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Received: 7 February 2020    Revised: 5 August 2020    Accepted: 7 August 2020

DOI: 10.1111/jonm.13131

ORIGINAL ARTICLE

Nursing rounds: A quality improvement project to improve

outpatient satisfaction

Qing Qiu Fan RN, BSN, Associate Professor, Head Nurse1  | Xiu Qin Feng RN, MSN,
Professor of Nursing, Vice Director2 | Jing Fen Jin RN, MHA, Professor, Director2

1
Outpatient Department, The Second
Affiliated Hospital of Zhejiang University Abstract
School of Medicine, Hangzhou, China Aim: To implement the nursing rounds to improve the quality and patient satisfaction
2
Nursing Department, The 2nd Affiliated
of the outpatient department.
Hospital of Zhejiang University School of
Medicine, Hangzhou, China Background: Patient satisfaction is one of the most critical standards for judging the
quality of hospitals. Clinical daily nursing rounds significantly increase patient satis-
Correspondence
Xiu Qin Feng, Nursing Department, The 2nd faction and influence safety.
Affiliated Hospital of Zhejiang University
Method: SQUIRE guidelines directed the execution of a quality improvement project,
School of Medicine, Hangzhou, China.
Email: fengxiuqin@zju.edu.cn which used the Driver Model to improve patient satisfaction in a Chinese outpatient
department with 15,000 visits per day (4  million/year). Patient satisfaction based
on questionnaires (1,541), pre-intervention and (1,219) post-intervention provided
increased satisfaction (p < .05).
Results: Improvements validated were satisfaction with outpatient services from pa-
tients, effective nurse–patient communications, an increase in the quality of nursing
care, doctors' satisfaction with the outpatient department operations, reduced wait
time and more efficient management, all impact safety.
Conclusions: The institution of daily nursing rounds made an overall improvement in
the operations of the outpatient department, which increased patient satisfaction,
quality of care and safety.
Implications for Nursing Management: Nursing rounds promote patient satisfaction
through assessment of operations, addressing patient and staff needs, and appropri-
ate interventions to rectify issues and reduce adverse outcomes. Patient satisfaction
impacts quality, outcomes and safety in clinical settings.

KEYWORDS

nursing rounds, patient satisfaction, quality improvement, safety, SQUIRE

1 |  BAC KG RO U N D the quality of health care, the feelings associated with diagnosis
and treatment programmes, and the reflection of patients' per-
Patient satisfaction is multidimensional based on the degree of ceptions of medical care processes (Bowling et al., 2012; Leach
consistency between the patient's experience in medical services, et al., 2013; Pouragha & Zarei, 2016). Service quality plays a primary

Author's institutional affiliation where the work was conducted: 2nd Affiliated Hospital
of Zhejiang University School of Medicine, Hangzhou, China.

J Nurs Manag. 2020;00:1–9. wileyonlinelibrary.com/journal/jonm© 2020 John Wiley & Sons Ltd     1 |
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2       FAN et al.

