Construction and Application of a Comprehensive Evaluation and Assessment System for Clinical Nurses Based on the Support of an Information Technology Platform

Introduction

Hierarchical employment of nursing manpower and professional nursing competence progression is a way to promote nursing professional development, encourage nursing echelon growth, enhance nursing staff job satisfaction and stabilise the nursing echelon.^1–3 Nurse hierarchical appraisal is a process of checking, measuring, evaluating and giving feedback on nursing staff’s performance based on certain criteria.^4–6

In order to guarantee fulfilment of the standard of care, performance evaluation is a necessary activity in healthcare companies. This process employs techniques to provide staff members with the details they need to assess whether they are performing up to expectations or need to improve.⁷ The objectives of nurse appraisal may be as follows: to determine professional competence, to enhance staff development, to inspire staff to achieve more, to improve communication between managers and staff and to promote better relationships among nurses.⁸ However, productivity is not always increased by performance reviews. The reviews may be untruthful, prejudiced or not well liked by those being evaluated. A rise in unhappiness, lack of motivation and resistance, particularly on the side of the appraiser/employees, have sometimes been connected to performance assessment systems. These issues are brought on by biases in the assessment process, inaccuracies in the substance of the evaluation, conflict between the requirements of the employees and the objectives of the appraisal, or a lack of distinct and independent performance aspects.⁹

Our hospital has been trying to implement a nurse hierarchy since 2010, but lacks of scientific, objective, comprehensive and hierarchical evaluation and assessment criteria. Therefore, this study attempts to design a set of comprehensive evaluation assessment criteria for clinical nurses by reviewing the literature and combining the findings with the actual situation of nursing work in hospitals. Then, the results will be used as a basis for nurse promotion and assessment management during promotion, and the effects will be verified during clinical practice.

Material and Methods

Study Design

This study was a prospective, single-centre study that explored the effects of a newly developed evaluation system for nurses in clinical practice. The main components included the following: 1) the indicators for evaluation were designed and given weights with a scoring rule; 2) the effects and problems of the system in the actual operation process were assessed; 3) the evaluation system was optimised based on the feedback given during the trial operation; and 4) data on the clinical nurses’ satisfaction with the evaluation system and willingness to use it were collected via questionnaire.

Evaluation and Assessment Index Design

Index Design

By reviewing the literature and combining the findings with the actual situation of the nursing work in the hospital to design the comprehensive evaluation and assessment criteria for clinical nurses, the work tasks and objectives, job responsibilities and core competency development of the nurses were decomposed into the evaluation and assessment indexes of the nurses, and the assessment items were given different weights for different nursing levels. From January to February 2021, to ensure the rationality and operability of the evaluation and assessment indexes, the departments of neurology, cardiothoracic surgery, nephrology, urology and critical care medicine were selected for the pre-evaluation, and the indicators were revised according to the pre-evaluation results. In the end, there were six primary indicators, as follows: I) medical ethics, II) attendance, III) performance of duties, IV) theoretical study, V) professional skills and VI) teaching. There were 18 secondary indicators, as follows: ① receiving praise letters and pennants; ② medical ethics assessment results; ③ receiving/refusing red envelopes and gifts; ④ taking sick leave (including late arrival and early departure); ⑤ number of night shifts taken; ⑥ quality of nursing work; ⑦ participation in training; ⑧ performing nursing ward round; ⑨ nursing defects and errors; ⑩ completion of nursing medical records; ⑪ solving difficult problems; ⑫ theory assessment; ⑬ basic and specialised techniques; ⑭ new techniques and projects; ⑮ teaching new nurses and nursing students; ⑯ teaching advanced students; ⑰ participation in academic activities; and ⑱ guiding a graduation thesis. There were also six tertiary indicators, as follows: ① department management, ② staff deployment, ③ public emergencies, ④ rewards, ⑤ scientific research and ⑥ instrument management. Each index was quantified in terms of points (see Table 1). This study was approved by the institutional review board (W2022028), and all participants provided their signed informed consent.

Table 1 Clinical Nurse Comprehensive Assessment Evaluation Indexes and Scores

Scoring Rules

The appraisal and evaluation criteria were designed based on a system of adding and deducting points; the specific scoring criteria are shown in Table 2, focusing on the weight distribution of nursing work quality, professional skills assessment, thesis supervision and emergencies.

