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Improving the performance appraisal system for nurses

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The aim of this project was to explore appraisal systems in my place of work, identifying the importance of the appraisee and appraiser role within the process to promote a positive and effective system.

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”

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Redshaw, G. (2008) Improving the performance appraisal system for nurses. This is an extended version of the article published in Nursing Times; 104: 18, 30–31.
This article describes a project in one organisation that aimed to improve the appraisal system for nurses. Evidence suggests appraisals have been poorly implemented in some organisations. Questionnaires were completed by eight nurses, who expressed mostly negative attitudes towards appraisals. The article outlines improvements put in place as a result of the analysis, and details plans for the future.

Graeme Redshaw, RGN, Dip HE, RMA, Cert Man, FETC, is nurse manager, Risedale at Lonsdale Nursing Home, Risedale Estates, Cumbria.


Appraisal is a contentious issue. The aim of this project was to explore appraisal systems in my place of work, identifying the importance of the appraisee and appraiser role within the process to promote a positive and effective system. Questionnaires and summaries were completed by nurses in the organisation to gather views on the current process. It was intended to highlight staff perceptions of the appraisal system and help develop an updated system.

Few topics have caused more dissatisfaction within organisations than the appraisal scheme. Appraisal has become an emotive word, partly due to poor implementation and partly because much of the public sector has had to adopt appraisals as government policy.

Fletcher (2004) suggested that, as a result of negative feelings surrounding appraisals, many organisations have attempted to rename them and have shown ingenuity in thinking up alternative titles for much the same process, such as ‘performance reviews’ or ‘work planning and review’. These changes have aimed to stress the more innovative aspects of appraisal and to minimise the retrospective assessment element.

A general observation, highlighted by Cleveland and Murphy (1992), is that managers often allow the appraisal process to be influenced by non-performance issues. Evidence within organisations supports this, and Cleveland and Murphy (1992) suggested that arriving at an objective and accurate assessment of performance is usually not the appraiser’s highest priority.

Duffin (2006) suggested that in healthcare appraisal systems are inadequately implemented, with only six out of 10 NHS staff in England ever receiving an appraisal or personal development review. However, government guidelines advocate that all nurses have the right to management support in care delivery (Department of Health, 1993). This guidance suggests that regular staff appraisal can benefit both nurses and managers.

Support for staff - including performance review - can raise standards in the workplace. However, the quest for better performance has not always been accompanied by a better system of appraisal. The most important process for improved performance is not to set goals and order staff to achieve them, but to improve relationships in which they are highly valued and have a sense of belonging (DH, 1993).

The DH further suggested that people’s needs and capacities are different. It is accepted that, beyond certain levels, asking more of people without providing support, guidance and reward can be counterproductive; and it is only through valuing the contribution of every staff member and producing a framework of continual development that targets can be set and achieved. The DH statement supported Maslow’s (1943) ‘hierarchy of needs’ pyramid, in which a person cannot proceed and develop without being valued and supported.

Although this aspect of improving performance through support and appraisal is widely recognised, a different, more cynical view is that appraisals have been implemented to streamline staffing, increase efficiency and cut costs. Anecdotal evidence also suggests that appraisals can support organisations in litigation and at industrial tribunals.

This reinforces the idea that the content of appraisal should not surprise employees, and that annual evaluation should be preceded by ongoing informal or formal reviews throughout the year. Staff should always have the opportunity to improve weaknesses before the annual appraisal or be totally aware of issues if dismissal is to be considered as a result of poor performance. However, it is widely accepted that an annual appraisal should not be used as an opportunity to discipline staff.

Staff roles in appraisal
A good understanding of the role of the appraiser and appraisee is vital in the process of satisfactory appraisals.

A daunting challenge for any healthcare manager is to have a personality conflict with an employee and then maintain objectivity in appraising that person’s performance. This suggests that conducting effective appraisals is one of the most important staff relations challenges facing healthcare managers.

Fletcher (2004) strongly advocated the promotion of manager/employee dialogue as one of the aims of an effective appraisal. This text also suggested that, without positive dialogue, a formal structure used for two parties to discuss performance will establish a negative basis and result in negative outcomes.

Healthcare managers’ increasing responsibilities may make communication demands greater or more complex. This could cause conflicts and communication breakdowns with employees to become more likely. Such conflicts will have negative effects and staff will have difficulty accepting criticism and feedback, possibly creating a downward spiral of performance, with wider impact on company performance. This is especially relevant in team-based work in which an informal leader can trigger negative support from colleagues.

Healthcare professionals need to acknowledge the difficulties of implementing an appraisal system, including the lack of guidelines on skills and knowledge required or the processes that can lead to helpful outcomes. Research by Walker and Jones (2004) constructed a support tool to highlight the main points of a successful appraisal. Integral parts of the process include: preparation; ensuring support from line managers; and a good understanding of the procedure, each other’s job descriptions and related competencies. In addition, they strongly recommended training before undertaking appraisal interviews.