role in achieving patient satisfaction (Margaritis, Katharaki, & quality (Evans,  2016; Ortiz, Chandros Hull, & Colloca, 2016). The
Katharakis, 2012). In recent years, there has been a growing interest nurse–patient relationship is the core of nursing service (Wiechula
in the assessment of patient satisfaction to identify service quality. et al., 2016), and recent research indicates the importance of nurse–
According to the American College of Healthcare Executives, pa- patient interaction conducted in a wide range of primary care set-
tient satisfaction, as one of the essential points in evaluating health tings, hospital care, communities, schools and factories to name a
service outcomes, has now become a criterion for assessing the few (Bentley, Stirling, Robinson, & Minstrell, 2016; Cardona-Morrell
quality of medical institutions and hospitals (Bao, Fan, Zou, Wang, et al., 2016; Haugan, Moksnes, & Lohre, 2016). Patient satisfaction
& Xue, 2017; Pouragha & Zarei, 2016; Shirley & Sanders, 2013). and patients who engage in high-quality nurse–patient interactions
However, there is still a gap for managers to achieve goals in qual- have a greater sense of care, less anxiety and depression, and im-
ity service and patient satisfaction. WHO (2019) reports indicate prove overall health (Haugan, 2014).
that worldwide adverse service is experienced by one of 300 pa- Clinical rounds described with a variety of approaches provide
tients. The rate of adverse service in developing countries is at least evidence of converting the theory of nurse–patient interaction into
20-fold more than that in developed countries, reported as 10%. practice (Aitken, Burmeister, Clayton, Dalais, & Gardner,  2011).
OECD study reported that four of 10 patients are harmed in primary Substantial evidence exists that regular and systematic nursing
and ambulatory care settings (Auraaen, Slawomirski, & Klazinga, ). rounding has been used in some settings to provide beneficial ef-
Each year in low- and middle-income countries (LMICs), recent ev- fects, particularly in improving patient safety, service quality and the
idence implies that 134 million adverse events occur due to unsafe outcomes of patient satisfaction (Black, Clauson, & Fraser, 2013).
care in hospitals, resulting in 2.6 million deaths annually (National International studies on nursing rounds for inpatient services
Academies of Sciences, Engineering, & Medicine, 2018). in recent years have indicated increased patient satisfaction, pa-
The Chinese government has realized the importance of patient tient safety and improved clinical outcomes building patient trust;
satisfaction and increased attention to improving patient service reduced hospital-acquired conditions decreased patient anxiety as
quality and satisfaction. In 2015, the National Health and Planning a few benefits (Shin, Park & Bae, 2018; Negarandeh, Bahabadi, &
Commission and the State Administration of Traditional Chinese Mamaghani, 2014; Death, 2019).
Medicine jointly stated that the hospital should actively deepen the Based on the previous research and the well-developed concept
quality of nursing care and carry out personalized, high-quality nurs- of nurse–patient interaction, the daily clinical round programme in
ing service, especially in the departments of emergency and outpa- the outpatient department was designed using the Driver Model
tient services. Outpatient departments are the entry into the health (Goldmann, 2020) to improve outpatient service satisfaction.
system, especially in large general hospitals and health institutions,
and affect patient satisfaction directly (El-Jardali, Sheikh, Garcia,
Jamal, & Abdo, 2014). Outpatient departments are a critical area to 2 | M E TH O D
implement the health care reform policy, reflect the hospital pub-
lic welfare and optimize the service model and process. Moreover, 2.1 | Setting
tremendous changes have taken place in the outpatient department
of major general hospitals, including the outpatient workload, pa- This study took place in a 3000-bed university affiliated hospital in
tient composition and treatment needs, under the new situation of Southeastern China in the outpatient department. The outpatient
medical reform (Yao, Zhao, & Xiangping, 2013). Management of pa- department has more than 15,000 visits per day, more than four mil-
tient service quality and satisfaction is a relatively new change of de- lion visits each year in the 20-storey building with 280 clinic rooms.
mands in the public areas in this hospital with more than four million
outpatient visits per year, shared with the larger hospitals currently
in China, a significant challenge for all Chinese nursing managers of 2.2 | Study design and framework
outpatient departments.
Nursing's description and assessment of quality began long be- The study design selected the Driver Model (Goldmann, 2020) to
fore the current national interest and the formal-level emphasis on organise the project, as illustrated in Figure 1 Standards for QUality
quality improvement (Neville, DiBona, & Mahler, 2016). Previous Improvement Reporting Excellence (SQUIRE 2) method for report-
reports have indicated that nursing reaction and responsiveness ing. The Institute for Healthcare Improvement suggests the use of
were crucial factors in patients' experiences of care during the vis- a tool, a Driver diagram to visualize a team's theory of what ‘drives’
iting process and captured in most patients' satisfaction surveys the achievement of a project aim (2019). The diagram presents the
(Mitchell, Lavenberg, Trotta, & Umscheid, 2014). Moreover, nurses team's shared view of the relationship between the overall aim of the
spend more time with patients than any other health care staff. project, the primary and secondary drivers, and the change ideas for
Nurses are the primary caregivers and responders to identify the testing (2019). The tool provides for frequent monitoring and revis-
presence of patients and measure the intensity of need. The respon- ing as the project advances. The focus of the report includes the
sibility of the leadership role in the administration of outpatient ser- following questions: Why did you start? What did we do? What did
vice is to focus on the provision or enhancement of health service we find? (Ogrinc et al., 2016).
FAN et al. |
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F I G U R E 1   Key drivers for nursing round implementation project

