https://nmsjournal.kaums.ac.

ir/
Nursing and Midwifery Studies. 2023; 12(3): 142-150
https://doi.org/10.48307/nms.2023.406538.1225

Research Article Open Access

The effect of intentional nurse rounding and nurse prompt response

time to Call system on patient satisfaction, patient complaints, and
patient clinical outcome: An Audit trial
Hussam Al-Nusair 1
, Rafi Alnjadat 2 *
, Doreen Macherera Mukona 1
, Mariezl Fonbuena 2
, Saleem
Perinchery 2
1
Fatima College of Health Sciences, UAE
2
Al-Balqa Applied University, Jordan

* Corresponding author: Rafi Alnjadat, Assistant Professor, Al-Balqa Applied University, Jordan. Email: Rafi.alnjadat@bau.edu.jo

Received: 27 April 2023 Revised: 24 July 2023 Accepted: 5 August 2023 e-Published: 22 September 2023

Abstract
Background: Improving patient satisfaction and safety is a critical goal for hospitals around the world. Healthcare providers have
increasingly recognized the importance of strategic initiatives and the impact they have on patient outcomes.
Objectives: This study examines the effect of intentional nurse rounding and the call system's response times on patient satisfaction,
patient complaints, falls, and hospital-acquired pressure injuries (HAPI).
Methods: This descriptive study was conducted between December 2017 to August 2018 in a hospital in the United Arab Emirates. The
Intentional Nurse Rounding (INR) and Prompt Response to Call System (PRTCS) were introduced in December 2017. It comprised of:
(1) hourly nurses’ rounds between 07:00 hours to 23:59 hours and 2 hourly rounds between 24:00 hours to 06:59 hours daily, (2)
measurement of nurses’ response time to call bells, (3) leadership rounds to assess patient satisfaction. The outcomes were patient
satisfaction, patient complaints, fall rates, and HAPI rates. Baseline data were collected through retrospective reviews of the data on these
outcomes in December 2017. The second period of data collection was conducted over eight months after the initiation of the system,
from December 2017 to August 2018. The Chi-square test was used to detect significant differences in outcomes pre and post intervention.
Results: The overall adherence to the “Intentional Nurse Rounding and Prompt Response Time to Call System” was 91% while the overall
patient satisfaction rate was 97% in August 2018. The average response to call time was 1.2 minutes. Patient complaints decreased from
0.75/month to 0.125/month between December 2017 to August 2018. During the same period, the rates of patient falls and HAPI
decreased from 1.17/month to 0.38/month and 0.35/month to 0.24/month respectively. Though the observed differences were not
statistically significant, there was a promising difference in patient complaints pre and post intervention (P=0.08).
Conclusion: Integrating nursing-led strategic initiatives such as intentional nurse rounding and reduced response time to the call bell
system can positively impact patient satisfaction, complaints, and clinical outcome.

Keywords: Nurse rounding, Patient satisfaction, Call bell system, Fall, Hospital-acquired pressure injury.

Introduction desired health outcomes and this has been the top priority
Quality care, patient safety, and patient satisfaction are in the healthcare sector of the Abu Dhabi Government in
very important concepts to uphold for healthcare the United Arab Emirates (UAE).[2]
organizations. According to the World Health Consequently, there has been a continuous drive to
Organization (WHO), a considerable focus on the quality develop innovative strategies that foster the delivery of safe
of health services to improve healthcare delivery is still and high-quality nursing care because nurses have a very
required.[1] important role in maintaining patient safety and offering
This involves providing effective, safe, and people- quality care.[3]
centered care that is timely, equitable, integrated, and Patient falls in healthcare facilities are common and can
efficient. Quality healthcare increases the likelihood of result in serious injuries. It is considered one of the global
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 The effect of intentional nurse rounding and nurse prompt…

