Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China

Abstract

Objective:

This study investigated Chinese nurses’ preferences for (a) proximity of break areas, (b) functionality of break areas, (c) amenities, and (d) nature-related environmental features.

Background:

While nurses in China need support to adequately perform their jobs, little is known about how restorative spaces impact their mental and physical health.

Methods:

Data were collected through interviews (N = 12), survey questionnaires (N = 88), and visual assessments (N = 88) from nurses who worked in inpatient settings in China.

Results:

Nurses preferred the break room to be close to nursing stations; to have visual privacy from patients; and to provide space and facilities for drinking, taking naps, dining, and chatting with colleagues. Balconies and windows were shown to have a significant restorative effect. Well-designed break areas were perceived to have positive impacts on nurse perceived levels of well-being and increase nurses’ satisfaction levels with their work environment.

Conclusion:

The study outcomes emphasize the importance of restorative spaces for inpatient nurses and recommend including natural elements in the break rooms.

Keywords

nurse respite hospital break rooms nurse preference Chinese hospital design staff surveys

Background

Current Status of Nurses’ Work Environment in China

With a population of 1.4 billion, including 249 million people over the age of 60 (Ministry of Civil Affairs of P.R. China, 2019), China is facing a serious nursing shortage as a result of the increasing demand for healthcare. According to a report on the development of healthcare 2019, the nurse-to-population ratio was 3.18 nurses per 1,000 people (National Health Commission of P.R. China, 2020). In many countries, such as Germany, the United States, and Japan, the number of nurses is higher than 10 nurses per 1,000 people (World Health Organization, 2020). The growing nurse shortage directly threatens patient safety and exacerbates caregivers’ pressure under extremely stressful working conditions (Ulrich et al., 2008). While hospitals are difficult to affect the outcome of a national nurse shortage, providing a supportive work environment for nurses has become more critical under this circumstance.

Nursing has been considered as a high risk profession with high levels of burnout in different countries (Aiken et al., 2011). Multiple studies have demonstrated that nurses in China were suffering from high levels of burnout, especially during the COVID-19 outbreak (Hu et al., 2020; Zhang et al., 2014). Data collected from western countries indicated that both physical environmental factors (e.g., noise, lack of illumination, inadequate daylight, and long-distance walking) and organizational job factors (e.g., exposure to pain and death, intense emotional contact, role stress, and lack of control) can have negative impacts on nurse well-being (Knupp et al., 2018; Ulrich et al., 2008). Researchers in China also found that “work environment and resources” was one of the main stressors for nurses (Yau et al., 2012). Nurses who reported better work environments were less likely to report high levels of burnout and had less intention to leave than nurses who worked in poor environments (Zhang et al., 2014).

While it is clearly important to provide a better work environment for healthcare workers, many hospitals in China fail to support nurses’ daily work. In a case study, Hao (2016) investigated six large public hospitals’ nursing unit spaces and nurses’ needs. The results show that there is a serious lack of space in the duty rooms, locker rooms, and restrooms. The national standards of hospital design in China, detailed in Construction Criteria of General Hospital, have been in effect since 2008. Hao (2016) believes hospitals built to this standard are insufficient to satisfy the demands of patients and healthcare workers.

Restorative Breaks and Environment

Restoration is an important process to restore people’s physical and psychological resources when they are used to meet the demands of everyday life (Collado et al., 2017). Several pilot programs in western countries found that scheduling reasonable breaks and naps can effectively alleviate fatigue and increase the cognitive performance of nurses (Mitra et al., 2008; Smith-Coggins et al., 2006). Restorative environments have also been found to help (rather than merely allow) the recovery of adaptive resources (Collado et al., 2017). Empirical studies suggest that access to nature can reduce stress and promote emotional, physical, and cognitive restoration, in comparison to the built environment (Cordoza et al., 2018). Table 1 lists the design features that were identified from previous research as having positive impacts on nurse outcomes. Several restorative theories have offered explanations of why humans are drawn to natural settings. In the attention restoration theory, natural environments were found to provide effortless attention to facilitate mental restoration (Kaplan, 1995). The biophilia hypothesis also addresses the fact that humans have an inherent inclination to affiliate with nature for their physical and mental health, productivity, and well-being (Myers, 1996).

