Finding a healthy balance between personal care and the demands of a job are a part of every worker’s life. When your job is to care for others and even to save a life, it is easy and often necessary to put your own needs aside in the midst of stressful, demanding situations.

However, this is not a sustainable approach in healthcare—the costs of chronic stress and fatigue are high for not only care providers but for the entire system around them. This includes their patients, their colleagues, and the organization for which they work, as well as for their friends, family, and community outside of work.

One of the ways that stress and fatigue are addressed in healthcare is through the use of planned breaks for rest and rejuvenation so staff members are ready and able to resume work. Unfortunately, there are barriers to quality break-taking, including individual and community beliefs about work, the structural/operational demands of healthcare work itself, as well as the quality of the built environment in which that work is being performed.

An interdisciplinary team of researchers from Spectrum Health and Nurture by Steelcase in Grand Rapids, Michigan, were interested to see how the built environment, in particular, could be used to help improve the quality of the break-taking experience and its possible related outcomes.

To do so, we underwent a human-centered design research project where we could work with healthcare staff to envision and evaluate new break room experiences in the inpatient hospital.


An extreme break room makeover?
The project began with a Spectrum Health staff satisfaction survey where break rooms were identified as an opportunity area for improvement. Leveraging a bit of a pop culture phenomenon, the organization held an “Extreme Break Room Makeover Competition” so staff could nominate areas to participate in the project.

More than 60 units within the health system submitted applications; three units were chosen to not only get makeovers but to participate in the research and design for their spaces: a perioperative unit, a medical-surgical nursing unit, and a health information management unit.

Following Nurture’s human-centered design approach, the units’ delegates began with secondary research around the nature of healthcare workplace stress and fatigue, and qualities that support rest and rejuvenation.

Impact on individuals
It is widely recognized that nurses have some of the highest rates of work-related injury in the United States. While the physical toll can be high, there is also an emotional toll. According to the work of Karl and Peluchette, “Recent studies of various healthcare professions indicate that emotional exhaustion and job burnout are common problems associated with such occupations and that emotional detachment, increasing caseloads of patients, close interaction with patients, and emotional strain are prominent sources of emotional exhaustion. The intensity of emotional exhaustion tends to be highest in acute care situations.”

When staff do not have the opportunity to decompress in a safe, appropriate, and comforting environment, they carry their emotional and physical burdens with them throughout and beyond their shift.

Impact on colleagues and patients
The repercussions of this can be serious and far reaching. Perhaps the main concern regarding staff rest in healthcare is the impact on patient safety. Rogers, Hwang, and others (Rogers, 2004) studied the relationship of working hours of hospital staff nurses to error. The odds of making an error were three times as great when the shift was longer than 12.5 hours compared to when it was 8.5 hours or less.

Working overtime was associated with increased error regardless of the length of the scheduled shift. With the changes in reimbursement policy around “never events,” increased attention is being paid to ways to reduce the potential for error.

In the study titled “Rest Breaks and Accident Risk,” researchers from the University of Wales in Swansea found that the accident rate in the last half-hour of work was almost double the accident rate during the first half-hour of work for employees working continuously for two or more hours. Ultimately, the researchers recommended short rest breaks every hour to help reduce the risk of accidents.

Impact on the organization
There can be other costs to a healthcare organization that is experiencing high levels of staff stress and fatigue. This can take many forms, including absenteeism, higher medical costs, staff turnover, and reduced productivity and efficiency (“What is Workplace Stress?”, 2001).

According to a study on nurse turnover by the Robert Wood Johnson Foundation, the cost of replacing a registered nurse ranges from about $22,000 to more than $64,000 nationwide, which reflects the expenses associated with filling temporary vacancies, and hiring and training new staff. In the 13 healthcare systems evaluated in that study, the average replacement cost of full-time registered nurses totaled $36,567.


Influencer model of behavior change
With so many factors contributing to and outcomes associated with staff stress and fatigue, the research team found that it was important to situate the study in a framework that would help account for the role of design in a holistic view of break-taking. We recognized that a built environment with qualities that could support rest and rejuvenation would have no effect if it went unused.

With that in mind, we looked to a model of behavior change presented by Patterson, Grenny, Maxfield, McMillan, and Switzler, 2008, in “The Six Sources of Influence.” This model addresses both the motivation and ability to effect change on a personal, social, and structural level.

From a personal motivation standpoint, staff members need to recognize that taking a break is necessary to provide safe, effective patient care. The Safety Assessment Questionnaire (SAQ) is a tool used to measure safety culture transformation. Three items address stress recognition and the performance impairment which may occur when staff is fatigued or have excessive workload. Staff from Spectrum Health may overestimate their personal ability to be safe even when they are stressed and fatigued.