burdens of disease and injuries in 204 countries and on patient satisfaction, patient complaints, patient fall
territories according to the Global Burden of Disease Study rates, and HAPI in an acute care hospital in the Northern
in 2019.[4] Emirates.
One of the studies in UAE considered fall as the second
cause of trauma deaths from vehicular accident.[5] Methods
However, falls can be prevented by identifying patients at Study design and participants
risk of falls, implementing fall prevention strategies, and This utilized surveillance of staff nurses on inpatient
educating patients and their families on fall prevention.[6,7] units in a 132-bed acute care hospital in UAE to assess
Hospital-acquired pressure injuries (HAPIs) are also a response times to the call bell and adherence to the nurse
major healthcare issue affecting patients of all ages, and rounding system. The project was initiated and monitored
can lead to significant morbidity and mortality. HAPIs are for eight months in the Medical-surgical ward (MSW),
defined as localized damage to the skin and/or underlying Pediatric, and Maternity departments of an acute care
soft tissue usually over a bony prominence or related to a hospital in the UAE from January 2018 to August 2018.
medical or other device. HAPIs are largely preventable These units are manned by 310 nurses (registered nurses,
through the implementation of evidence-based prevention Charge Nurses, Senior Charge Nurse (SCN) and porters.
strategies.[8]
Intentional Nurse Rounding (INR) and Prompt Audit interventions
Response Time to Call System (PRTCS) are two innovative The project comprised several activities. A series of
approaches that have been shown to promote patient briefings and education were conducted by the SCN
satisfaction and reduce the incidence of HAPIs and falls. during unit meetings, nurse handovers, and safety huddles
INR involves a systematic approach to patient care that to increase the staff's awareness of the project and its
includes regular check-ins by nursing staff at specified purpose [Table 1]. Patients in admission were also
intervals to assess patient needs, provide comfort oriented by the nurses on the concept and its purpose
measures, and address any concerns. PRTCS is a system [Table 1]. The adherence of nurses to the rounding system
that facilitates prompt response to patient call bells, was monitored through leadership rounds and monthly
reducing the risk of falls and injuries. INR has been shown through regular audits. Feedback on trends in
to improve patient satisfaction and reduce the incidence of performance and outcomes was also published monthly
pressure injuries. A study by Spano-Szekely et al.,[9] found on bulletin boards. These data were presented to all
that INR led to a significant reduction in the incidence of managers and nursing staff during the quarterly quality
hospital-acquired pressure injuries in a medical-surgical council meetings.
unit. Similarly, a study by Brosey and March[10] found that
INR was associated with higher patient satisfaction scores. Data collection
PRTCS has also been shown to have a positive impact on Data were collected in phases as outlined below:
patient safety. Retrospective record review
A study by Daniels[11] found that hourly rounding, The baseline data were collected through a retrospective
combined with a prompt response to call bell system, led review of data on call bell response time, patient
to a significant reduction in the incidence of falls and call satisfaction, fall incidents, and HAPI incidence before the
light use. intervention period from January 2017 to December 2017.
In addition, PRTCS has been associated with improved The data on call bells were retrieved from a computerized
patient satisfaction scores. system, that records the number of calls, response times as
While there has been research on the effectiveness of fall well as the percentage of calls, attended to within 3
prevention strategies or programs, there is a need for more minutes. Baseline patient satisfaction scores on surveys as
research on the long-term sustainability of these well as the number of patient complaints were taken from
programs,[12] and more research on the cost-effectiveness Patient Services Office (PSO) every month. Monthly data
and the use of technology systems to prevent hospital- on incident rates of falls and HAPI are routinely submitted
acquired pressure injuries.[13,14] to the quality management department where they are
routinely reviewed by the Quality Management and
Objectives Wound Care Specialists for accuracy and appropriateness
This study examined the effect of intentional nurse of actions taken. The monthly incidence rate of HAPI is
rounding and nurse prompt response time to call system measured by dividing the total number of HAPI reported

Nurs Midwifery Stud. 2023;12(3):142-150 | 143

Al Nusair et al

within a month by the total number of patient days of the applies to the incidence rate of falls. Results of the HAPI
same month, then multiplying it by a thousand to get the and Fall incidence rates are coming from Quality
HAPI rate per thousand patient days. The calculation Department.

Table 1. Education sessions

Area Participants No. of Timing Title Contents
educations
Education sessions for staff
Medical surgical 37 staff nurses 4 During - International nurse - Rounding guide
ward 1 senior charge nurse handover rounding - Rounding form
Pediatric 14 staff nurses 2 (07:00 – 07:30) - Patient response time to - Responsibilities
1 senior charge nurse (19:00 -19:30) call system - Monitoring of
Maternity 37 staff nurses 4 - Leadership rounding compliance
1 senior charge nurse
Orientation sessions for patients
Medical surgical Patients admitted Once during Anytime - International nurse - Concept
ward during study period admission rounding - Purpose
- Patient response time to - Call System
Pediatric call system
Maternity - Patient satisfaction survey
form

