School of Nursing
Online Journal

Therapeutic design features for hospital staff break areas: The role of nature in nurse wellbeing.

Amy M Wilson

Introduction

The New Zealand healthcare industry is currently facing challenges retaining nurses (Duffield, Roche, Homer, Buchan & Dimitrelis, 2014). This has a major impact on both hospital budgets and patient care alike (Duffield, et al 2014). This literature review focuses on the role nature can play in hospital break areas to improve the quality of nurses’ breaks, reduce stress, improve job satisfaction and thereby help retain nurses to the profession. Recurring themes in the literature relate to the positive impact viewing and/or spending time in nature has on stress and the cognitive capacity to direct attention. Other themes include improved healing time for patients exposed to nature and how therapeutic design can be used to promote health. The literature also looked at the implications of mental fatigue on nursing staff and how that relates to nurse retention. This review will then discuss the clinical implications of exposure to nature on nurses; making recommendations and providing rational for the therapeutic design of hospital staff break areas in New Zealand.

The Clinical Issue

One of the current major challenges of the healthcare industry is a shortage of nurses and difficulty retaining new nurses to the profession. Nurses make up the largest regulated health care workforce in New Zealand and they supervise the largest unregulated health care workforce in New Zealand (Ministry of Health, 2015; National Nursing Organisation, 2014). There are 52,729 nurses with practicing certificates registered with the Nursing Council of New Zealand as of March 2015, with the majority working in hospital settings (Ministry of Health, 2015). Healthcare facilities have been ranked among the most stressful workplace environments (Nejati et al., 2016). This is particularly true for nurses. Work related stress, job dissatisfaction, fatigue, and quality of work environments were found to be contributing factors in nurse’s decisions to leave the profession (McHugh, et al., 2011). Although stress reduction, psychological and physical restoration have been found to be important to workplace environments, healthcare facilitates are often reported to lack restorative stress reducing break rooms (Witkoski et al., 2010).

I have chosen to research the effects of nature exposure on nurse’s work breaks because of the significant impact stress has on nurse retention in New Zealand (North, Huges, Finlayson, Rasmussen, Ashton, Campbell & Tomkins, 2004; Duffeild, et al 2014). Nature has long been intuitively believed to have restorative effects on health and wellbeing. Nature exposure could be a cost-effective ameliorator of stress and attentional fatigue among nurses, thus improving job satisfaction, retention to the profession, and subsequent patient outcomes. This is of interest as it seems there is little research into therapeutic design aspects of break areas for hospital staff. I find this interesting considering nurse theorist Florence Nightingale of the nineteenth century developed the theory of environment effecting patient’s wellbeing which has long been accepted, yet there seems to be little thought into the design environment in which nurses take their breaks, and the effects these spaces have on nurse wellbeing (Schweitzer, Gilpin, & Frampton, 2004). Improving the quality of nurses’ breaks may be a cost-effective way of reducing work related stress and retaining nurses to the profession. This literature review aims to examine the value of health-promoting break areas and therapeutic design interventions for improving the quality of nurses’ breaks thereby reducing stress and attentional fatigue and improving retention to the profession.

The Question

The PECOT model was used to help develop and refine my research question. This model has helped me to critically examine each part of my question in order assist in finding the relevant literature. The PECOT model helped to refine my search question to:

Do therapeutic design aspects in nurses’ break areas decrease stress and improve nursing staff retention?

The PECOT

(Schneider, Whitehead, LoBiondo-Wood, & Haber, 2013).

Evidence and Findings

Over the past several decades a considerable amount of research in a variety of fields shows that views of, or time in nature has positive influences on health and wellbeing (Ulrich, Simons, Losito, Fiorito, Miles & Zelson, 1991; Ulrich, 2001). Escape from physical and psychosocial stressors has long been illustrated as a motivation for seeking out natural environments (Home, Hunziker & Bauer, 2012). Research on this topic has been conducted in a range of settings including workplaces, urban settings, hospitals and laboratories (Ulrich et al, 1991; Nejati et al, 2016). 