Why did you start? member of the administration responsible for patient services, a stat-
In recent years, workplace violence towards doctors and nurses has istician and a data management specialist. The Driver Model begins with
increased steadily in China. Cook (2020) reports a survey of health care the identification of the goal of the quality improvement project.
providers reported 87% had experienced workplace violence defined
as physical or psychological, including but not limited to verbal abuse,
bullying, mobbing, pushing, biting, pinching, kicking, slapping, beating, 2.4 | Aim
stabbing or shooting (ICN, 2002). The evaluations of the outpatient
department in 2015 indicated issues of concern to the administration. The aim of this study was to improve the quality and safety of the
The significant causes of workplace violence, patient dissatisfaction outpatient department with a quality improvement project, and
and lack of safety in China are long wait times, rejection of a request, to assess how the institution of nursing rounds increases patient
dissatisfaction with the treatment process, dissatisfaction with staff satisfaction.
attitude, dissatisfaction with treatment outcome and death-related is- The research questions included the following:
sues (Cai et al., 2019). The issues that contribute to patient dissatisfac-
tion and impact the safety in the department were issues identified by • What are the performance measures in the outpatient depart-
patients on the hospital–patient satisfaction questionnaires. ment related to service delivery and satisfaction?
What did we do? • How does the institution of nursing rounds influence the degree
of clinical doctors' satisfaction with the outpatient department
service?
2.3 | Participants • What changes in wait time and nurse–patient communication re-
flect the impact of the intervention to improve patient satisfac-
Therefore, the administration decided that improvement needed to be tion and safety?
made and explored various options. The Driver Model was chosen to
guide the process. Included in the team were the director of nursing, The team evaluated pre- and post-implementation tools. The hos-
the nurse manager, the head nurses of the outpatient departments, a pital assesses the quality of patient satisfaction regularly. The patient
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4       FAN et al.

F I G U R E 2   Concept map depicting

Daily nursing nurse–patient interaction
rounds service

Nurse outpaent
interacon
Characteriscs of Health directed
outpaent health educaon
visual assessment
Expectaons from Mul dimensional
outpaent roles teachers, Outpaent
resource, leader, counselor sasfacon
Dynamic acons responses
Medical experience registraon consulng
from outpaent examinaon and
treatment guidance
Other services
Health concern triage