Table 1.

Design Factors Identified From the Literature Review.

Design Features	Impact	Design Interventions
Physical access to nature	Taking breaks in hospital gardens may mitigate burnout for nursing staff (Cordoza et al., 2018)	Balcony
Exterior and nature view	Perceived visual access to nature views strongly predicts two subscales of nurse burnout (Mihandoust et al., 2021).	Window Artwork
Availability of daylight	A possible microrestorative effect of daylight may have psychological, physiological, and behavioral benefits for nurses (Zadeh et al., 2014)	Window Balcony
Indoor plants	Indoor plants were found to moderate the influence of hospital medical directors’ physician–patient relationship stresses on their short-term health complaints (Lin et al., 2013)	Indoor plant
Nature artwork	Artwork related to nature was perceived to have greater restorative effects than indoor plants (Nejati et al., 2016)	Artwork Photo wall
Aquaria	Aquaria may be potentially as restorative as some nature settings and may therefore offer valuable opportunities for easy and regular access to a restorative environment (Cracknell et al., 2017)	Sea video

While there is a rising awareness of how to provide a less stressful work environment for the staff, there is no code requirement for providing staff break areas, nor are there regulations for mandated breaks in China. In addition, the architectural studies that focus on nursing staff restorative spaces are mostly limited to western countries, such as the United States, Canada, Australia, and Europe (Rechel et al., 2009). Designers, planners, and hospital administrators in China need to understand how the presence, or lack, of restorative spaces and breaks impacts the mental and physical health of their staffs. This study aims to investigate whether restorative rooms are appropriate for and utilized by nurses in China and examine what kinds of functions and design features those restorative spaces should have to meet the needs of nursing staff.

Method

Both qualitative and quantitative methods were used in this study. Figure 1 summarizes the process, and Figure 2 depicts the interview and survey structure. To allow for a cross-cultural comparison, the interview guidelines, questionnaire, and visual assessments were all modified from the tool used by Nejati et al. (2016) in a national study conducted in the United States. This previous study evaluated the usage, preferences, and perceived restorative qualities of staff break areas in the inpatient settings with 10 interviewees and 958 survey respondents. Due to the different protocols associated with Chinese hospitals, several changes were made to the original interview guideline and questionnaire. For example, the question about race was removed since it is inapplicable in the Chinese context. Interviewees were asked to review the questionnaire before the interviews and provide feedback during interviews. Based on the responses to the interview questions and the feedback on the questionnaire draft, the questions and options were revised. Lastly, a pilot study was distributed to two chief nurses to ensure its effectiveness. The suggestions from these two nurses were incorporated in the final questionnaire. This study was approved by the Cornell University Institutional Review Board. Interview and survey participants were inpatient nurses from three public nonprofit hospitals. All hospitals located in the urban area of Shaoxing, a city in eastern China’s Zhejiang province with a resident population of approximately 5 million with a subtropical monsoon climate similar to southeastern United States. The directors of the nursing departments helped post recruiting information in chat groups through WeChat, a Chinese social platform offering mobile instant text, audio and video messaging services.

Figure 1.

Research procedures.

Figure 2.

The structure of the interview and questionnaire.

Interview

The interview session lasted about 40 min in all, including 30 min for open-ended questions and 10 min for questionnaire feedback. The interview guideline (see Online Appendix A) included questions about nurses’ perceptions of their current work environment, nurses’ preferences for their future work environments, and nurses’ views on restorative spaces and breaks. Each interview was conducted as an online one-on-one video or audio meeting on WeChat. The audios were recorded with participants’ permission.

The textual information gathered from the interviews was examined by thematic content analysis. The goal of the analysis was to generate detailed and mutually exclusive themes addressed in the interviews and to link the themes and the interviews under an exhaustive category system (Burnard, 1991). The researcher began by reading the recording transcriptions and offering a summary statement for all of the topics discussed. The notes from all interviews were then grouped together and similar categories were combined. Next, the researcher linked each coded section of the interviews to categories and subheadings. Each category was color coded and each interviewee was assigned identifying tags, such as “Nurse 1,” “Nurse 2,” and so forth. To improve the validity of the categorization procedure and avoid lone researcher bias (Burnard, 1991), another researcher was invited to independently generate a category system and file cards under the new system. Adjustments were minimal and there is no distinction of consequence. For example, one researcher grouped shift and break patterns together, while another categorized them separately. Finally, an organized data set was made and the findings were written based on that.