Table 2 Clinical Nurse Comprehensive Evaluation Assessment Scoring Rules

Assessment Frequency

An evaluation assessment was completed by the nursing department. Different assessment items were assessed at different frequencies. The items recorded in the assessment at any time included nursing defects and errors and instrument management. The items recorded in the monthly assessment included medical ethics, attendance, nursing work quality, participation in training, staff deployment and nursing department examination results. The items recorded in the annual assessment included departmental theory, skill examination results, awards, scientific research, nursing ward rounds and completion of nursing medical records.

Evaluation and Assessment Results

The appraisal cycle of the comprehensive evaluation and assessment system of clinical nurses took place from October 1, 2020 to September 30, 2021, and the evaluation and assessment were carried out by the nursing department and the clinical departments. The base score was 100, and the assessment was carried out via adding or deducting points to the base score. The assessment results were divided into three grades: ≥100 as excellent, 100–95 as qualified and <95 as unqualified. An appraisal result of one failure would delay the promotion for one year, two failures would delay the promotion for two years, and three failures would demote the grade level. Nurse promotion conformed to the standards for the promotion of N0–N4 nurses as stipulated in the Nursing Staff Hierarchy Management System. In the promotion of the nurses, the assessment result was the most basic index, and only those who had passed the comprehensive evaluation assessment results would be qualified for promotion. At the same time, one point would be deducted for nursing errors and accidents during the current level, and then, the chief nurse, section chief nurse and nursing department would approve the promotion level by level to complete the promotion. The assessment standard converted the behavioural and outcome goals of each work duty in the clinical nursing work into measurable quantitative and objective indicators. The assessment results could be used as the basis for the nurses’ promotion and the assessment index utilised during promotion as well as the basis for the department’s selection of star nurses and excellent nurses.

The Nursing Management System Platform Supports Informatisation

The information management office provided information technology support and established a comprehensive evaluation and assessment module for the clinical nurses on the nursing management system platform to realise the evaluation and assessment operations on the computer system. Authorised by the information management office, the nursing department evaluated and assessed all clinical nurses in the hospital; the nurse manager and department administrator could only evaluate and assess nurses in their departments, and ordinary nurses had access rights but not operation rights on the platform. From March to April 2021, the urology and nephrology departments were selected for the trial operation to further improve the operation process.

Clinical Applications

Evaluation and Assessment System Workflow

The workflow was summarised as follows (Figure 1):

1. The nursing department shall formulate comprehensive assessment standards and scoring rules.
2. The information management department shall provide information support, design and install evaluation and assessment modules in the nursing management system, and assist in solving technical problems in the evaluation and assessment system.
3. The nursing department shall conduct operation training for head nurses and administrators in all departments of the hospital.
4. Each department shall establish an evaluation form for each person in the department on the evaluation module of the nursing management system.
5. The head nurse of the nursing department, the head nurse of the department and the head nurse of various clinical departments shall evaluate and assess each nurse in accordance with the scoring rules according to their authority. Nurses can check their assessment at any time.
6. The assessment results will provide the basis for the promotion of nurses from October 1 to September 30 of the next year, and the promotion of nurses will be completed in the fourth quarter.

Figure 1 Management flow chart of the comprehensive assessment and evaluation system for clinical nurses.

Hospital-Wide Trial Run

From May to September 2021, the nurse managers and evaluation administrators of all departments in the hospital were trained to establish evaluation and assessment forms for the nursing staff in their departments, to evaluate and assess the nursing staff on the nursing management platform and to optimise the assessment system based on feedback regarding problems during the trial run. The specific optimisation contents were as follows:

Optimisation of the Secondary Indicators of Primary Indicator II (Attendance)

Determination of the Night Shift Base for Each Level

Originally: it was determined by the nursing department based on the number of night shifts completed in each department in the previous year.

Optimised to: it was determined by the department on a section-by-section basis.

Adjustment of the Value of Sick Leave

Originally: there was a maximum deduction of 10 points: sick leave for each day off, –1 point; tardiness and early departure each time, –1 point; and absenteeism, –1 point/hour.

Optimised to: this was changed to a sick leave and personal leave accumulative points deduction, with no upper limit: sick leave ≤3 days/year, no points deduction; sick leave >3 days, –1 point for each additional 7 days of rest; personal leave ≤3 days/year, no points deduction; personal leave >3 days –0.5 points for each additional day of rest; overtime, +1 point/3 h; late, tardiness and early departure, –0.5 points/time; unexcused absences, –3 points/day.

Optimisation of the Secondary Indicators of Primary Indicator IV (Theoretical Learning)

Originally: ≥85 exam points, + 1 point; ≥90 exam points, + 2 points; <80, – 1 point; 70 exam points, – 2 points; <60 exam points, – 3 points; did not participate in the assessment, –5 points/time.