satisfaction assessment questionnaire was made by the Hospital communication to resolve patient concerns and needs. The ad-
Customer Service Center, according to Wei's research and the char- ministration recognized that the evaluations reflected the com-
acteristics of the study hospital (Yao et al., 2013). The total reliability munication process in the outpatient department needed to be
coefficient of the questionnaire was 0.859, and the validity analysis improved among the nurses, patients and doctors. An interactive
was 0.833. The questionnaire consisted of two parts: the first part inservice programme was done for the staff focused on improving
included eight items on patients' demographic and socioeconomic communication with patients and families. The management team
variables; and the second part divided into seven dimensions included instituted the programme in the outpatient department initially by
39 items on the quality of hospital outpatient services developed by identifying the key drivers of the project (Figure 1), planning the
the previous studies (Alfred, Ubogaya, Chen, Wint, & Worral, 2016; change strategies to be employed and specifying the tools and re-
Chen, Li, Dai, Deng, & Zhang, 2016). The tested dimensions were the sources needed.
hospital guiding facilities, the medical environment, medical staffs' Before the intervention, there was only one place on the first
service attitude, waiting time, therapeutic progress, safety quality floor of the outpatient building, where a volunteer without any
management, convenience-for-patient services and patient's overall medical knowledge was available to respond to patients' questions
satisfaction. Outpatients rated the degree of agreement with every and requests for consultation. Initial programme planning began
statement using a 6-point scale. Items were first measured by a YES in early 2016. The outpatient nursing department assumed the
or NO answer. If it was YES, then a 5-point Likert scale was used responsibility for the execution of the programme management.
with answer choices ranging from total satisfaction to total dissat- All registered nurses in the department invited to participate. The
isfaction (Aitken et al.), that is response options of 0 (incompatible), head nurse assigned a nurse to conduct the nursing rounds who
1 (very dissatisfied), 2 (dissatisfied), 3 (moderate), 4 (satisfied) and had a minimum of one year of working experience with exper-
5 (very satisfied). The designed questionnaire was distributed and tise in each specialty section of the outpatient department. The
collected by the hospital volunteers. nurse was dedicated exclusively to the nursing round service daily
from 8:00  a.m. to 4:30  p.m. The responsibilities of the nurse in
this programme were primarily to provide inspection services and
2.5 | Intervention actively supervise the facility, helping patients with impaired mo-
bility walk, mentor communication between nurses and patients,
The intervention of nursing rounds is based on a literature review clarify doctors' communications and monitor the patient flow. The
related to nursing rounds and factors impacting the quality of ser- magnitute of the department may be overwhelming to patients.
vices and patient safety. Searches for background and tools included The inclusion criteria for participation in nursing rounds were any-
EMBASE, MEDLINE, Cochrane Database of Systematic Reviews and one who visited the hospital outpatient department for medical
PLoS. advice. Registration, consulting, visual assessment, triage assist-
The daily nursing round programme used in this study was de- ing, infection prevention, maintenance of order, examination and
veloped based on King's nurse–patient interaction theory. King's treatment guidance, health education, and other needs or com-
theory focuses on the importance of effective nurse–patient plaints to be solved promptly are among the services provided by
FAN et al. |
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the nurses in the outpatient department. Nursing supervisors do explored the influence of specific demographics in overall outpatient
daily quality supervision. To more fully clarify the content of daily satisfaction.
nursing rounds, Figure 2 presents a concept map depicting nurse– To further examine the factors influencing patient satisfaction,
patient interaction (Evans, 2016). the Pearson correlation analysis assessed the internal relations
The team met monthly to review the progress of the interven- among testing items of patient satisfaction.
tion and to make subtle revisions about the development and obser- What did we find?
vations of patient and staff responses to the nursing rounds. Also,
the recent patient evaluation review determines whether there are
suggestions for strategic changes in the process and areas requiring 3 | R E S U LT S
modification.
3.1 | Demographic characteristics of the
participants
2.6 | Ethical considerations
In 2015, a total of 1,750 patient satisfaction assessment question-
The Hospital Ethics Committees' approval was obtained before the naires were distributed, in which 1,727 questionnaires were re-
onset of the study. turned, and 1,541 questionnaires were completed and considered
suitable for analysis, providing a response rate of 88.06%. The re-
sults were deemed unsatisfactory by the hospital administration and
2.7 | Data collection and analysis found the department was at risk for unsafe practices. The pressure
from the Central Government to improve patient satisfaction as a
The outcomes measured for this study included the patients' sat- prevention of the recent violence towards doctors and nurses was
isfaction, the satisfaction evaluation from the clinical doctors, the the impetus for this study. The administration decided to take ac-
patient evaluations of services rendered and their experience in the tion and seek improvement in the outpatient department services to
clinic. The Hospital Customer Service Center made the question- increase safety and reduce the risk of potential harm to patients. The
naire on Patient satisfaction assessment. nursing round programme was instituted.
A self-administered questionnaire for clinical doctors assessed During 2017, a total of 1,485 patient satisfaction assessment
nursing service satisfaction. The Hospital Quality Management questionnaires were distributed, in which 1,318 questionnaires
Office designed the questionnaire to evaluate work attitude, per- were returned, and 1,219 questionnaires were completed with
sonal appearance and behaviour, outpatient clinical environment, a response rate of 82.09%. The participants in the survey had a
work responsibility, communication skills, clinical management, mean age of 43  years (SD  = 17.27, range =  10–83). Women ac-
procedure arrangement and physician–nurse relationship. The counted for 51.78% of the participants, and men represented
total reliability coefficient of the questionnaire was 0.747, and the 48.22% of the participants. More than 70% of the participants
validity was 0.825. A pilot was conducted with 50 questionnaires. had a high school education or college. Most of the participants
Cronbach's coefficient was 0.797. (52.57%) were urban residents, half of whom were from Zhejiang
All the data on satisfaction tested results for this study were col- Province (40.51%). About 82.75% of participants considered to re-
lected and saved by the staff in the Hospital Quality Management visit the hospital, if necessary. The main reasons for choosing this
Office. The data of patients' responses are entered into EpiData hospital were medical technology, the hospital's reputation, med-
version 3.1 (Centers for Disease Control and Prevention, Atlanta, ical equipment and proper service attitude. No significant group
GA, USA), and satisfaction assessment results from doctors were differences were found in the demographic characteristics of the
entered into Excel 2017 database. participants at baseline (Table 1).
After obtaining records from the Hospital Quality Management
Office, data for this study were entered into a computerized data-
base and analysed by using Excel 2016 and SPSS 22.0 (SPSS 22.0, 3.2 | Patient satisfaction
Inc., Chicago, IL, USA) statistical software. All returned question-
naires corresponding to the data were checked by two persons to Table 2 shows the questionnaire outcomes of outpatients' satisfaction
exclude the incomplete forms. A 0.05 level of significance was ad- during the period of study from the data gathered in 2015 that initiated
opted. The demographic characteristics of patients were assessed the study until year 2017. The participants in both groups presented
by descriptive statistics and reported as numbers and frequency, significant positive changes after the initiation of the nursing round pro-
percentage, mean and standard deviations, with nonparametric gramme. The differences between the two groups regarding the satis-
tests for statistical inference. The independent-sample t test exam- faction testing items were statistically significant (p < .05). The comfort
ined the difference in satisfaction scores between pre-nursing round item about ‘Guiding facilities/Medical environment’ received the high-
groups and post-nursing round groups. Logistic regression analysis est score, with the mean score of (4.35  ±  0.70) and (4.40  ± 0.63),
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TA B L E 1   General characteristics of the sample (N = 2,760)