Survey

The survey included a total of 34 items, consisting of 24 multiple-choice questions, eight open-ended questions, and two sets of visual assessments.

In visual assessment, participants were asked to rate two sets of photographs of break-room spaces in terms of the restfulness and refreshment that they engendered on a scale of 0 (low quality) to 10 (high quality). Each visual assessment set included an original photo of the real break room and six variations. Two original images represented two typical kinds of staff break rooms. Using Photoshop CC editing software, features were superimposed on each basic image: a plant, nature art, a window, a balcony, a sea video, and a photo wall (see Figures 3 and 4). The original photo and the first four variations were created by Nejati et al. (2016), and the last two features were based on interviewee preferences. Using this tool enhanced the credibility of the research and allowed for a cross-cultural comparison regarding the results. All design factors added in this study were generated as part of the literature review (see Table 1).

Figure 3.

First set of visual assessments (reprinted with permission from Adeleh Nejati).

Figure 4.

Second set of visual assessments (reprinted with permission from Adeleh Nejati).

Results

Interview Results

Twelve nurses participated in the interviews, consisting of three nurses from Hospital A, four nurses from Hospital B, and five nurses from Hospital C. All of them were female and had more than 5 years of work experience in inpatient settings. The departments they worked in included medical oncology, cardiology, pediatric surgery, surgery, maternity, and intensive care units.

Work intensity

All interviewees indicated that nursing practice in the inpatient setting was very intensive. It required the full attention and immediate response to patients. Staffing shortages aggravated the insufficient coverage. The recommended ratio of the number of nurses to the number of beds is 2.5 in China. However, the interviewees indicated that few departments could meet this standard. Even for those departments that seemed to have enough nurses, the shortage remained a potential problem when nurses were on leave. In addition to an intense workload, working long shifts was another challenge. All interview stated that they worked 8-hr shifts. In most cases, day shifts were from 8 a.m. to 4 p.m., the evening shifts were from 4 p.m. to 12 a.m. (midnight), and the night shifts were from 12 a.m. (midnight) to 8 a.m. Despite these three regular shifts, departments may have helper shifts (bang ban), lunch shifts (zhong ban), duty shifts (zhi ban), and so on, as needed.

Handover between shifts is time-consuming. Typically, it takes 30 min before and after each shift, resulting in an extra hour beyond the scheduled shift time. In most departments, there was no scheduled break during the day shift to avoid extra handovers. However, shift patterns, working hours, and working pace varied from department to department (see Figure 5).

Figure 5.

Examples of shifts.

Current break spaces and preferences for restorative spaces

The available spaces nurses can use to take breaks include on-duty rooms and dining rooms. On-duty rooms are places for nurses or doctors to sleep at night while they are on call. All interviewees indicated that they had an on-duty room, which was close to the patient care area, usually located within the units. Overcrowding is the most serious issue in on-duty rooms, which was mentioned by more than half of the interviewees. The occupancy availability of an on-duty room was far below the number of nurses who wanted to take naps during their lunch breaks. Even though some departments had added lounge chairs and recliners, the space and furniture were insufficient to satisfy nurses’ needs. The majority of nurses had to share a bed with another nurse or doctor. Dining rooms are where nurses and doctors eat and store drinks and food and seven of the 12 interviewees said that they had a dining room. All nurses indicated that they remodeled their rooms and purchased the equipment themselves, since the appliances and amenities in the original room are often inadequate. In terms of outdoor spaces, all of the participants indicated that the hospital did have public outdoor break areas such as gardens and balconies. However, none of the interviewees had the habit of going outside for breaks. The reason most frequently stated for staying inside was the lack of time. Compared to walking outside, eating and napping had a higher priority during nurses’ lunch breaks.