Intentional nurse rounding for the month, the response times, and the percentage of
The assigned nurses on duty were expected to do an response times that are within the recommended 3
hourly rounding for every assigned patient regularly. minutes.
Rounding is done hourly between 07:00 hours and 23:59
hours and 2 hourlies between 24:00 hours and 06:59 hours Leadership rounds
daily in attending their patient’s needs. Using a Leadership rounds involved SCN doing visits for 2 main
standardized form which is posted in the patient’s room, categories of patients: (1) new admissions, and (2) the
the nurses logs the patient’s needs attended, documents, existing patients. They do twice weekly rounds using a
and sign on the form during each round. The needs monkey survey in a tablet to assess, follow up, and address
attended included bathroom needs, diaper changes, other patient needs and concerns. They checked, among
repositioning, transfer and mobility, pain or discomfort, other concerns, if intentional rounding was being adhered
and the patient's safety through a quick environment to by staff nurses, if patients were involved in their plan of
survey. Patients were oriented about the rounding care, if medications were given timeously, and if the pain
program during admission to ensure their full was adequately being managed. Adherence of the SCN to
participation and understanding. Staff compliance is these leadership rounds was monitored through the data
monitored through the completed form by an audit received from the monkey survey, data is gathered and
nursing team on a monthly basis. summarized by a designated person in the Nursing Quality
and reported as monthly Key Performance Indicators
Call bell system (KPIs) of the units.
The call bell system refers to the call light that the patient
uses in their room to call nurses' attention. The nurses are Outcome variables
expected to attend to every activation of the call bell system Patient satisfaction
within 3 minutes. A computerized system automatically A patient survey form in English and Arabic version is
records the response time, which is the time from which used to gather patient/family satisfaction which is given to
the call bell is rung to the time it is put off when the nurse all patients during their hospital stay or visit. It is a 24 items
attends to the patient. At the end of each month, the data survey questions in 11 dimensions of nurse’s care, doctors
is analyzed and reported by a designated person in the care, responsiveness of hospital staff, discharge
nursing department in terms of the total number of calls information, environment, treated with respect and

144 | Nurs Midwifery Stud. 2023;12(3):142-150

 The effect of intentional nurse rounding and nurse prompt…

dignity, allied health care, waiting time, dietary, Ethical considerations

communication about treatment, and overall hospital The Human Research and Ethics Committee of Al-Balqa
rating. Items are scored on a five-point rating scale from 4 Applied University gave their approval for this project
“Always”, 3 “Usually”, 2 “Sometimes”, 1 “Never”, and 0 number (244/2/3/6/33). Each participant in the study and
“Not at All” and the total score is 0-96, with scores more research facilitator was informed of its goals and
than 80 shows high satisfaction. This is being collected by methodology. Data collection was private. Except for a
the (Patient Services Office) PSO on a monthly basis from code that the research team devised, the questionnaire had
the suggestion dropbox. Additional source of patient no markings, names, or addresses. No participant was
feedback is through the Nurse leadership rounds under any duress to participate in this study; they were all
conducted by SCN/designee/Unit Head of the department. given the assurance that they could stop at any time and
were under no obligation to answer any questions they did
Patient complaints not choose to. The consent form also made it clear that
Patient’s complaint is gathered through personal, email, participation in the study had no additional risks beyond
or phone, and it is documented in the complaint reporting those associated with normal life.
form. Monthly reports of data related to patients’
complaints are shared with the relevant stakeholders for Results
their management. Figure 1 presents a summary of the calls as recorded by
The data is reviewed by the Patient Experience the computerized system. There was a total of 48605 calls
Committee where the primary focus is on improving received during January 2018 and August 2018, 45340
patient care, patient outcomes and the patient experience (93%) of which, were responded to within 3 minutes.
Figure 2 shows the results of adherence to the rounding
The incidence of falls system, patient satisfaction, and patient complaints from
The incidence of fall is measured through the incident 2017 to 2018. The average rate for patient complaints was
reports submitted by concerned departments to the quality 0.75/month in 2017 and had decreased by 83% to
department. The incidence is logged by the quality team 0.125/month in 2018. The overall rate for patient
after careful review and validation of the concerned satisfaction increased from 94% in December 2017 to 97%
departments into an excel format with the specific details in August 2018, while the average adherence to the hourly
to the fall incidence. Monitoring is done on a monthly rounding program was 91%.
basis. Table 2 shows that 22.2 % of pre-intervention group had
complaint while 9.3 % only from the post intervention
The incidence of HAPI group.
Likewise, with HAPI, thru incidence reports submitted to Figure 3 shows the relationship between the average calls
quality and it is routinely reviewed by the quality per patient per day and the call bell response time. Call
management and wound care specialists for accuracy and bells were reduced to 8.4%, and the average response time
appropriateness of actions taken. was 1.2 minutes.
Figure 4 shows the average monthly incidence of falls
Data analysis from December 2017 to August 2018. The incidence in
Data analysis was done using Microsoft excel and December 2017 was 1.17, and it decreased by 68% to 0.38
descriptive statistics were used. Chi square test was used to in August 2018.
establish the relationships between the interventions (INR Table 3 shows that 22.2% of pre-intervention group had
and PRTCS) and the outcome variables. The number of falls while 13.3% only from the post intervention group.
calls was reported as totals, frequencies, and percentages. Figure 5 shows the incidence of hospital-acquired
Data on falls and HAPI were reported as incidence rates pressure injuries from December 2017 to August 2018.
while patient satisfaction was reported as rates. The incidence was 0.35/month in December 2017, and
Compliance with the intentional rounding system was decreased by 31% to 0.24/month in August 2018.
reported as a percentage. P values less than 0.05 were Table 4 shows that 7.4% of pre-intervention group had
considered significant. HAPI while 1.3% only from the post-intervention group.