Pre-nursing rounds Post-nursing rounds

Total (n = 2,760) (n = 1,541) (n = 1,219)

Variables N Percentage N Percentage N Percentage X2 p

Age (years)
10~20 116 4.20% 50 3.24% 66 5.41% −0.48 .631
21~40 1385 50.18% 732 47.48% 653 53.57%
41~55 855 30.98% 505 32.77% 350 28.71%
56~65 291 10.54% 165 10.73% 126 10.32%
66~75 103 3.73% 80 5.20% 23 1.90%
Over 76 year 10 0.36% 9 0.58% 1 0.10%
Gender
Male 1331 48.22% 741 48.09% 590 48.42% 0.027 .87
Female 1429 51.78% 800 51.91% 629 51.58%
Education
Above bachelor's degree 303 10.98% 166 10.78% 137 11.24% −1.443 .149
Undergraduate 789 28.59% 446 28.97% 343 28.14%
High school 903 32.72% 490 31.77% 413 33.88%
Other 765 27.72% 439 28.48% 326 26.74%
Census register
Urban resident 1451 52.57% 813 52.78% 638 52.35% −0.289 .773
Inside province (except 1118 40.51% 625 40.54% 493 40.42%
city of Hangzhou)
Outside province 183 6.63% 101 6.55% 82 6.71%
Foreigner 8 0.29% 2 0.13% 6 0.53%
Willingness to visit again
Yes 2284 82.75% 1269 82.37% 1015 83.30% −0.218 .827
No 17 0.62% 4 0.25% 13 1.10%
Uncertain 458 16.59% 268 17.37% 190 15.60%
Reasons for choosing this hospital (multiple choice)
Hospital reputation 1608 58.26% 911 59.14% 697 57.18% −0.63 .529
Medical service attitude 913 33.08% 503 32.61% 410 33.63%
Medical equipment 974 35.29% 530 34.40% 444 36.42%
Medical technology 1668 60.43% 918 59.54% 750 61.53%
Friend’s 454 16.45% 251 16.31% 203 16.65%
recommendation
Location convenience 354 12.83% 189 12.29% 165 13.54%
Visit habit 147 5.33% 77 5.02% 70 5.74%
Transfer from other 67 2.43% 37 2.42% 30 2.46%
hospitals