One of the most frequently highlighted functions of break areas was to help nurses escape from stressors. Interviewees working in oncology and intensive care units characterized their working experience as challenging. One described the experience as “encountering emergencies and sudden death of patients all the time.” In terms of appliances and furniture, all interviewees constantly highlighted the need for refrigerators, microwaves, electric water kettles, and water dispensers. These appliances were perceived to provide fundamental support for eating and drinking, especially for nurses on evening shifts and night shifts when food was difficult to obtain. Dining tables for four to eigth people were also mentioned repeatedly. Other strongly preferred amenities were comfortable furniture with soft materials on the surface, such as couches and reclining chairs.

In the interview, the restorative effects of natural elements also were tested. All participants indicated that windows and balconies would be the strongest stress reliever. Additionally, windows and balconies were perceived as having other benefits. “Letting nurses know what time it is when they wake up,” “having natural ventilation,” and “providing spaces for drying clothes in the sun” were all mentioned by the interviewed nurses. Several nurses expressed a desire for plants, as well as concerns about a lack of time to care for them.

Survey Results

Responses were received from 88 nurses. The link for the online survey was sent to the nurses’ chat groups and the directors estimated that the total number of nurses who clicked on the survey link was 255. Thus, the estimated overall response rate is 24.4%. On average, the participants took 14 min and 24 s to complete the survey. Demographic information is provided in Table 2. Most of the participants worked in medical (34.1%) or surgical practices (42.0%). About half of the nurses (47.7%) indicated that they had been working in an inpatient care unit for more than 10 years.

Table 2.

Survey Demographic Information.

Demographic information	Frequency, n	Percentage, %
Age
<24	5	5.7
25–29	20	22.7
30–34	28	31.8
35–39	18	20.5
40–44	13	14.8
45–49	4	4.5
Level of education
Technical degree	9	10.2
Bachelor’s degree	77	87.5
Master’s degree	2	2.3
Professional status
Nurse	13	14.8
Senior nurse	25	28.4
Charge nurse	39	44.3
Associate chief nurse	10	11.4
Chief nurse	1	1.1
Work position
Student	3	3.4
Staff nurse	67	76.1
Head nurse	14	15.9
Director/associate director	2	2.3
Nurse supervisor	2	2.3

Work intensity

The average working time per week was 43.1 hr (SD = 6.1). The average number of working shifts per month was 23.0 (SD = 3.0) and the majority of shifts (65.7%) were during the day (day shifts and lunch shifts). However, only 3.7% of the participants worked day shifts only. In terms of break patterns, the majority (65.9%) took 2-hr breaks and a few of the participants (23.9%) had no breaks. Other participants provided explanations such as “Sometimes I have to work during my breaks,” “I have scheduled lunch breaks, but it is not 2 hours,” and “It depends on which specialty I am working in.” Aside from lunch breaks, a small percentage of the participants (12.5%) had nonmeal breaks (mean = 3.3, SD = 1.5) and several nurses (6.82%) indicated that it depended on busyness (see Table 3).

Table 3.

Work Intensity.

Work and break patterns	Frequency, n	Percentage, %
Working hours per week
35–39	11	12.5
40–44	46	52.3
45–49	13	14.8
50–54	9	10.2
55–59	7	8.0
≥60	2	2.3
Working shifts number per month
<20	2	2.6
20–24	59	76.6
25–29	11	14.3
≥30	5	6.5
Lunch breaks
Two-hour lunch break	58	65.9
No lunch break	21	23.9
Other	9	10.2
Nonlunch break
Have nonlunch break	11	12.5
No nonlunch break	71	80.7
Other	6	6.8

Note. Number of participants = 88.

The participants were asked to describe how stressful their work environment was on a scale of 0 (low) to 10 (high). The average stress level was 6.65 (SD = 1.78). A multiple regression analysis was performed to understand the extent to which individual nurse factors, such as work environment and meal break patterns, correlated with nurse perceived stress levels. Together, the predictive variables were shown to contribute significantly to the regression model, F(10, 77) = 2.302, p = .020, and to account for 23% (R ² = .2301) of the variation in perceived stress in the work environment. Nurses’ positions, whether they were working in surgery departments or not, and overall satisfaction with break areas were the significant predictors of perceived stress (see Table 4).

Table 4.

Multiple Linear Regression Analyses of Perceived Stress in the Work Environment.