Nature and stress reduction

The literature points consistently to the value of exposure to nature in reducing stress, improving emotional wellbeing, and improved ability to focus attention. For example, regarding employees, a study by Dravigne, Waliczek, Lineberger and Zajiceck, (2008) on job satisfaction found that employees who worked in offices with either plants, or windows with views of plants, had greater job satisfaction, higher moral and increased productivity than those without. This finding is reiterated in a similar study which found that employees whose office windows have forest views report greater job satisfaction and lower stress levels than those without (Shin, 2007). Themes emerged in the literature around three levels of engagement with nature: viewing nature and landscapes from a window, being in the presence of nature, and actively engaging with nature (Maller, Townsend, St Leger, Henderson-Wilson, Pryor, Prosser & Moore, 2009; Pretty, 2004; Heerwagen, 2006). These studies found that as the level of engagement with nature increases, the degree of stress incrementally decreases. The Maller et al and Pretty papers both discuss the importance of nature exposure post the industrial revolution in which an increasing number of people now find themselves living in wholly urban settings. This has relevance to nursing due to most of the workforce practicing in urban hospital settings (Ministry of Health, 2015). The literature also revealed numerous studies that identify stress being a leading cause of nurses leaving the profession (Applebaum, Fowler, Fiedler, Osinubi & Robson, 2010; Farquharson, Bell, Johnston, Jones, Schofield, Allen, Ricketts, Morrison, & Johnston, 2012; Hayes, Douglas & Bonner, 2015). Both Maller et al and Pretty also discuss the attentional wellbeing gains from exposure to nature.

Attention restoration theory

Attentional wellbeing, or attention restoration theory, holds that during the wilful direction of attention, a neurocognitive inhibitory mechanism is engaged to block out unnecessary stimuli. When this mechanism becomes fatigued, the attention engaged by the effortlessly fascinating aspects of nature allows this mechanism to rest (Hartig, Mitchell, de Vries & Frumkin, 2014; Kaplan & Kaplan, 1989; Kaplan, 1995). People need to block out task-irrelevant stimuli in order to direct attention at work and during many other activities. Fatigue of this directed attention capacity occurs frequently, impairs effective action and decision making, and can increase one’s susceptibility to stress (Kaplan, 1995; Hartig et al, 2014). This theory is supported by the more recent attention-resource model by Warm, Parasuraman and Matthews (2008) which empirically supports an attentional resource theory that the workload of vigilance tasks is high, requires hard mental work and is stressful. For nurses at work, vigilance/directed attention is necessary for routine functioning, such as administering medication or deciphering colleagues notes in patient files. It is also essential for executive level functioning, such as performing complex medical interventions or deciding what action to take during triaging. Attentional restoration theory is further supported by a 2012 study which confirms that forty second micro-breaks spent viewing a green meadow boosted sustained attention by boosting sub-cortical arousal and cortical attention control (Lee, Williams, Sargent, Williams, & Johnson, 2015). The direct empirical evidence provided by the Lee et al (2015) study extends attention restoration theory and the benefits of micro breaks with views of nature.                                                                                                                                                                                                                                                                                                                                    

The above studies illustrate the restorative benefits of nature for different population groups where interaction with nature occurred during both non-work time and work time. The studies that used nature as an intervention illustrate the potential use of nature access and interaction in a more concise way. The next set of studies focus specifically on restorative break areas and use of nature in the work environments of nurses.