respectively. The average rating of the item about ‘Overall assessment 3.3 | Assessment of satisfaction from
from outpatients’ increased from (3.20 ± 0.94) to (3.78 ± 0.82). clinical doctors
The regression test between demographic characteristics of
outpatients and outpatient satisfaction indicated that the variables The satisfaction with the nursing services from clinical doctors
of gender, education level and the reasons for visiting this hospital was also significantly improved during the period from the Patient
(hospital reputation, medical service attitude, medical equipment, Assessment that stimulated the nursing round programme. The in-
medical technology and transfer from another hospital) had a posi- terpersonal relationships in such a busy environment are a signifi-
tive impact on patient's overall satisfaction (p < .05). cant factor for confusion of information, misunderstandings about
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TA B L E 2   Comparison of outpatient satisfaction between the two groups (N = 2,760)

Variables Pre-nursing rounds Post-nursing rounds t p

Total 1,541 1,219

Guiding facilities/medical environment 4.35 ± 0.70 4.40 ± 0.63 −3.366 .001
Medical staff service attitude 4.02 ± 0.99 4.10 ± 0.70 −4.729 <.001
Waiting time 4.00 ± 0.97 4.18 ± 0.75 −11.929 <.001
Therapeutic process 4.15 ± 0.81 4.24 ± 0.66 −7.636 <.001
Convenience-for-patient service 4.09 ± 0.84 4.16 ± 0.80 −2.895 0.004
Safety quality management 3.88 ± 0.93 4.02 ± 0.70 −4.557 <.001
Total assessment from outpatients 3.20 ± 0.94 3.78 ± 0.82 −12.886 <.001

TA B L E 3   Nursing service satisfaction assessment from clinical doctors (N = 545)

Items Pre-nursing rounds Post-nursing rounds t p

Are you satisfied with the work attitude of outpatient nurses? 4.25 ± 0.68 4.50 ± 0.63 −3.676 .001
Are you satisfied with personal appearance, words and deeds in the clinic? 4.25 ± 0.86 4.44 ± 0.66 −7.596 .000
Are you satisfied with the environmental sanitation in the outpatient 4.00 ± 0.47 4.46 ± 0.80 −2.745 .004
department?
Are you satisfied with the job responsibility of the outpatient nurses? 3.92 ± 0.48 4.44 ± 0.81 −3.183 .001
Are you satisfied with the communication ability of outpatient nurses? 4.05 ± 0.95 4.34 ± 0.65 −2.467 .018
Are you satisfied with the management of outpatient nurses? 3.97 ± 0.29 4.52 ± 0.69 −5.927 .000
Are you satisfied with the nurse's arrangement of medical visit procedure? 4.00 ± 0.89 4.67 ± 0.37 −6.775 .000
Do you think the relationship between doctors and nurses is harmonious? 4.06 ± 0.52 4.13 ± 0.75 −2.098 .029
Total assessment about outpatient department nursing service 4.15 ± 0.80 4.24 ± 0.65 −2.359 .018