Predictive Variables	Coefficients β	p Value
Age	−.080	.148
Level of education	−.239	.707
Professional status	.280	.478
Position	−.497*	.030
Specialty—surgery versus other	−.923*	.030
Work hours	−.019	.415
Direct patient contact	−.007	.477
Interpersonal relationship	.135	.282
Meal breaks—no versus other duration	.707	.136
Overall satisfaction with break areas	−.608**	.008

Note. Number of participants = 88.

*p < .05.

**p < .01.

Available break areas and future restorative spaces

When asked whether they had spaces for quick naps in their units, the majority (85.2%) stated that they used on-duty rooms. The vast majority of respondents (78.4%) had on-duty rooms in their units and a very small number of respondents (2.3%) had on-duty rooms outside their units. In addition, it is common (94.3%) for nurses to have an on-duty room with a window or balcony, which allowed nurses to have a view of the outside. The participants reported a significant lack of break rooms; only 42.2% indicated that they had break rooms in their units. Taking breaks outdoors was not common among nurses. The majority (85.4%) did not go outside even in good weather, and for nurses who went outside during their breaks, the average number of outdoor breaks was 1.7 (SD = 0.67) times each week.

Table 5 shows the participants’ preferences for space functionality, amenities, and design features. In general, participants wanted break rooms to serve as a place for drinking, taking naps, dining, and chatting. When nurses were asked about their preferences for nature-related features in break areas, windows, balconies, and plants were preferred at a much higher frequency than other features. In terms of the desired location for a break area, “close to the nursing station” and “have visual privacy from patients” were mentioned. On average, nurses indicated that the walk time from the nurses’ station to the restroom should be less than 1 min.

Table 5.

Preference for Future Break Areas.

Design features	Frequency, n	Percentage, %
Functionality
Drinking	83	94.3
Taking naps	82	93.2
Dining	79	89.8
Chatting	76	86.4
Writing reports	18	20.5
Meeting	11	12.3
Amenity
Electric kettle	56	63.64
Dining table	54	61.36
Watercooler	48	54.55
Chairs	46	52.27
Locker	38	43.18
Coffee maker	31	35.23
Television	30	34.09
Exercise	23	26.14
Computer	21	23.86
Nature-related design features
Window	81	92.05
Balcony	81	92.05
Plant	77	87.50
Nature artwork	36	40.91
Nature sound	30	34.09
Nature photography	28	31.82
Spatial relationship of on-duty rooms and break rooms
Should be together	12	13.60
Should be different places	51	57.90
Either way works for me	26	29.50
Other^a	1	1.14

Note. Number of participants = 88.

^a The participant who chose Other did not answer the reason.

Visual assessments

In this section, the participants were asked to evaluate two sets of images, according to the effectiveness of each room in relieving stress and relaxing on a scale of 0 (low) to 10 (high). Overall, the second set of images had higher scores than the first. Rooms with balconies were given the highest scores for restorative quality. The images without nature-related amenities in both sets had the lowest scores. The average scores of plants, nature artwork, sea video, and wall photo were similar across the two sets (see Tables 6 and 7).

Table 6.

Descriptive Results for Visual Assessment Set 1.

Set 1	Response	Mean	SD	Standard Error	95% Confidence Interval for Mean		Min.	Max.
Set 1	Response	Mean	SD	Standard Error	Lower Bound	Upper Bound	Min.	Max.
Original	88	3.50	2.35	.25	3.01	3.99	0	10
Plant	88	4.94	2.37	.25	4.45	5.44	0	10
Artwork	88	5.02	2.45	.26	4.51	5.54	0	10
Sea video	88	5.05	2.40	.26	4.54	5.55	0	10
Photo wall	88	5.49	2.59	.28	4.95	6.03	0	10
Window	88	6.59	2.26	.24	6.12	7.06	0	10
Balcony	88	7.33	2.22	.24	6.87	7.79	0	10

Table 7.

Descriptive Results for Visual Assessment Set 2.