Therapeutic design

Therapeutic design involves the inclusion of aesthetic enhancements that aim to reduce stress and promote healing. What makes therapeutic design so compelling is the number of benefits that have been identified in the literature. These include observable medical signs of improvement for patients, subjective improvements such as reported satisfaction of patients, visitors and staff, and economic benefits of reduced pain medication and staff retention (Neducin, Krkljes, & Kurtovic-Folic 2010; Heerwagen, 2006). In a study on restorative design features for hospital break areas, Nejati et al (2016) found nurses are most likely to use staff break areas if they have complete privacy from patients and their families, and if they provide opportunity for individual privacy as well as for socialisation with colleagues. Physical access to private outdoor spaces was shown to have substantially greater perceived restorative potential than window views, artwork or potted plants. The results of this study support the proposition that specific environmental characteristics are important for job satisfaction and fatigue reduction among nurses. This theme appears in the literature again in an empirical study by Nejati, Rodiek and Shepley (2016) which found that improvements to nursing staff break areas would be of significant benefit to nurses and in turn, the patients they serve. The study found that taking outdoor breaks was a significant predictor of positive perceptions of break areas and staff performance. This is further supported by a study on the effects of nature on hospital nurses. Findings from Nesbitt’s (2004) study include nurses reporting that after having a break in nature they felt refreshed, relaxed and energised open return to work as though they were starting the day anew. They also reported having less difficulty concentrating on their work and a greater sense of wholeness than those who took their breaks indoors. Although review of the literature revealed that therapeutic design features specifically in relation to nurses is limited, the results of these three studies have implications for the physical design of health facilities and the management of natural areas. Furthermore, the literature suggests that exposure to plants during recovery on a surgical ward has shown to have a significantly positive influence linking directly to health outcomes of surgical patients. A study by Park & Mattson (2009) found that patients in hospital rooms with plants had considerably lower systolic blood pressure, lower ratings of pain and lower analgesia required for pain as well as lower rating of anxiety and fatigue. Enhanced pain management with exposure to indoor plants is a recurring theme in the literature (Bringslimark, Hartig & Patil, 2009) as well as subjective reported stress reduction (Beukebroom, Langeveld & Tanja-Dijkstra, 2012; Park et al, 2009; Neducin et al, 2010). The literature suggests that exposure to nature can reduces stress, improve the ability to direct attention, increase job satisfaction and improve health outcomes for patients. The results of these studies have implications for the design of healthcare facilities and their staff break areas.

Recommendations

The literature revealed that significant health benefits are gained from exposure to nature. These include stress relief, attention restoration, job satisfaction and well as improved patient outcomes. While the literature suggests that therapeutic design features have positive impacts on patient’s health outcomes, few studies look directly at therapeutic design of hospital staff break areas and the benefits this has on nursing staff retention and satisfaction. Although there was a substantial amount of literature on the positive effects of nature on health, as well literature on therapeutic design impacting positivity on health, there was limited research on exposure to nature in break areas of nurses and whether this impacts job retention. This gap in the literature leaves room for further research that directly addresses what impact therapeutic design features of break rooms has on nursing staff job satisfaction and retention.

In addition, my further recommendation after critiquing the literature is that therapeutic design features that include the natural environment should be used in hospital staff break areas. My suggestion is a sheltered garden within the hospital grounds that is exclusively for staff use. The rational for this recommendation is because it is a low-cost intervention that would impact positively on the nursing retention issue we are facing in New Zealand. Moreover, being in nature is the highest level of engagement with nature which the literature affirms has the most restorative benefits. Furthermore, it would meet the criteria of a quality break area that was identified by nurses in the Nejati et al (2016) study. As aforementioned, New Zealand along with the rest of the world is facing challenges retaining nurses to the profession. The literature has revealed that the environment in which we work can significantly affect mood, concentration and job satisfaction. Job satisfaction is a determinant of whether one stays in a job or not, therefore I think it prudent to evaluate how job satisfaction in nursing can be improved. By improving the quality of the breaks that nurses have through the implementation of therapeutic design, we may have better results retaining nurses to the profession.

Conclusion

When posed the question: do therapeutic design aspects in nurses’ break areas decrease stress and improve nursing staff retention, although the research was limited, the literature does suggest that nurses gain significant benefits from therapeutic design interventions. This has implications for the design of healthcare facilities and their break areas. It also has implications for the nursing profession. In New Zealand and gloabaly, the healthcare industry is facing challenges recruiting and retaining nurses. The literature revealed that some of the precipitating factors for nurses leaving the profession include work related stress, fatigue and the quality of the work environment. A recurrent theme was around the levels of engagement with nature becoming incrementally more beneficial as the level of engagement increased. A sheltered garden within hospital grounds exclusively for staff and their breaks would help to improve the quality of nurse’s breaks. This would increase job satisfaction and potentially retention to the profession. Opportunities also exist for making meaning contributions to this field of research that will make a significant impact on nurses and the patients they serve.