Nurs Midwifery Stud. 2023;12(3):142-150 | 145

Al Nusair et al

Table 2. Differences between Intentional nurse rounding and prompt response to call system and the Patient Complaints
Variable Patient complain n (%) X2 (df) P value
Group Yes No
Pre-intervention 6 (22.2) 21 (77.8) 2.966 (1) 0.085
Post-intervention 7 (9.3) 68 (90.7)

Table 3. Differences between INR and PRTCS and the Patient Fall
Variable Patient falls n (%) X2 (df) P value
Group Yes No
Pre-intervention 6 (22.2) 21 (77.8) 1.186 (1) 0.276
Post-intervention 10 (13.3) 65 (86.7)

Table 4. Differences between INR and PRTCS and the HAPI

Variable HAPI n(%) X2 (df) P value
Group Yes No
Pre-intervention 2 (7.4) 25 (92.6) 2.566 (1) 0.109
Post-intervention 1 (1.3) 74 (98.7)

Figure 1. Number of total calls and response time

Figure 2. The effect of intentional nurse rounding on patient satisfaction rate and patient complaints
146 | Nurs Midwifery Stud. 2023;12(3):142-150
 The effect of intentional nurse rounding and nurse prompt…

Figure 3. Average calls, patient, day vs. average call bell response time

Figure 4. Average incidence of fall pre and post intervention

Figure 5. Incidence of hospital acquired pressure injury

Nurs Midwifery Stud. 2023;12(3):142-150 | 147

Al Nusair et al

Discussion Patient falls remain to be a collective adverse event in

Patient satisfaction increased after the implementation of acute care facilities. However, several studies prove that
the system, while complaints, falls, and HAPI rates nurse rounding improves fall rates.[11,19] A study in an adult
decreased; however, it was not statistically significant. Call medical unit found a 10% reduction in call bell use and
response times also decreased to consistently under 1.5 inpatient falls when the staff asked specific questions to the
minutes and 93% of them were attended within 3 minutes. patient about comfort and their basic needs.[20] Another
Several factors could have been responsible for the study found moderate-strength evidence that hourly
generally positive outcomes in our study. This prompt and rounding programs improve patients' perception of
alert response to call bells might as well explain reduced nursing responsiveness, reduce patient falls, and call light
patient complaints and increased patient satisfaction. use.[17] However, the study of Brown et al. found no
Another possible enabler could have been enhanced by the significant difference in patient falls with the
physical layout of the inpatient care areas in the hospital. implementation of hourly rounding.[21] Likewise, no
With three proximal nursing stations within the impact on fall rates but exhibit improvement in the patient
departments, nurses are well-spread and are always near satisfaction score was noted in the study by Nelson and
patient rooms. This enables them to respond promptly to Staffileno.[22] The decrease in hospital fall rates (68%) of the
call bells. In support of this finding, Varghese and Punjotre present study may be attributed to the high adherence rate
pointed hospital infrastructure as an enabler of prompt to nursing rounding and the call bell system. Regarding the
response to call bells with 94.88% of call bells in their study impact of nurse rounding on staff engagement, the
being responded to within a minute and fewer call bells literature suggests that staff education and engagement are
due to nurse rounding.[15] essential in promoting their level of engagement.[23]
The high adherence rate of 91% to the nurse rounding Leaders who implement employee engagement strategies
system by staff nurses might also have resulted in the are noted to have higher employee engagement,[24]
observations made onpatient complaints, satisfaction, improved customer satisfaction, productivity, and
falls, and HAPI rates. The effect of the nurse rounding was profit.[25] In the current study, all staff was briefed and
found not only significant for patients but also for staff. educated before the initiation of the program, which may
The 8.4% reduction in call bells also led to reductions in have contributed to the increase in adherence of the staff
miles walked by nurses while on duty. This is particularly in the nurse rounding and call bell systems.
important for nurses as it also has benefits for their Furthermore, discussing with the staff to keep them
physical health. This will prevent fatigue, and low back aware of their performance during meetings might have
pain and increase the productivity of the workforce. This contributed to the increase in their adherence to the hourly
also promotes efficient use of time as nurses tend to attend rounding and prompt response to call bells. Posting the
to patients’ needs during the hourly rounds rather than data such as falls, pressure ulcers, and patient satisfaction
entering and exiting patients’ rooms multiple times during will allow the nurses to see the tangible difference and will