Set 2	Response	Mean	SD	Standard Error	95% Confidence Interval for Mean		Min.	Max.
Set 2	Response	Mean	SD	Standard Error	Lower Bound	Upper Bound	Min.	Max.
Original	88	6.70	2.34	.25	6.22	7.19	0	10
Plant	88	7.23	2.36	.25	6.73	7.72	0	10
Artwork	88	7.23	2.25	.24	6.76	7.70	0	10
Sea video	88	7.23	2.34	.25	6.70	7.68	0	10
Photo wall	88	7.06	2.28	.24	6.58	7.53	0	10
Window	88	7.95	1.99	.21	7.54	8.37	0	10
Balcony	88	8.77	1.87	.20	8.38	9.16	0	10

A one-way analysis of variance was used for each image set to determine whether there were any statistically significant differences between the means of participants’ ratings for various design interventions. The results indicated that at least one design intervention was perceived to have a different restorative quality in each set, Set 1: F(6,609) = 23.9, p = .000 and Set 2: F(6,609) = 8.646, p = .000. Tukey’s honestly significant difference test was applied to two sets of all pairwise comparisons simultaneously. It identified differences between two means that are greater than the expected standard.

Figure 6 shows the mean score for two sets of images. For image Set 1, six images with various design features were perceived to have higher restorative quality than the original image. Windows and balconies were perceived to be more restorative than other design interventions. However, there was no significant difference between the images with a plant, artwork, sea video, and a photo wall. Similarly, no significant difference was shown between the images with a window and a balcony in Set 1. In terms of image Set 2, there was no significant difference between the original image, the image with a plant, artwork, sea video, and a photo wall. As with Set 1, balconies were perceived to be more restorative than plants, artwork, sea video, and photo wall. No significant difference was shown between the images with a window and a balcony.

Figure 6.

Visual assessment rating score (Set 1 and Set 2).

Regression models have been run to examine what features contributed to the perceived satisfaction levels. The features include age, level of education, professional status, position, specialty, work hours, direct patient contact, and interpersonal relationship, whether have scheduled meal breaks, satisfaction levels with the current work environment, and stress levels. The chosen targets are the average satisfaction levels of Set 1 and the average satisfaction levels of Set 2. However, the results are not strong enough across two sets to suggest significance.

Discussion

Work Intensity

Nurses in this study reported working 43.1 hr per week, which is much higher than the number reported in other countries. One study conducted with nurses in Sweden showed that full-time nurses worked 38.25 hr per week (Furåker, 2009). A study in the United States indicated that nurses worked 37.2 hr a week (Stimpfel et al., 2020). Nurses who work overtime with inadequate breaks or meal periods do not have enough time to rest between consecutive shifts, which can result in fatigued and stressed nursing staff and a greater incidence of medical errors (Bae & Fabry, 2014; Rogers et al., 2004; Stimpfel et al., 2020). Therefore, there is a significant need for healthcare facilities to schedule restorative breaks to help nurses to lower their fatigue and thereby increase patient outcomes.

However, the study results indicated that nurses did not have enough breaks. Departments generally do not schedule breaks during shifts in order to reduce the number of handovers. Only a few departments scheduled lunch breaks for nurses depending on the work content of departments. Nurses who had scheduled meal breaks mainly worked in medical oncology, surgery, maternity, and cardiology. Since shift patterns vary from department to department, policies and schedules should be tailored to meet the needs of each department.

However, the study results indicated that nurses did not have enough breaks.

The empirical data collected in this study showed that high levels of stress were prevalent among nurses. Although some hospitals in China experienced nurse burnout during the COVID-19 outbreak (Hu et al., 2020), this was not the case at these facilities. Nurses did not mention that the pandemic had affected their workload, which could be explained by the fact that the outbreak in the region is not severe. There were no positive cases in Shaoxing during the study period (August and September of 2020; Shaoxing Health Commission, 2020).The findings of a multiple linear regression analysis of perceived stress levels revealed that nurses with higher positions (such as directors and head nurses) and those working in surgery departments were prone to having higher levels of stress. One explanation may be those nurses had greater work intensity and responsibility. The findings also revealed that hospital break areas accounted for a significant portion of the variation in reported stress. Nurses perceived higher levels of stress when they were dissatisfied with the current break areas. This connection demonstrates why hospitals should provide nurses with restorative spaces.

Nurses perceived higher levels of stress when they were dissatisfied with the current break areas.