Walker and Jones’ (2004) guidance also stated that it is essential to be aware of each other’s competencies and feelings. The appraisal process should involve challenging assertions, seeking clarification and offering feedback, with a risk that the outcomes will result in conflict.

The appraiser needs to be sufficiently autonomous to commit the necessary time to the appraisal and to have control over their diary. This suggests that inconsistent time-keeping, cancelling appraisals due to other commitments or not recognising the importance of prioritising the scheduled appraisal could have a negative effect on the process.

Evaluating appraisal

Overall, evidence suggests appraisal systems are poorly implemented, and there is a lack of knowledge and experience around them.

Consequently, a small study was carried out in the form of a questionnaire to assess the process within the organisation, involving staff for whom I am directly responsible as line manager. The questionnaire’s aim was to identify staff perception, understanding and experiences of appraisals. This method was chosen because staff might feel uncomfortable in an interview should they want to make negative comments about an already accepted procedure.

The nurses were randomly selected with a mixture of age, nursing experience and supervisory experience. Ten staff nurses received the questionnaire. Names were not disclosed to ensure confidentiality (NMC, 2008). Eight staff returned the questionnaires.

The results were meaningful and consistencies in criticisms were evident throughout.


Feelings before the appraisal
Seven staff nurses were nervous and some said they dreaded the appraisal appointment because of fear of criticism and being informed of poor performance. One staff member looked forward to the appraisal.

I would suggest that employees should prepare for an appraisal in a positive manner and use the opportunity to discuss career opportunities, salary increases and professional growth.

Previous experience of appraisal will have a great bearing on preparation and approach; therefore negativity will influence the system. The seven nurses who expressed nervousness had all previously thought their appraisals were poorly delivered or had negative outcomes. Four had been appraised by the same manager and emphasis was placed on the manager’s performance. The nurse who was positive had an excellent previous review with reward benefits.

Appraisal literature suggests that not all managers are efficient at recognising high potential and positive performance and concentrate more on the organisation itself, tailoring personal development to meet those needs instead of the individual’s needs. Therefore staff who do not fully fit into the organisation’s mould or philosophy could be viewed as underperformers, and often have feelings of resentment and alienation.

All eight nurses were uncomfortable writing about themselves in the pre-appraisal questionnaire. Traditionally, employees have been encouraged to reflect on their own performance for 2-3 weeks before the appraisal interview, and this self-assessment has then formed the basis for discussion.

A review of the literature on previous organisational surveys has shown that employees invariably consider themselves to be better than average. This then poses a problem for the appraiser who has to inform staff that the self-assessment is too positive, which almost certainly creates a negative relationship.

To prevent conflict and interpersonal difficulties, appraisers tend to agree with the appraisee to the detriment of the process. Taylor (1998) suggested that a badly conducted appraisal is worse than no appraisal at all in terms of its adverse effect on motivation, job satisfaction, commitment and trust between managers and employees.

All eight nurses agreed with feedback and were satisfied with the outcomes at the appraisal. However, they felt disillusioned that feedback and action plans were never revisited and completed, and the result carried forward to the next appraisal.

This suggests feedback is one of the most vital parts of the appraisal system, since any person who receives positive feedback can be motivated to continue or improve performance to meet organisational requirements. Negative feedback must be accompanied by advice on how to remedy or improve performance.

Setting aside time for the appraisal interview and then planning time for reviews and further feedback is paramount in maintaining motivation and enhanced performance. It is important that planned reviews are adhered to, as failure to attend or cancelling the appointment will demotivate staff.

Cancelling appointments
Four out of the eight nurses had experienced at least one cancelled appointment due to either their own or their manager’s other work commitments. This led to feelings that both the appraisal system and the appraisee personally lacked importance. However, they also expressed relief that the appointment was cancelled.

Managers and employees need to be clear about the purpose of appraisal and how to measure success or failure. For any appraisal to be worth the time and cost, all levels and grades of staff must feel they have a valuable contribution to make in developing their organisation’s strategy and ensuring achievement.

Failure to adhere to the time designated devalues the importance and reduces commitment to the appraisal system. Although executives block out large sections of their diaries to ensure attendance, all too often the appraisal is the first appointment to be cancelled when other needs arise.

Motivation to improve
Due to the negative nature of seven of the eight nurses’ previous appraisals, motivation and improved performance were not achieved directly.

The threat of disciplinary procedures due to inadequate standards of practice could have been a possible factor in motivating two to improve, as their performance was being managed. However, each acknowledged the extensive support offered, and felt that this was the true factor in their motivation to improve.

Five nurses suggested they continued at the same level. One was extremely motivated and ensured performance standards were maintained because of the rewards gained, recognition and potential for promotion.

Overall view
All eight staff completed the necessary documentation and had undergone an appraisal review. None had seriously given much thought to the process, accepting it as part of the organisation’s system. However, they all acknowledged some areas could be improved significantly to meet their development needs.

Improving appraisals

The questionnaire and summary proved extremely informative. Taking into account experience, suggestions and current evidence, an improved appraisal system is clearly required to replace the existing one.

