The Impact of Two Hourly Purposive Rounds (2HNR) on Nurses’ Perception and Satisfaction: A Cross-Sectional Study

Nurses are the backbone of healthcare organizations, and they play a crucial role in delivering quality care and ensuring patient safety, and that, in turn, can be achieved through the two hourly purposive nursing rounds (2HNR). The 2 HNR is a structured rounding conducted by the bedside nurses on a one to two hourly bases. It has been associated with increased patient satisfaction and nursing care quality, improved nurse-patient interaction


Introduction
Nurses are the backbone of the healthcare organizations and they play crucial role in delivering quality care and ensuring patient safety [2]. The two hourly purposive nursing round (2HNR) can fulfill the last point [3]. In 2018, a tertiary hospital in Oman, has implemented the 2HNR in both adult and paediatric general medical and surgical wards, to ensure equity, quality, and standardized nursing care. The 2HNR has been studied by several authors and has been associated with positive outcomes [1,2].
The 2 HNR is a structured rounding conducted by the bedside nurses on one to two hourly bases [2]. The 2HNR is referred to as intentional rounds, timely rounds, and structured rounds in the literature and has been associated with increased patient satisfaction and the nursing care quality, improved nurse-patient interaction, reduced incidence of fall and call bell frequency, and early identification of patients' needs [1,2]. To the best of our knowledge, this is the first study done on the 2HNR in Oman; hence, it is an addition to the entire body of knowledge of the effect of 2HNR in hospital settings. This study aims to evaluate the impact of 2 HNR on nurses' perception and satisfaction at a tertiary hospital in Oman [3].

Study setting
The research study was conducted at a tertiary hospital in Oman to evaluate the impact of 2 HNR on nurses' perception and satisfaction.

Study design and population
A cross sectional design study was conducted from January 2020 to July, 2020. Nurses working in general units such as medical, surgical, pediatrics, maternity, cardiac units, as well as oncology were invited to participate by filling the online survey. A total of 513 nurses filled the online survey, to assess their satisfaction and perception about the Two Hourly Purposive Nurses Round (2HNR) [4]. The online link to participate in the survey were sent to the nurses by their ward in-charges and clinical nurse educators. Nurses working in critical care units and outpatient units were excluded. The total number of nurses who work at general units (i,e 1000) and the sample selected for the study is (i.e 513 nurses) is representative to the target population.

Study tool
The survey questionnaire was designed in English as it is the common language used in the hospital. The questionnaire consisted of closed ended questions to reveal perception of the nurses in regard to the 2HNR. A total of nine closed ended questions were established. Likert scale was used with five options from strongly agree to strongly disagree. These types of scales are commonly used to assess the attitude and opinion of the participants . The questions were about nurses' perceived ability of performing the round during the three shift duties, the perceived benefits and values for nurses and patients, the perceived work load and time consumption; reduction of call bell from nurses' point of view, satisfaction, and challenges of performing the 2NHR [5]. A survey questionnaire was constructed by the researchers based on program's objectives, and later on was piloted among 20 nurses in 2019. Nurses' feedback revealed that the survey questionnaire was clear.

Data collection
The online link to the survey questionnaire was distributed by the researchers to all general units through their ward nurses and clinical educators to invite them for participation. Ward nurses and clinical educators were utilized for the recruitment process as they were having access to all nurses' contact. A seven-month period was given to allow nurses participate and give feedback on the practice based on their experience. Frequent reminders were sent to reach the targeted sample size and that was with the help of ward incharges and the clinical nurse educators.

Statistical analysis
Descriptive analysis was performed to describe the characteristics of the participants such as percentage, frequency, counts of the gender, length of experience, and qualification ( Table  1). Chi-square and cross tabulation analysis were conducted to correlate nurses' qualification with perceptions (i.e the perceived ability of the nurses in performing the round during the three shift duties, perceived benefits and values for nurses and patients, perceived workload and time consumption, reduction of call bell from nurses' point of view, satisfaction, and challenges of performing the 2NHR) (

Ethical consideration
This study was approved by the Hospital Scientific Research Board under approval number 62/2019. Participants of this study were informed about the objective of the research and voluntary participation was explained via an online link prior to introducing the survey questions. Additionally, participants were informed through the link that once they click on the bottom of the agreement; they automatically would agree to participate in the study. No details were required for the tool to identify specific participants. To secure the collected data, all data were transferred directly online to the primary researcher.

