A cross-sectional descriptive correlational design was utilized.

The study was conducted in different hospitals in Jordan that implement hourly rounding. Three were from the private sector, four governmental hospitals, two university-affiliated hospitals, and one military hospital.

The convenience sampling technique was utilized in this study to recruit nurses from the targeted hospitals. The inclusion criteria were nurses working in the hospitals for at least three months and willing to participate. Registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) working in medical, surgical, pediatrics, orthopedics, oncology, renal, and respiratory units in the selected hospitals were invited to participate in the study. Nurses working in other units, like emergency rooms or intensive care units, were excluded from the study due to different observations and rounding systems.

The sample size was calculated using a survey calculator [23]. The estimated sample was calculated based on a 95% confidence interval, a three-confidence level, and a 24000 population, which resulted in at least 1022 participants. One thousand five hundred questionnaires were distributed to compensate for missing data. The response rate was 95.2% (N= 1428). The final sample size was 1378, excluding 50 responses due to (10 items or more) missing data.

The ethical approval was obtained from the ethical and research committee at Al-Ahliyya Amman University (رج/ص/12/1825). Participants received a cover letter outlining the study's goal, the respondents' anonymity, their right to withdraw at any time, and the data's confidentiality, with no one other than the researcher having access to the data. Moreover, a consent statement must be checked before participants respond to questionnaire items. Permission was obtained from the authors of the CDI questionnaire and hourly rounds questionnaire to adopt and use in the study.

Data collection began after obtaining the required ethical approvals. The study adopted electronic self-administered questionnaires using google forms due to the COVID-19 pandemic lockdown and to minimize human contact and disease transmission. The data was collected between Sep/2020 and Mar/2021. A facilitator was assigned in each hospital to serve as a resource and liaison person to reach all nurses at different shifts and provide the needed information to the participants. The researcher’s contact information was available to participants for any further inquiries.

The online questionnaire consisted of three parts: the demographic data sheet, the Hourly Rounding Questionnaire (HRQ), and the Caring Dimension Inventory (CDI-25).

Data were analyzed using the Statistical Package for Social Science (SPSS) version 21 [26]. Descriptive statistics, including frequencies, mean, percentage, and standard deviation, were calculated to describe demographics, HRQ items, and the CDI-25 items. T-test and Kruskal-Wallis H test were conducted to examine differences in nurses' perceptions of hourly rounding and caring according to demographic characteristics. Pearson r was used to examine the correlation between age, hourly rounding, and caring.

The lowest agreements (strongly disagree and somewhat disagree) between nurses were on the items “Putting the documentation tool on Soarian would make it more convenient to complete,” 233 (16.9%), and “After implementation of hourly rounding, there was continued support and resources available,” 239 (17.3%). On the other hand, the highest agreements (somewhat agree and strongly agree) between nurses on the items “Hourly rounding makes my patients safer by preventing patient falls,” 1211 (87.9%), and “Hourly rounding makes my patients safer by preventing hospital-acquired pressure ulcers,” 1201 (87.2%) (Table 2).

The mean of the participants caring total sores was 105.39 (SD = 14.92), ranging between 25 and 125, indicating a high level of caring. The possible range was between 25 and 125. The highest means were for the items “measuring the vital signs of a patient (e.g., pulse and blood pressure)” (m = 4.61, SD = 0.75), “providing privacy for a patient” (m = 4.6, SD = 0.79), and “being neatly dressed when working with a patient” (m = 4.51, SD = 0.87). However, the lowest means were for the items “sitting with a patient” (m = 3.96, SD = 1.062), “exploring a patient’s lifestyle” (m = 3.76, SD =1.127), and “sharing your personal problems with a patient” (m = 2.22, SD = 1.59) (Table 3).