Optimised to: 80 points in the theory exam to meet the standard; 80 to 85 exam points, + 1 point; 86 to 90 exam points, + 2 points; 91 to 100 exam points, + 3 points; 60 to 79 exam points, – 1 point; 50 to 59 exam points – 3 points; <49 exam points, – 5 points; did not participate in the assessment, –5 points/time.

Optimisation of the Secondary Indicators of Primary Indicator V (Professional Skills)

Originally: –1 point for each substandard item; did not participate in the assessment, –5 points/time.

Optimised to: 85 exam points in the skills assessment to meet the standard: 85 to 89 exam points, + 1 point; 90 to 95 exam points, + 2 points; 96 to 100 exam points, + 3 points; 60 to 84 exam points, – 1 point; <60 exam points, – 3 points; did not participate in the assessment, –5 points/time.

Willingness Survey

To further understand the satisfaction with and willingness of the nursing staff regarding participating in the comprehensive evaluation and assessment work, a questionnaire survey was conducted on 18 June 2021, and 945 questionnaires were collected from the nursing staff of the whole hospital. Approximately 75.4% of the nurses were satisfied with this work, and 82.7% were willing to regulate their behaviour according to the evaluation and assessment content.

Results

In 2021, a total of 1037 nurses in the hospital were evaluated through the comprehensive evaluation and assessment system of clinical nurses; among them, 38 nurses did not participate in the assessment due to resignation, job transfer, support the hospitals in remote regions, etc. Among the 999 nurses who completed the assessment, 888 passed the assessment, and 111 failed. The pass rate of the comprehensive evaluation assessment was 88.89% (see Table 3). The hierarchical distribution of unqualified nurses in the assessment and the reasons why they were unqualified are shown in Table 4. Based on the comprehensive evaluation and assessment results from 2022, 367 nurses received a promotion, and among the 259 who were promoted, 118 had excellent assessment results, accounting for 45.56%, and 141 had qualified assessment results, accounting for 54.44%. The number and hierarchy of the newly promoted nurses are shown in Table 5.

Table 3 Results of Comprehensive Evaluation Assessment Results of Nurses in 2021

Table 4 Distribution of Nurses Who Failed the Evaluation Assessment Hierarchy and Reasons for Failure in 2021 (Percentage and Person-Time)

Table 5 Tier and Number of Newly Promoted Nurses, 2022

Discussion

In this study, we explored establishing a comprehensive evaluation system and validating it in clinical practice. The main findings can be summarised as follows: 1) a nurse evaluation system based on multiple indicators was constructed after a literature review was conducted and the findings combined with clinical work, resulting in a large amount of data being collected. 2) In the trial operation of some departments, information was collected through the evaluation system, and the system was improved. 3) After the use of this evaluation system, the nurses’ satisfaction with the assessment and willingness to regulate their behaviour reached a good level. The present study provided a powerful aid for nurse promotion management, and this platform made the assessment more convenient and, thus, could be translated into potential clinical benefit.

The Significance of the Comprehensive Evaluation Assessment of Clinical Nurses

The purpose of the comprehensive evaluation and assessment of clinical nurses was to cultivate and create a high-quality and skilled nursing team to provide high-quality and efficient nursing services to patients.^10–12 The system realised a quantitative evaluation assessment, which made it clear what nurses at each level should achieve and accomplish so that the nurses could correctly assess their work, see their strengths and weaknesses and continue to improve their weaknesses and grow while giving full play to their strengths; this offered positive guidance for the improvement of nurses’ comprehensive quality.^13–15 At the same time, the evaluation standard objectively evaluated and assessed the clinical nurses comprehensively, continuously improved the nurses’ motivation through rewarding diligence and punishing laziness, promoted their initiative to accomplish their work goals and created an atmosphere of active learning and mutual learning, which played a positive role in improving nursing quality and helping nursing staff to seek future development.¹⁶

Evaluation Indicators Shall Be Given Different Weights According to Different Levels

The evaluation and assessment standards gave different weights to different levels, with strict requirements for nurses at lower levels in terms of attendance, performance and theoretical skills learning and high requirements for nurses at higher levels in terms of management, scientific research and teaching. The adoption of different assessment standards for different levels was conducive to guiding the nurses at lower levels to focus on the improvement of theoretical knowledge and nursing skills, perform their duties conscientiously according to the standard requirements and eliminate nursing defects and errors; it guided the nurses at higher levels to play the role of “passing on, helping and leading” in clinical work^17,18 and to take an active role in departmental management, teaching and scientific research, which is conducive to the career growth of nursing staff.^19,20

