Date of Award

Spring 3-23-2022

Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Sarah M. I. Cartwright, DNP, MSN-PH, RN-BC, CAPA, FASPAN

Second Advisor

Jane Crable DNP, APRN, CNS


Practice Problem: A hospital in the Sacramento County area seeking the ANCC Pathway to Excellence Program® designation determined upon performing a gap analysis that Element of Performance 2.8, a peer evaluation program, was absent, thus creating a deficiency in the fulfillment of the requirements for the designation.

PICOT: The PICOT question that guided this project was: In nurse leaders (P) how does the development of a formal peer evaluation process (I) compared to no formal process (C), influence the performance outcome score of self-efficacy (O) over 8 weeks (T)?

Evidence: The evidence demonstrated that if a peer evaluation process is implemented among nurse leaders and the outcome is measured using a pre- and post-survey, it can affect self-efficacy scores of those nurse leaders.

Intervention: A formal peer evaluation program for nurse leaders was developed to include a pre- and post-survey tool measuring self-efficacy. Post implementation the facility policy was amended to include the peer evaluation process at the annual performance review.

Outcome: Nurse leader participants (n = 22 pre-survey, n = 16 post-survey) completed the new peer evaluation process including self-efficacy scoring. There was a noted increase in the post self-efficacy scores overall after the implementation of the peer evaluation process. Project results were not statistically significant but were clinically significant.

Conclusion: Project results replicated literature findings that implementing a peer evaluation process correlates to an increase in nurse leaders’ self-efficacy scores. This program development, implementation, and policy amendment is beneficial to the hospital which will continue to move forward with obtaining the ANCC Pathway to Excellence Program® designation.


Scholarly project submitted to the University of St. Augustine for Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

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This work is licensed under a Creative Commons Attribution 4.0 License.