their shifts. Subsequently, they will have more time for appreciate the result and benefits of what they are doing,
other important tasks such as patient education.[9,10,16] thus will eventually make hourly rounding a success.
Several studies have shown similar findings regarding the Nurses in other studies have reported intentional
positive impact of nurse rounding on patient satisfaction, rounding as an additional, unnecessary task, however, the
falls, and call light use. For instance, Mitchell et al.[17] effectiveness of intentional rounding depends on external
found that hourly rounding programs improved patients' factors such as leadership and formal rounding education,
perception of nursing responsiveness, reduced patient workload, ward layout, staffing, and experience level.[26]
falls, and call light use. Similarly, a study by Brosey and The intervention implemented led to an increase in
March[10] reported decreased rates of patient falls and patient satisfaction and a decrease in complaints, falls, and
HAPI during the project period. Another study by HAPI rates. The prompt response to call bells and physical
Daniels[11] also demonstrated that nurse rounding layout of the inpatient care areas could have played a role
improves fall rates. However, not all studies support these in achieving these outcomes. Nurse rounding not only had
findings. For example, Farndale and Murrer[18] found no positive effects on patients, but also on staff, reducing call
significant difference in patient falls with the bells and improving their physical health. Staff education
implementation of hourly rounding, and Nelson and and engagement were essential in promoting adherence to
Staffileno[14] reported no impact on fall rates but exhibited the nurse rounding and call bell systems. The study
improvement in the patient satisfaction score. highlights the importance of nurse rounding in improving
148 | Nurs Midwifery Stud. 2023;12(3):142-150
 The effect of intentional nurse rounding and nurse prompt…

patient outcomes and staff engagement. Senior Charge Nurse: SCN

To minimize potential biases, our study has employed Patient Services Office: PSO
consistent and standardized data collection methods. This Key Performance Indicators: KPIs
includes using the same data collection tools pre and post-
intervention phases, as well training the data collectors by Authors’ contributions
the primary investigator to ensure consistent application Hussam Al-Nusair is responsible for the study concept,
of the tools. design, literature search, data collection and analysis,
This study was conducted in a single hospital and during manuscript preparation. Rafi Alnjadat, Doreen Mukona,
Mariezl Fonbuena and Saleem Perinchery assisted in
a specific time period, which may limit the generalizability
literature search, data collection, data analysis, and
of the findings to other hospitals or different time periods.
manuscript preparation and editing.
Also, the data on patient satisfaction and complaints were
based on self-reported surveys, which may be subject to
Funding
bias or inaccuracies. There may have been other factors,
No funding was received by the researchers for this project.
such as changes in staffing levels or patient acuity, that
could have influenced the outcomes. The SCN’s adherance Role of the funding source
to the Leadership rounding was not presented in this Not Applicable
study.
Availability of data and materials
Conclusions Data related to this study are available upon reasonable
The implementation of the intentional nurse rounding request. Please contact the corresponding author for inquiries
and nurse response time to call system resulted in regarding access to the data.
decreased complaints, falls, and HAPIs, and increased
patient satisfaction. The prompt response to call bells and Ethics approval and consent to participate
the physical layout of the inpatient care areas in the The Human Research and Ethics Committee of Al-Balqa
hospital were identified as possible enablers. The high Applied University gave their approval for this project
adherence rate to the nurse rounding system by staff number (244/2/3/6/33). The consent form also made it clear
nurses resulted not only in significant improvements in that participation in the study had no additional risks beyond
those associated with normal life.
patient outcomes but also for staff, leading to reduced call
bells, miles walked by nurses, and promoting efficient use
Consent for publication
of time. The impact of nurse rounding on staff engagement
All authors have reviewed the final version of the
was also identified as essential in promoting adherence to
manuscript and have provided their consent for its
the system. The findings suggest that nurse rounding is an
publication.
essential strategy to reduce inefficient use of call lights and
promote patient and staff satisfaction.
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