References

Applebaum, D., Fowler, S., Fiedler, N., Osinubi, O., & Robson, M. (2010). The      Impact of Environmental Factors on Nursing Stress, Job Satisfaction, and Turnover Intention. The Journal of Nursing Administration, 40, 323-328. DOI: 10.1097/NNA.0b013e3181e9393b

Beukeboom, C, J., Langeveld, D., & Tanja-Dijkstra, K. (2012). Stress-Reducing    Effects of Real and Artificial Nature in a Hospital Waiting Room. Journal of    Alternative & Complementary Medicine, 18, 329-333. Retrieved from: http://dare.ubvu.vu.nl/bitstream/handle/1871/39368/beukeboometal2012jacmstressnature.pdf?sequence=1

Bringslimark, T., Hartig, T., Patil, G, G. (2009). The psychological benefits of indoor plants: A critical review of the experimental literature. Journal of Environmental Psychology, 29, 422-433. doi.org/10.1016/j.jenvp.2009.05.001

Dravigne, A., Waliczek, T, M., Lineberger, R, D., & Zajicek, J, M. (2008). The Effect of Live Plants and Window Views of Green Spaces on Employee Perceptions of    Job Satisfaction. Retrieved from: https://journals.ashs.org/hortsci/view/journals/hortsci/43/1/article-p183.pdf

Duffield, C., Roche, A, M., Homer, C., Buchan, J, M. (2014). A comparative review of nurse turnover rates and costs across countries. Journal of Advanced Nursing,    70(12). DOI: 0.1111/jan.12483

Farquharson, B., Bell, C., Johnstone, D., Jones, M., Schofield, P., Allen, J., Ricketts, I., Morrison, K., & Johnston, M. (2012). Nursing stress and patient care: real-time investigation of the effect of nursing tasks and demands on psychological stress, physiological stress, and job performance: study protocol. Journal of Advanced       Nursing, 22, 2327-2334. Retrieved from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.12090

Hayes, B., Douglas, C., & Bonner, A. (2015). Work environment, job satisfaction, stress and burnout among haemodialysis nurses. Journal of Nursing Management, 23(5), 588-598.

Heerwagen, J, H. (2006). Investing in People: The Social Benefits of Sustainable Design. Retrieved from: https://pdfs.semanticscholar.org/4b48/7f37b80b2ba6793975737489544627ab91ed.pdf

Home, R., Hunziker, M., & Bauer, N. (2012). Psychosocial Outcomes as Motivations for Visiting Nearby Urban Green Spaces. Leisure Sciences. 34, 350-365. DOI: 10.1080/01490400.2012.687644

Kaplan, R., & Kaplan, S. (1989). The Experience of Nature: A Psychological Perspective. New York: Cambridge Univ. Press

Kaplan, S. (1995). The Restorative Benefits of Nature: Towards an Integrative Framework. Journal of Environmental Psychology, 15, 169-182. Retrieved from: http://willsull.net/la270/LA_270_Readings/LA_270_Readings_files/Kaplan%201995.pdf

Lee, K, E., Williams, J, H, K., Sargent, L, D., Williams, N, S, G., & Johnson, K, A. (2015). 40-second green roof views sustain attention: The role of micro-breaks in attention restoration. Journal of Environmental Psychology, 42, 182-189. Retrieved from: https://www.ltl.org.uk/wp-content/uploads/2019/02/40-second-green-roof-views-sustain-attention.pdf#page=7

Maller, C., Townsend, M., St Leger, L., Henderson-Wilson, C., Pryor, A., Prosser, L., & Moore, M. (2009). Healthy Parks, Healthy People: The health Benefits of Contact with Nature in a Park Context. The George Wright Forum, 26, 51-83. Retrieved from: http://www.georgewright.org/262.pdf#page=53

McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., Aiken, L. H., 2011, Nurses' widespread job dissatisfaction, burnout, and frustration with   health benefits signal problems for patient care, Health Affairs, 30, 202-210.