The most fundamental question facing those setting up appraisals is: ‘What is the aim of the exercise to be?’ (Fletcher, 2004). The organisation in which I work already has an aim in its appraisal system; it is to promote equality and support staff to perform and achieve their full potential within the organisational framework. Anecdotal evidence suggests, however, that the original appraisal system was not implemented for this reason and was constructed in 1986 as part of a management qualification of one of the senior managers.

Fletcher (2004) acknowledged that appraisals were not given any credibility until the 1990s. Therefore, in one aspect, the organisation was indirectly adopting a pioneering concept. However, appraisals and performance reviews have been implemented since the 1950s with content as discriminatory as assessing personal traits and moral courage.

To implement an appraisal system that will be successfully embraced by all users, it must have clear aims and objectives, be able to be implemented fairly and have relatively simple documentation. One of the main issues in my organisation’s appraisal is the lack of guidance for managers and nurses on how to undertake and complete appraisals. Initial guidance produced for their introduction in 1986 remains the only advice available. It has not been reviewed or updated since then.

It is essential that nurses complete a pre-appraisal questionnaire to demonstrate self-awareness and to establish a basis for communication. However, as previously mentioned, appraisees overestimating their abilities can result in a negative atmosphere when actual abilities or managers’ beliefs differ. Consequently, the existing pre-appraisal questionnaire has been altered to lead to open dialogue during the appraisal.

A further significant adjustment is the recognition of structured feedback and action planning with follow-up throughout the year. Some managers in the organisation have not followed up set targets and not ensured that action plans are completed, leading to inconsistencies and a devaluing of the process and aims. We are introducing an additional document to ensure these become integral to the process. This once again suggests that feedback is a vital part of the appraisal process, fundamental to achieving outcomes and assessing performance.

Training for managers
It is apparent that to have efficient staff who feel respected and valued, managers must reward current work and give constructive criticism carefully to promote performance improvement. Failure to deliver an appraisal in this manner can deplete enthusiasm and commitment. Managers must be aware of employees’ abilities and have the knowledge and skills to adapt to situations. Staff training is a vital component as not all managers will have qualifications or experience in human resource management.

There is an increasing recognition in the organisation that training and support for appraisers is inadequate. This includes managers undertaking trained nurse appraisals, and trained nurses and shift leaders carrying out healthcare assistant supervisions and appraisals.

To validate the required training, a recognised external body has been appointed to deliver accredited training for appraisers. All appraisers must undertake at least two days of training before performing appraisals. In this manner, the theory and application of the appraisal process can be clearly understood and recognised methodologies applied within the company.

The accreditation of this training further acknowledges the value of the appraisal cycle within the organisation. It will become an integral part of an internal degree pathway for all registered nurses. In addition, all new registered nurses and shift leaders will undertake the two-day training before undertaking appraisals. This training is a significant financial commitment for the organisation.

The development of an open, participative, learning environment is part of the company’s development ethos. A review of the appraisal system is now viewed as an integral part of this development.

Support from all levels of management is required to ensure consistency between staff and managers. To change employees’ attitudes it is necessary to inform them of the benefits and the importance of appraisals. This message must be delivered and relevant structures adopted to achieve changed attitudes and acceptance. It is very clear from both internal and external research that employees at all levels need praise, guidance and supervision to support them in their role to both develop performance and enhance personal achievement.

The revised appraisal system, whereby appraisers have received appropriate training before undertaking the process, should now be an integral part of the organisation’s culture and not simply a tick-box exercise.

Implications for practice

Organisations should consider the following points to improve the appraisal system:

  • Existing practice and systems should be reviewed to ensure up-to-date practice and awareness of government guidelines;
  • The appraisal process should be carried out in a non-judgemental, unbiased manner to ensure positive delivery and increase staff motivation;
  • Consistent appraising and feedback is required to allow staff to prepare and accept appraisals as a support tool and not a paper exercise;
  • The timing of appraisals and their content must be conducive to development and not used as an opportunity to discipline a staff member;
  • In order to complete a satisfactory appraisal, a structured system must be used. The result should leave the appraiser and appraisee clear about the aims, plans and future development objectives, with specific dates for reviews set and adhered to.


In summary the organisation had an open, participative environment of which personal development was viewed as an integral part. However, the appraisal process was an outdated paper exercise with negative connotations for most staff involved.

Literature indicates that appraisals have often been completed in a haphazard way with poor feedback on performance. This view was reflected in the organisation, as the appraisal form was filed following interviews and not reviewed or subject to further feedback.

The external, accredited appraisal training has focused awareness on the importance of regular review and feedback, to ensure motivation and personal development.

The use of appraisal to support personal and organisational development is now becoming established in the company, and the revision of appraisal records will assist with these improvements.

It is extremely important that this impetus is not lost and the use of continuing appraisal training will assist with this goal.

In addition, two senior managers will become responsible for managing and reviewing the appraisal tracking and ensuring that all new staff receive appropriate training. A small appraisal subgroup will be formed to ensure documentation and systems are regularly reviewed and updated, maintaining appraisal as an important part of working life in the organisation.

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