Kruskal–Wallis H test revealed significant differences in nurses’ perceptions of hourly rounding in relation to hospital type χ 2(3) = 50.678, P ≤ .001; nurses in private hospitals reported the highest mean rank (MR = 793.27), and the lowest mean rank was for the educational hospitals (MR= 549.83). Moreover, the test showed significant differences in the shifts nurses most often work χ 2(3) = 34.205, P ≤ .001; nurses working in shift rotation reported the highest mean rank (MR= 744.24), and the lowest mean rank was for nurses working in afternoon shifts (MR= 581.01). Lastly, the test revealed significant differences in nurses' perceptions of hourly rounding in comparison to their working units χ 2(7) = 51.380, P ≤ .001; nurses working in respiratory units reported the highest mean rank (MR=948.29), while the lowest mean rank was for nurses working in orthopedic units (MR=614.56).

The t-test showed significant differences in nurses’ perceptions according to their gender (t (1062) = -2.98, P < 0.05). Male nurses reported lower mean scores (83.14) than female nurses (85.82). No significant differences or associations were found between nurses’ perceptions of hourly rounds and their age, job title, years of experience, and years of experience in the current job.

Nurses’ perceptions of caring differed significantly according to age, duty shifts, hospital type, and nursing units where nurses usually work. No statistically significant differences or associations were found in nurses’ perception of caring according to years of experience, years of experience in the current job, job title, and gender.

A Pearson correlation coefficient was computed to assess the linear relationship between nurses’ perceptions of caring and their age. There was a positive correlation between the two variables, r (1376) = .0.61, p = .024, which means that nurses’ perceptions of caring increase with age. The Kruskal–Wallis H test revealed significant differences in nurses’ perceptions of caring according to hospital type, χ 2(3) = 32.468, P ≤ .001, with the highest mean rank for nurses working in private hospitals (MR= 728.87) and the lowest mean rank for nurses working in military hospitals (MR= 580.71). Moreover, the test showed statistical differences in nurses’ perceptions of caring according to their duty shifts, χ 2(3) = 20.242, P ≤ .001; the highest mean rank was for the nurses working in shift rotation (MR= 724.71), while the least mean rank was for the nurses working in night duty (MR= 551.45). Lastly, the test revealed statistical differences in nurses’ perceptions of caring based on the nursing units in which they usually work, χ 2(7) = 40.487, P ≤ .001. Nurses working in respiratory units reported the highest mean rank (MR=932.4), while nurses working in orthopedic units reported the lowest mean rank (MR= 619.55).

A Pearson correlation coefficient was computed to assess the linear relationship between nurses’ perceptions of hourly rounding and their perception of caring. The test revealed a strong positive correlation between the two variables, r (1376) = .473, p = <.001.

The majority of participants perceived hourly rounding to be useful in making patients safer by preventing patient falls and hospital-acquired pressure ulcers. This is similar to many studies [27]. Studies suggest that hourly rounds in which patients are regularly asked if they need help with movement or using the toilet would also reduce patient falls because patients are less likely to have an urgent need to go to the toilet before a caregiver can assist them. Likewise, other studies reported that nurses perceived hourly rounds as an excellent tool to change the patient’s position that would be expected to reduce pressure ulcers [23, 28]. While most of the participants in this study perceived documentation on Soarian as a burden, this result was in line with other studies reporting a concern about the documentation requirement and completion associated with hourly rounding [17, 29, 30]. The previous result may be due to the heavy workloads of the nurses that made it challenging to achieve rounding visits on an hourly basis, and the obligation to document the rounding was perceived to be a burden and considered to be of last priority. Also, some nurses may look at documentation as a waste of time and irrelevant. Moreover, most participants perceived continuous support and resource availability after the implementation of hourly rounding as the lowest-ranked item, reflecting a negative perception in this domain. This may be due to a lack of support by the units leaders and hospital administrators after implementing hourly rounds and this lack of leaders or available resources that act as a role model to provide nursing staff ongoing educational and emotional support and help ensure the commitment of the process [14, 24, 30].