treatment, and other activities in the department. Table 3  presents nursing rounds found a significant impact on patient satisfaction with
the details. During the period of this study, a total of 651 question- care. However, in the United States, Halm 2016) reviewed evidenced-
naires for the doctors were distributed, in which 597 questionnaires based studies on nursing rounds and identified that patient satisfac-
were returned, and 545 questionnaires were completed and consid- tion was increased overwhelmingly. Rounding has been primarily
ered suitable for analysis. After the daily nursing round programme focused on inpatient facilities. However, the documented benefits
executed, doctors in outpatient clinical settings were more satisfied gave rise to use the concept to address the common concerns in the
with the nursing service than before, reflected in a significant inter- outpatient department of meeting patient care needs, ensuring pa-
action effect (p = .001). tient safety, decreasing the occurrence of patient preventable events
and proactively addressing problems before they occur.
The team determined to use nursing rounds to alleviate the
4 | D I S CU S S I O N low patient satisfaction rating, which required restructuring how
the nurses functioned in the clinic. The King theory of goal attain-
Patient satisfaction is paramount to patient safety. Studies in many ment combined with the implementation of the goals of the Driver
countries have focused on patient satisfaction, safety and outcomes Model facilitated the implementation of this programme. Also, the
of treatment. In Sweden, Arnetz and Arnetz (2001) reported that physicians' input was needed as they were also dissatisfied with the
nursing care is negatively affected by nurses who have experienced nurses. Unfortunately, the questionnaires were not given to them
violence in the workplace. The increases in workplace violence in for a pre-assessment level. The questionnaires were given after the
China in recent years have made many nurses fear injury if patients project was operational for a year. The outcome indicated many pos-
are not satisfied. The reasons cited for the stimulation of violence, itive comments about the operations of the outpatient department.
long wait times, dissatisfaction with treatment and poor communica- The outcomes of care are affected by several factors. The most
tion by doctors and nurses were all factors that could be improved dominant, according to a study done in Switzerland, indicated staff-
with nursing interventions focused on communication and improved ing ratio is critical. This study did not address the staffing but may be
interpersonal relationships. Nursing rounds have evolved through the influenced by the shortages of nursing staff in the unit, prohibiting
years. In Australia, Lyons et al. (2014) raised the question, is it going time allocation for effective communication with patients. Patient
too far to return to doing them. Negarandeh, Hooshmand Bahabadi, satisfaction, according to Kennedy, Tevis, and Kent (2014), indicates
and Aliheydari Mamaghani (2014) in Iran in an inpatient study on a correlation with low mortality and good outcomes. Nurses have
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8       FAN et al.

the opportunity in the outpatient department to make sure patients AC K N OW L E D G E M E N T S

understand the doctors' orders, which will impact the successful Our sincere appreciation goes to all nurses in the outpatient depart-
resolution of the medical issue. The communication skills of nurses ment in this programme, all volunteers for their most exceptional
enhance the clarification for patients of what the doctor has said patience and all the participating outpatients for their cooperation.
concerning diagnosis and instructions for follow-up. Sincere appreciation goes to Zhang Yi Jin for her guidance and edit-
ing of the final manuscript and encouragement.

4.1 | Limitations C O N FL I C T O F I N T E R E S T
None of the authors have any conflict of interest to declare.
The limitations of the design of the study include the setting as
only conducted in one outpatient department in a Chinese medical AU T H O R C O N T R I B U T I O N S
centre. The correlations between study variables and outcomes at- All authors participated in designing the study, planning the inter-
tained from questionnaires do not demonstrate causality, nor is the vention, interpreting the data, and writing and critically reviewing
data comprehensive. The significant differences may not reflect of the paper. FQQ wrote the first draft of the report. FQQ, FXQ and
the entire status of outpatients' satisfaction with the nursing ser- JJF did the analyses.
vice post-programme implementation. Other factors may explain
outpatient satisfaction. Therefore, a more comprehensive survey, E T H I C A L A P P R OVA L
including patients of diverse backgrounds and more items for test- The Hospital Ethics Committees' approval, according to the hospital
ing the impact factors on patient satisfaction, is recommended. guidelines, was obtained before the onset of the study. Therefore,
the current study approval was by the Research and Ethical
Committee of the Second Affiliated Hospital of Zhejiang University,
5 |  CO N C LU S I O N School of Medicine. The approval record number is the 2017 ethics
review research #087.
The study improves patient satisfaction and promotes quality and
safety in the outpatient department by instituting daily nursing ORCID
rounds. The results provide evidence that the programme has a posi- Qing Qiu Fan  https://orcid.org/0000-0002-6833-4109
tive impact regarding outpatient management and nursing service, a Jing Fen Jin  https://orcid.org/0000-0001-7671-3590
significant function in improving the doctors' satisfaction with out-
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