Participants' characteristics
Based on the survey findings, a total of 513 nurses have completed the survey and female constituted the highest proportion (96.1%). In terms of experience, 27% were more than 12 years' experienced, followed by 24% of the participants having 3-6 years of experience. About 54.1% of the participants held Diploma in general nursing . MSN qualified nurses formed the least percentage of participation (Table 1).

Benefits and challenges of the 2HNR
Around 53.9% of the participants believed that the two hourly nurses round (2HNR) had enhanced their skills of time management. Moreover, 61.1% were able to prioritize their patients care as a result of the two hourly rounding. The participants were able to perform the two hourly nurses round at all shifts, the morning shift (54.5%), the afternoon shift (61.1%), and the night shift (69.1%), respectively [6][7][8].
Looking at the benefits and values that are added by the 2HNR, the participants agreed that it does pose benefits and value to the patients (76%) and the staffs (67%). The 2HNR is seen as an approach to decrease the workload and save time among 32.6% of the participants, while it is not the same case among 36.9% of the participants, who disagreed on having the 2HNR as a way to reduce the workload and save time. Approximately 50.8% of the participants were satisfied with the 2HNR. About 53.4% of the Based on the findings, the following significant correlations were found. There is a significant relationship between the qualification level and the nurses' ability in managing the time (p value 0.024). The 2HNR is deemed significant to add value and benefits to both patients (p value 0.018) and the staff nurses (p value 0.035). 2 HNR decreases the workload and saves time (p value .003), reduces the call bell frequency whenever performed on regular basis (p value 0.14).

Discussion
Female represented the highest proportion in this survey (96.1%) as at the local hospital the number of females is obviously nineteen times more than the male. As the 2HNR tackles the basic needs of the patients, general diploma nurses, who are usually the bedside nurses, formed the highest percentage of participation.