In our study, it was recognized that the level of perception of caring behavior among nurses was high, similar to many other studies [17, 31-32]. It is agreeable that the level of perception regarding caring behavior was high among the nurses in our study. However, technical aspects, such as “taking vital signs,” have been seen as a crucial caring activity in our study and ranked as the highest item by the participants. Assessment of vital signs and interpretation of the results are valued in nursing, which could monitor and guide the patient’s treatment. This is similar to the studies conducted by Akansel et al. (2012) and Ayyub et al. (2015), where the participants agreed on the same item [32, 33]. Sometimes technical aspects of nursing, such as taking vital signs, are considered time-consuming because of the number of patients assigned to each nurse. At the same time, in our study, it was the opposite, possibly due to two reasons. First, nurses usually assess their patients while taking vital signs and monitoring the changes that may occur to the patient. Second, nurses perceive taking vital signs as primary nursing practice. Other studies mentioned that previous results might be due to priorities in nursing care activities which could change according to patients’ and nurses’ expectations and nurses’ willingness to practice the nursing profession [34, 35]. In addition, providing privacy for a patient was considered the second highest ranked item in our results, similar to many other studies [32, 33]. Middle eastern culture and the Islamic region emphasize the importance of the protection of the privacy of all people. Moreover, providing privacy by nurses is the most satisfaction to patients from the nursing care they receive [34]. The third-ranked item to be one of the most agreed caring behaviors among our study participants was nurses being neatly dressed when working with a patient. This is clearly related to how much the nurse will appear to be professional in front of the patients. Professional characteristics of the nurses are considered to be one of the most important factors affecting patient satisfaction and improving their perception of nurses [35]. This result is similar to Erol and Turk’s (2019) study, which indicated that professional appearance and attitude are essential indicators of caring behavior; they improve self-confidence among healthcare professionals, increase competency, and consequently will improve the quality of care that is reflected by the high level of patients satisfaction [19].

However, as perceived by the participants, the lowest ranked item in our study was in consecutive order: sitting with a patient, exploring a patient’s lifestyle, and sharing nurses’ personal problems with a patient. This result is similar to the findings of a study conducted by Akansel et al. (2012), supporting the fact that psychosocial aspects of nursing, such as spending time with the patients and exploring their lifestyles, are essential concepts that should not be ignored in nursing care [32]. Many other studies highlighted that nurses sitting with patients is a valuable caring behavior for hospitalized patients that helps them to pass their fears and concerns [34, 36]. This result may be due to nurses’ inability to spend time getting to know the patient because of high patient ratios and work overload. However, the third lowest ranked item, “sharing nurses’ personal problems with a patient,” is realistic and common sense because it is one of the most important professional attitudes that all nurses should implement.

Significant differences were reported in nurses’ perceptions of hourly rounding with hospital type, as nurses in private hospitals reported the highest positive perception of hourly rounding, while the lowest was for educational hospitals. This is because private hospitals have strong, well-developed policies and protocols for providing nursing care, improving the quality of care services, and, consequently, patient satisfaction. This may force the private hospital’s place in a highly competitive healthcare market. According to our literature review, no studies globally correlate the hospital type to hourly rounding, making this result very important to hospital administrators and stakeholders. Moreover, the results showed significant differences in the shifts in which nurses most often work; nurses in shift rotation reported high perception, and the lowest was for nurses working afternoon shifts. These results are similar to Fabry’s (2015) study results [16]. The nurses in shift rotation need to assess their patients so they will get familiar with the changes that might happen in other shifts. On the other hand, the afternoon shift is considered the time for patients’ family visits, mainly in Jordanian hospitals, so nurses try to minimize unnecessary interactions with the patients during family visits. This result supports the fact that hourly rounding needs continuous observation, support, and evaluation by the leaders and administrators to keep the workflow during hourly rounding. Still, in the afternoon shift, with the absence of each unit administrator, nurses may feel unsupported, so their accountability may be affected.