Lack of Spaces

Based on staff responses in written surveys and interviews, nurses’ current break areas cannot fulfill their needs. On-duty rooms were nurses’ top choice to take meal breaks. All participants stated that they had on-duty rooms and almost all on-duty rooms were located within their units. As for dining rooms, the results of the interviews and questionnaires were considerably different. While a small percentage of survey respondents (12.5%) indicated that they did not have eating areas on the unit, nearly half of the interviewees (46.7%) stated that they did not have dining rooms. Since some nurses ate lunch in on-duty rooms, some survey respondents might have considered on-duty rooms as dining rooms, which caused the difference in data.

Overall, on-duty rooms were mainly used for sleeping and relaxing. In the departments without dining rooms, nurses also used on-duty rooms for eating and drinking. The main problems of the indoor break areas were overcrowding and insufficient appliances. Nurses renovated the spaces and added appliances to their on-duty rooms or dining rooms, which reflects their desire for well-equipped break areas. Those problems were also identified in previous research. In a case study, Hao (2016) investigated six large Chinese public hospitals’ nursing unit spaces and found a serious lack of space in the duty rooms, locker rooms, and restrooms.

Lack of spaces forces nurses to use the rooms in multiple ways. Because the majority of nurses take their breaks at the same time, they share the break areas, including dining rooms and on-duty rooms. As a result, when nurses nap in an on-duty room, the window or balcony is usually covered by a curtain, despite the fact that almost all on-duty rooms have a window or balcony, nurses rarely have a chance to enjoy the view. Nurses used outdoor spaces extremely infrequently. Few nurses choose outdoor spaces to take meal and nonmeal breaks. Accordingly, walking outdoors was relatively uncommon among nurse break activities. Resting outdoors is prioritized after dining, taking naps, and writing unfinished reports. One explanation for this inadequate usage may be tied to the local climate. Shaoxing has a humid climate and abundant rainfall throughout the year. From June to September, the average daily high temperature of Shaoxing is over 83°F. Surprisingly, long travel distances may not be the main reason for the infrequent usage of outdoor spaces. Many nurses indicated that they have gardens within a 3-min walking distance but almost never think of going to gardens.

Implications for Future Break Areas

With limited time available for breaks, nurses strongly preferred to locate break areas in close proximity to patient care areas and nurse stations. With break areas nearby nurse stations, nurses can quickly react to patients’ emergency conditions if the need arises. A shorter walking distance to a break area increases the likelihood that nurses will be able to take breaks. Past research showed that break areas with easy access to work stations encouraged higher levels of usage (Shukor et al., 2012). Nurses requested that restorative spaces have visual privacy from patients and their families, as well as only be able to be accessed by medical professionals. This is because the patients and their families could be a distraction for nurses during their breaks. Similarly, nurses preferred that restorative spaces be “separate from but close to on-duty rooms.” In this way, the nurses who use the break room will not disturb the nurses who take naps.

The results of visual assessments suggest that break rooms with necessary amenities were perceived to have much greater restorative effects than normal break rooms (i.e., rooms with a table and chairs). While all nature-related design features were perceived to have restorative effects, they have greater enhancement of restorative effects for normal break rooms than the break rooms with amenities. The basic functions that the design of restorative spaces should support include drinking, taking naps, dining, and chatting. Kitchen appliances are essential for nurses’ daily diet since they rarely have time to go to the cafeterias within the hospital or restaurants outside the hospital. Comfortable furniture such as sofas, recliners, and chairs covered with soft (but cleanable) material are strongly suggested. Good, ergonomically supportive furniture could reduce nurse fatigue from long hours of standing and walking, as well as create a cozy atmosphere. The restorative spaces should be clean, quiet, and home-like. Amenities such as soft music background, counters and tables and ecological tanks were welcomed by nurses.

While all nature-related design features were perceived to have restorative effects, they have greater enhancement of restorative effects for normal break rooms than the break rooms with amenities.

Differences and Commonalities Between China and the United States

Compared with previous studies that Nejati et al. (2016) conducted with nurses in the United States, the data collected in this study showed several differences and commonalities (see Table 8). This discrepancy in shift patterns, break patterns, and napping habits between the United States and China may be due to different cultural norms.

This discrepancy in shift patterns, break patterns, and napping habits between the United States and China may be due to different cultural norms.

Table 8.

Difference Between Nurses in China and the United States.