Ministry of Health. (2015). Health of the Workforce 2015. Retrieved from: https://www.health.govt.nz/system/files/documents/publications/health-of-  health-workforce-2015-feb16_0.pdf

National Nursing Organisation. (2014). Report from the National Nursing Organisations to Health Workforce New Zealand. Retrieved from: https://www.nzcmhn.org.nz/files/file/707/23%20May2014_%20NNO%20paper.pdf

Neducin, D., Krkljes, M., & Kurtovic-Folic, N. (2010). Hospital Outdoor Spaces – Therapeutic Benefits and Design Considerations. DOI: 10.2298/FUACE1003293N

Nejati, A., Rodiek, S., & Shepley, M. (2016). The implications of high-quality staff break areas for nurses’ health, performance, job satisfaction and retention. Journal of Nursing Management, 24, 512-523.

Nejati, A., Shepley, M., Rodiek, S., Chanam, L., & Varni, J. (2016). Restorative design features for hospital staff break areas: A multi-method study. Doi: 10.1177/1937586715592632

Nesbitt, I, K. (2004). Work breaks and well-being: the effects of nature on hospital nurses. Retrieved from: https://search.proquest.com/docview/305180320

North, N., Huges, F., Finlayson, M., Rasmussen, E., Ashton, T., Campbell, T., & Tomkins, S. (2004). Nursing Turnover and Staffing Practices in New Zealand’s DHBS: A National Survey. Labour, Employment and Work in New Zealand. Retrieved from: https://ojs.victoria.ac.nz/LEW/article/download/1252/1054/

Park, S.H., & Mattson, R, H. (2009). Effects of Flowering and Foliage Plants in Hospital Rooms on Patients Recovering from Abdominal Surgery. Journal of        Alternative Complimentary Medicine, 9, 975-980.   

Pretty, J. (2004). How Nature Contributes to Mental and Physical Health. Retrieved from: https://www.researchgate.net/profile/Jules_Pretty/publication/240033610_How_nature_contributes_to_mental_and_physical_health/links/5a7ed230458515            4d57d5ed87  /How-nature-contributes-to-mental-and-physical-health.pdf

Schneider, Z., Whitehead., D., LoBiondo-Wood, G., & Haber, J. (2013). Nursing and midwifery research methods and appraisal for evidence-based practice (5th ed.). Sydney, NSW, Australia: Mosby.

Schweitzer, M., Gilpin, L., & Frampton, S. (2004) Healing Spaces: Elements of Environmental Design That Make an Impact on Health. The Journal of Alternative and Complimentary Medicine, 10, 71-83. DOI: 10.1089/1075553042245953

Shin, W, S. (2007) The influence of forest view through a window on job satisfaction and job stress. Scandinavian Journal of Forest Research, 22, 248-253. DOI: 10.1080/02827580701262733

Ulrich, R., Simons, R, F., Losito, B, D., Fiorito, E., Miles, M, A., & Zelson, M. (1991). Stress recovery during exposure to natural and urbane environments. Doi: 10.1016/S0272-4944(05)80184-7

Ulrich, R. Effects of Healthcare Environmental Design on Medical Outcomes. (2001). Journal of Healthcare Interior Design. Retrieved from: https://www.researchgate.net/profile/Roger_Ulrich4/publication/273354344_Effects_of_Healthcare_Environmental_Design_on_Medical_Outcomes/links/557ed93408aec87640ddee0b.pdf

Witkoski, A., & Dickson, V, V. (2010). Hospital staff nurses' work hours, meal periods, and rest breaks. A review from an occupational health nurse perspective. AAOHN   Journal: official journal of American Occupational Health Nurses, 58(11), 489-497.  DOI: 10.3928/08910162-20101027-02