There were significant differences in nurses' perceptions of hourly rounding compared to their working units; nurses working in respiratory units reported the highest positive perception, while the lowest was for nurses working in orthopedic units. This may be related to the type of work in respiratory units, which needs a continuous critical extensive assessment of the patient, especially respiratory rate and pattern, to prevent deterioration of the patients. In contrast, in orthopedic units, the patient mainly needs analgesics that act for a long time, and during this period, a patient usually needs rest and sleep. Lastly, significant differences were detected in nurses’ perceptions according to their gender. Male nurses reported lower perception in our study than female nurses, which is similar to Shin and Park’s (2018) study [37]. These results are related to the gender role, not the sex role because female nurses tend to reach perfection in work more than male nurses so that they will improve their status and position in the units. Also, the female ability to handle multiple tasks that need effort and concentration is also recognizable by many studies [37].

Nurses’ perceptions of caring differed significantly according to age, duty shifts, hospital type, and nursing units where nurses usually work. The nurses’ perceptions of caring increase with age as their years of experience increase, and the perception of caring behavior and the nursing profession as a whole will be articulated and improved [38]. Nurses working in private hospitals showed a more positive perception than those working in military hospitals. This may be due to the heavy workload and high nurses patients ratio of military hospitals, which are considered barriers for nurses to spare time for patients and focus on providing the utmost care needed by the patients. Also, our study results showed statistical differences in nurses’ perceptions of caring according to their duty shifts; the highest was for the nurses working in shift rotation, while the least was for the nurses working on night duty, which were similar to the findings of a study conducted by Oluma and Abadiga (2020) [4]. According to Oluma and Abadiga, nurses caring behaviors were associated with a caring environment, especially the presence of empowering nursing leader management that will support nursing staff while providing care [4]. Night shifts may pressure nurses because of the low staff ratio and having to be accountable alone for decisions without sharing critical decisions with leaders. Concurrently, night shifts may also have a negative effect on nurses [39, 40].

Nurses working in respiratory units reported the highest perception of caring, while nurses working in orthopedic units reported the lowest. This also related to the type of cases and work environment in the previously mentioned units and the burden that existed on the nurses regarding making decisions and a sense of responsibility and accountability concerning the patients.

Lastly, a positive correlation was reported between nurses’ perceptions of hourly rounding and their perception of caring. This means that when the perception of caring behavior is higher, the perception of hourly rounding consequently will be better, which is consistent with the findings of a study conducted by Papastavrou et al. (2015) [40]. Furthermore, it can be interpreted as the following: caring is a moral action that, once the nurses’ respect, will be reflected in caring practices, and their accountability regarding hospital protocols and nursing actions will be increased, such as hourly rounding. Hourly rounds are an essential part of quality patient care. Future qualitative research should focus on nurses’ and patients’ perceptions of hourly rounding, especially the time nurses spend with the patients. Future research also should examine a possible correlation between a caring environment and staff perception and practice of hourly rounds. Attention should be focused on assuring the presence of the staff leaders and administrators who act as champions, supporters, and encouragers for staff nurses in their workflow during hourly rounding in each shift. In addition, it is strongly recommended to establish a protocol and procedure for hourly rounding in all sectors and train the nurses on them. As implications for the education system, course teachers must drive nursing education toward patient center approach so the students will not focus only on technical and practice skills. Patient-centered approach, which supports the practice of hourly rounding and improves caring, can be included within the study programs at the level of intended course-learning outcomes. Nursing programs should cultivate between students the culture of the patient-centered nursing approach to make the patient the center of the care and nursing process by focusing on the patient’s unique needs, wants, desires, and goals. The limitations of this study are that the cause and effect relationship cannot be confirmed in this study since the research design is cross-sectional, the lack of randomization and the use of a convenience sampling method that might have affected the generalizability, and the use of a self-completed questionnaire that might lead to a self-report bias.