Respite patterns	The United States (Nejati et al., 2016)	China (This Study)
Shift pattern	The majority worked day shifts only (63.3%). A few (6.8%) worked a combination of day shifts and night shifts	Most participants (96.3%) in this study worked a combination of different kinds of shifts
Break pattern	A half-hour meal break and several short breaks	Two-hour lunch break and no other breaks
Dedicated room for napping	Only 7.5% of the participants had dedicated spaces for restorative naps	All nurses had on-duty rooms for taking naps
Napping habits	The majority (52.2%) did not want to share a napping room with other co-workers	All nurses shared on-duty rooms with other nurses

Nurses from two countries perceived images differently. Figures 7 and 8 show the ratings of the same images from nurses in China and the United States. Overall, nurses in China gave higher scores than nurses in the United States, especially for the original images. While nurses in the United States perceived artwork to have greater restorative effects than plants, Chinese nurses perceived them to have similar effects. Furthermore, nurses in the United States placed a higher value on physical access to nature than nurses in China. Nurses in the United States rated rooms with balconies significantly higher than rooms with windows in both Sets 1 and 2. According to the findings of this study, Chinese nurses did not perceive rooms with balconies be significantly better. The small sample size of the study, however, is likely to have influenced this result.

Figure 7.

Visual assessment rating scores comparison—Set 1.

Figure 8.

Visual assessment rating scores comparison—Set 2.

Conclusion

Regarding the limitations of this study, the participants of this study were recruited from three public hospitals, which were located in the same city and were of similar sizes. Therefore, the findings of this study may not be generalizable to nurses in other regions of China. Future research should examine nurses’ preferences in different regions and settings.

Regarding methods, although visual assessment can simulate reality in a straightforward way, it can only test design features in static images, which may mitigate their potential restorative effects in space. For future studies, it would be valuable to provide a pre/postcomparison to examine whether nature-related design interventions have restorative effects in a real-world setting. Future research tools might extend beyond self-report and visual assessments. More objective measures such as assessing users’ physiological and psychological changes or behavioral mapping would enhance our understanding of the use of potentially restorative spaces.

This study provided insights into the appropriate design of respite space for nurses in China and allowed for a cross-cultural comparison between China and the United States. As there is limited data on these topics, this preliminary study serves as the basis for future research leading to the improvement of healthcare environments for nurses. Important findings such as overall satisfaction with break areas being related to perceived stress, insufficient outdoor use being influenced by the local climate, and the relationships between desiring taking naps and culture should be the focus of future research.

Implications for Practice

The following are guidelines for respite areas for nurses in China.

Restorative breaks and spaces may play an important role in reducing nurses’ stress and increasing nurses’ job satisfaction.

Break areas should have easy and quick access from patient care areas, so that nurses can save walking time during breaks as well as react to patients immediately. In addition, break areas should have visual privacy from patients and visitors.

Break rooms should be separate from but close to on-duty rooms to reduce interference between nurses who are taking breaks and nurses who wish to take naps.

Drinking, taking naps, dining, and chatting are the basic functions that the design of restorative spaces should support. Related appliances and comfortable furniture should be equipped within the space.

Design interventions related to nature could improve nurses’ satisfaction with break areas. Balconies and windows were perceived to have higher restorative effects than indoor plants, artwork, photo walls, and sea video. It is therefore highly recommended to include natural elements, especially daylight and exterior views, in the design of future break areas.

Supplemental Material

Supplemental Material, sj-pdf-1-her-10.1177_19375867221075837 - Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China

Supplemental Material, sj-pdf-1-her-10.1177_19375867221075837 for Assessing Preferences and Perceived Restorative Qualities of Break Spaces for Nurses in China by Xiaoyi Zhu and Mardelle McCuskey Shepley in HERD: Health Environments Research & Design Journal

Footnotes

Acknowledgment

We would like to thank Dr. Adeleh Nejati for sharing the visual assessments tool, Susan Watkins and Dr. Tove Helland Hammer for their helpful comments, and Yuxuan Zhao for his support during data analysis. We would also like to extend our gratitude to the three directors of nursing departments for their sincere support in distributing recruitment information.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Xiaoyi Zhu, BA, MS

Supplemental Material

The supplemental material for this article is available online.

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