The Results of the Comprehensive Evaluation and Assessment of Clinical Nurses Provide the Basis for Nurse Promotion and Become a Powerful Aid to Nursing Management

The results of the comprehensive evaluation assessment provided the basis for nurse promotion and post-promotion assessment management. In 2021, 999 nurses completed the assessment through the comprehensive evaluation and appraisal system, and 888 passed, with a passing rate of 88.89%. Of these nurses, 392 were excellent, accounting for 39.24%, with a maximum score of 128 points. The main reasons for additional points were publication of journal articles, participation in scientific research, receipt of awards, deployment nomination for praise and receipt of praise letters or pennants. Moreover, 496 were qualified, accounting for 49.65%. These nurses reduced their scores within a range of five points; the range of points added and deducted was small and did not change much. Finally, 111 people (11.11%) failed; the main reasons for deduction of points were substandard theoretical achievements, sick leave, substandard number of night shifts taken, work errors and substandard nursing quality. Among the unqualified personnel, 61.98% of them were not up to standard; this was mainly reflected in N0- and N1-level nurses. The frequency of training and assessment of basic theory and basic skills for N0- and N1-level nurses was higher. Exams were held once a month for N0-level nurses, and exams were held once a quarter for N1-level nurses. Thus, the weight was greater for lower senior nurses. Sick leave and personal leave accounted for 26.45% and 4.13% of assessment failures, respectively; the points were calculated according to the specific number of days of sick leave and personal leave. Fewer points were deducted for nurses who took short leave ≤3 days/year without reducing points. More points were deducted for nurses who took long leave so that nurses could arrange their work and life reasonably, which was the main reason for the failure of N2-, N3- and N4-level examinations. The lowest score was 48.11 points, which was caused by taking sick leave throughout the year. A low number of night shifts taken accounted for 2.48% of failures. Extra points were given to reward nurses who actively worked night shifts. For nurses who were not willing to work night shifts, they were given a points reduction and punishment to improve their enthusiasm to work night shifts and facilitate the scheduling management of nurse managers. Work errors and substandard nursing quality both accounted for 3.31% of failures. Daily nursing work required implementation in strict accordance with all operational standards and norms, and the evaluation and assessment constantly corrected deviations by adding points in the positive direction and subtracting points in the negative direction to effectively prevent the occurrence of nursing errors and improve the nursing management effect.^21–23 In December 2021, 367 nurses completed their promotion, of which 108 N0-level nurses were new nurses who were recently hired at the hospital. Moreover, 259 nurses completed their promotion based on the assessment results of the comprehensive evaluation and assessment system. The 111 nurses who failed the assessment had their promotion delayed according to the regulations. Through the comprehensive evaluation and assessment of the clinical nurses, the nurses took the initiative to find their shortcomings, made continuous improvements and worked actively and hard. The nurses were transformed from being passively managed to actively taking initiatives, which became a powerful aid for the chief nurse management.²⁴

The Information Technology–Supported Evaluation and Assessment System is Easy and Fast to Operate

The evaluation assessment system was based on the support of the information technology platform, and the evaluation was conducted on the clinical nurse comprehensive evaluation and assessment module of the nursing management system, which was easy and fast to operate. The appraisees could also receive timely evaluation information; the evaluation results were transparent, and disputed evaluation results would be communicated promptly. In addition, when nurses transferred to another unit, it was sufficient to transfer the individual assessment forms to the new unit to continue the evaluation assessment, which greatly improved the efficiency of managers.^25,26

Limitations

Since this system was only tried in our institution, the results of this study are not yet universal, and continuous improvement of these evaluation criteria is still needed in the future under the management framework. It is worth noting that the satisfaction level of the nurses with this assessment was at 75.4% and that their willingness to regulate their behaviour according to the evaluation assessment content was at 82.7%, which was still a low level. This may have been related to factors such as the inertia of traditional thinking and heavy clinical workload. Therefore, the next step should be to study how to focus on nursing staff and continue to rely on the data information system to realise the management and evaluation of nursing staff, promote the overall development of medical education and research of nursing teams and discipline and, finally, improve nurses’ satisfaction and enhance nursing value.

Conclusion

In summary, this system can achieve an objective and quantitative evaluation and assessment of clinical nurses that is highly operable, and the validation results provide a management basis for the promotion and post-promotion assessment of nurses in the hierarchy.