who was harmed but the individual who may have been involved in the harm. Dekker’s model focuses on: healing those who are hurt from an event including first and second victims; asking what is responsible instead of who is responsible, getting to the truth through multiple accounts, understanding why actions made sense within the context of the situation , and foremost, building and healing relationships and trust through the process (Dekker, 2015). Nursing peer review implemented through the lens of a restorative just culture has the potential to build peer relationships, enhance a safety culture, and achieve sustainable changes that improve outcomes for patients.


The purpose of this project is to describe a process for pairing a restorative just culture into nursing peer review in order to heal, learn, collaborate, retain staff, and improve outcomes for patients.


Nursing peer review was described in 1988 by the American Nurses Association (ANA) as the process by which practicing nurses systematically assess, monitor, and make judgments about the quality of care their peers provide as measured against professional standards of practice. This definition has not changed, however, the patient safety landscape has changed, warranting a new lens through which nursing can implement peer review.

A nursing peer review process that focuses on a restorative just culture, effective peer to peer feedback and systems learning can be an effective tool to use to build a healthy work environment. There is a sparse amount of literature on how to effectively integrate just culture into nursing peer review and also a lack of information on aspects of a restorative culture in healthcare. Creating a model to integrate restorative just culture principles into nursing peer review and focus on strong system level interventions can lead to effective changes that will move outcomes and prevent adverse events by promoting honest, effective communication and collaboration between nurse peers as well as learning for the whole hospital.

Strategy and implementation

Review of literature showed a gap between organizational implementation of just culture and integration into the professional nursing peer review process. The project hospitals strengthened the standard peer review by creating a tool that integrated the tenants of a restorative just culture into the review format. The three duties of just culture are reviewed prior to the formal evaluation to view the evaluation within the correct duty : duty to avoid causing harm, duty to follow a rule, and duty to produce an outcome. Then the situation is placed into the three categories of human error, risky behavior or reckless behavior in order to decide upon scoring the actions of the individual and/or discuss system factors of error. Addition of the restorative nature of just culture then includes the following process pieces: Assessing first and second victims of the situation and the need and resources for healing, allowing for all accounts to be heard and understood in the context of the situation assuring that hindsight bias is recognized and minimized, and assessing for solutions collaboratively that hold the individual as well as the system accountable. The final step to the process is to close the loop by allowing the individual involved in the event, the opportunity to provide feedback to the nursing peer review group in order to assure that the group is promoting learning, healing, relationship and trust. Education to the nursing peer review group prior to implementation included just culture, causes of error, human factors effects, and causes of bias when reviewing human behavior such as hindsight bias and outcome bias.


The Nursing Peer Review group has reviewed 25 cases referred from occurrence reports, adverse events, physician referrals, and peer referrals. The main outcomes desired from nursing peer review include an expert review of the case; understanding from the individual who experienced the event point of view; collaboration between the nurse peer reviewer and reviewee for solutions, and referrals to system level groups for system learning. A mainstay of the process is closing the loop by asking the nurse who was reviewed to give feedback to the group regarding how well we communicated and collaborated and mutually provided a solution that will prevent the issue from happening again. Higher levels outcomes also have included a reduction in fall rate, a reduction in oversedation rate and an impact on failure to rescue. Nurse retention rate and effect on Patient Safety Culture are in process of evaluation .

Implications for practice

Organizations are challenged to meet quality outcomes performance standards and are also challenged to nimbly change nursing practice to drive positive outcomes. Peer review integrated with a restorative just culture drives nursing leaders to intervene at the point of care to align individual practice and system designs with standards of care and a healthy work environment.