Moreover, nurses who pose higher qualification
In term of ability in managing time and ability to prioritize the care by performing the intentional rounds, this study found that effective rounding could enhance the skills of nurses time management and task prioritization. This is supported by Fabry (2014) and Langley (2015) studies which found that intentional rounds causes fewer interruptions and spare of time during nursing activities [4,8]. Moreover, intentional rounds enhances nurses ability to manage their time, as it allows them to continuously assess and prioritize the nursing care, and identify patients concerns early [5,[9][10][11][12][13][14][15][16][17][18].
A significant percentage of more than 54% of the participants could manage to conduct the 2HNR during all the shifts and that indicates that the 2HNR is doable and can be integrated into the daily nursing practice. However, a special attention must be paid to the factors that rendered other participants who did not manage to perform the 2HNR in all the shifts. Proper planning of the 2HNR process and policy can be executed to overcome the barriers to implantation [18].
In terms of benefits and values associated with the 2HNR, it can be argued that a significant percentage of the participants have gained time and tasks' management skills which are crucial to the nursing task implementation. More than half of the participants acknowledged that the 2HNR poses benefits and value to both the staffs and patients; therefore it can add a lot of value to the overall quality of the nursing care. The latter findings go parallel with findings, stressing that intentional nursing round has positive effect on patients as it recognizes changes and deteriorations in patients' health status and spares time for nurses to stay with sicker patients (Patterson, 2014) [15,6,16]. Importantly, by checking on patient frequently, all patients needs like pain management, comfort, and safety needs would be met [13]. The 2HNR is seen beneficial to nurses and this finding supports the literature in terms of viewing the intentional rounds as beneficial too in understanding the patient and planning the care as accordingly, reducing patient's and family's anxiety and uncertainties [19].
In this study, some nurses perceived 2HNR as a burden and extra work for them. This result aligns with Fabry (2014), Harris et al. (2019) and Ryan et al. (2019) studies in which some nurses also perceived that intentional round was an additional work and burden to them [4,6,9,16]. The last was attributable to the following. First, the burden of rounds' documentation. Secondly, nurses perceived that they had been checking on their patients on regular and frequent basis in the normal course of patient care and the 2HNR would not add a lot in knowing patients basic needs [6,9,16]. In the current study, some nurses felt reluctant to perform the 2HNR as they thought that the 2HNR takes them away from focusing on sicker patients. Though the participants of this study valued the role 2HNR in prioritizing their patients care, the 2HNR was perceived as a workload [16]. This finding is contradicting with the 2HNR task prioritization component and goal and this point can be an indication of improper proper education on 2HNR and lack of buy-in of the task among nurses [9,16].
Based on the participants perception, whenever the 2HNR had been performed regularly, the call bell usage has had reduced. The last finding matches Krepper (2014), Mathew (2014) and Langley (2015) findings [7,8,10]. Attending call bells, at each two hours, ensures fulfillment of our patients' needs and reduction of the call bell [7,17].
This study found that more than half of the nurses were found to be satisfied with the current process of the 2HNR. Langley (2015) also found that intentional rounds have a positive effect on staff satisfaction, secondary to enhanced teamwork and communication [8].The 2HNR was found to be associated with some challenges since more than half of the respondents (53.4%) reported that they had challenges with performing the 2HNR. These challenges included rounds' documentation load, difficulty in structuring the rounds along with other nursing procedures, and rapid flow of patients. According to the literature, time constraints and perception of being too busy, fluctuating in patients' number and acuity, staffing levels, and rounds' documentation loads were the major challenges identified for the 2HNR [13]. The challenges can be overcome by performing a well-organized 2HNR process. A well-organized 2HNR can offer multiple benefits to nurses, patients, families, and the entire health care organization.

Conclusion
In conclusion, the current cross-sectional study aimed to evaluate the impact of 2HNR in a tertiary hospital in Oman. The study continued in general units from January 2020 to July 2020 (Seven Months). A total of 513 nurses responded to the online survey, which asses the perceived ability to perform the round during the three-shift duties, the perceived benefits and values for nurses and patients, the perceived workload and time consumption, reduction of call bell from a nurse's point of view, satisfaction, and challenges of performing the 2NHR. The collected data were processed and analyzed descriptively to describe the characteristics of the participants and by Chi-square and cross-tabulation analysis to correlate nurses' qualifications with studied variables. Ethical approval was obtained from the Hospital Scientific Research Board under approval 62/2019. The collected data shows that most of the respondent is female nurses with a percentage of 96.1%, and there is a good distribution of their experience, varying from less than one year to more than 12.
This study valued the role 2 HNR in prioritizing patients' care. Whenever the 2HNR was performed regularly, the call bell usage was reduced, and the majority of nurses were satisfied with the current process of the 2HNR. On the other hand, challenges that were perceived as workload, by nurses were the documentation load and difficulty structuring the rounds along with other nursing procedures and rapid flow of patients. Overall, this study acknowledges that a well and organized 2HNR procedure would contribute positively to the entire health care organization's quality and patient safety standards, and staff satisfaction. A more rigorous study needs to be conducted to further explore challenges to the 2HNR practice at the tertiary hospital in Oman, considering the staffing level, structure of the ward, leadership, structured rounding education, ward layout, and workload [11].

Limitation
The main limitations of the current study are as follows. This is a single center study and that might limit generalization of the results to other health care organizations. Moreover, the study was dependent on filling the onlineself-administered survey questionnaire. It would be a great input if the online survey findings would be verified with onsite clinical researcher's observations by the researches, to add more credibility to the entire study findings. Cross tabulation of data has been limited to the participants' qualifications, while years of experience and gender could have impacted the study findings.