To make headway in personal ability to take a break, staff members have to resolve to take the breaks or meals scheduled for them. “Self-care begins with each individual. Waiting for others to care for ‘yourself’ can lead to a lack of action and a lack of awareness regarding your responsibility to care for yourself” (Spectrum Health, 2010, pg. 2).

In terms of social motivation and ability, when everyone on a unit decides to take meals and breaks, it will encourage individuals to follow-through with their personal resolve to do this. They can demand accountability from each other, perhaps by introducing the covering nurse to their patients before leaving on break, giving up their phones, and taking the full amount of time allotted for meals and breaks.

Spectrum Health employs a care-delivery system known as relationship-based care (RBC). RBC’s principles of breaks, self-care, and a healing environment promote a staff culture that values rest and rejuvenation. Three elements of the RBC care delivery system include:

  • Breaks provide a restful and uninterrupted meal time for each staff member, allowing them to return to work with renewed focus, energy, and safety.
  • Self-care inspires and motivates the nurturing of ourselves personally, emotionally, physically, and spiritually.
  • The healing environ
    ment promotes an atmosphere of optimal physical, emotional, spiritual, and cultural health and healing for all (Spectrum Health, 2010). 

RBC has a social influence when the elements of care delivery are put into practice. For example, by “taking a break,” employees rest and nourish themselves; reassure patients and families who are worried about fatigue and mistakes (especially when staff work 12-16 hour shifts); and reassure peers that they, too, will get a break” (Spectrum Health, 2010).

The key behaviors related to breaks within the RBC care delivery system include: Plan breaks for yourself and your team members at the first team huddle; modify the plan as needed in subsequent huddles; conduct an hourly round on your patients and families prior to break to proactively meet their needs and inform them of the coverage plan; and support your team member’s break by accepting their telephone, pager, etc., and providing excellent patient care while they rest. (Spectrum Health, 2010, pg. 11).


How design fits into the influencer model
The final source of influence in this model is that of structural ability. This is where we believe the design of the built environment could impact break-taking. The project team used a combination of primary and secondary research to identify which principles should be followed in the design of the new break rooms.

These included some specific recommendations around providing a variety of lighting sources, types of storage, and different zones that better supported the activities that were occurring in the break room. For example, in order to drastically reduce the amount of visual clutter in the break rooms, the decision was made to relocate bulletin boards and remove personal items from locker fronts. 

These principles also addressed issues that were around protocols and values. The primary principle the staff expected the redesign to meet was to “demonstrate respect for all staff by designing break rooms that provide environments for rejuvenation and respite.” 

Another significant principle was “design break rooms that encourage staff engagement and promotes a sense of community.” These goals were addressed through a human-centered approach that employs end-user participation to uncover the needs to be addressed within a space and contributes to early buy-in and adoption.

End-users were instrumental in all phases of the project, from identifying issues to creating design principles, drafting plans, to selecting materials and furnishings. They also shared the process with their larger teams on the unit and helped to draft and communicate the “user guide” to the new spaces and acted as a point of contact if their colleagues had questions about the space or the measurement activities that the research team was conducting.


Better design = break experiences for staff
To see whether the redesign of the break room impacted the break experience of the users, the researchers surveyed the users three times about their use of and feeling about the break room, once before the redesign, as well as one month and six months after.

The questionnaire included questions around their actual break-taking habits of the week prior; the congruency of the design of the break room to the design principles; and the impact of the breaks they took on their feeling of rest, rejuvenation and readiness to resume work.

We also conducted a time-lapse video activity analysis of the break room use prior to and one month post-redesign. While there were distinctions between the different units, the overall findings were that the newly designed break rooms provided better break experiences for the staff. 

Both nursing unit and perioperative services areas demonstrated the sustained success and value of the break room makeover project, as evidenced by significant improvements in feeling rested, re-energized, and ready to resume work after taking a break in the renovated break rooms. 

The perioperative service’s area break room design intervention was successful, as evidenced by a significant increase in 20 of 24 user-centered design principle survey items from pre- to post-surveys. These changes in perception were sustained between the one-month and six-month post-surveys. Survey items that especially stood out revolved around engagement and community, the rejuvenating environment, and environmental sustainability. 

Four items did not show statistical improvement because staff perceived them as being present prior to the break room renovation. These included perceptions of the organization’s respect for employees and concern for their safety, and having protocols for getting things repaired and using the space. The perioperative services’ culture already emphasizes these aspects; thus, if it isn’t broken, there is no reason to “fix it.” 

Due to a larger campus plan effort, the health information management unit was relocated and was not included in the study. 

The nursing unit’s break room design intervention was successful, as evidenced by the significant increase in 21 of 24 user-centered design principle survey items from pre- to post-surveys and were sustained between the one-month and six-month post-surveys. 

Items that especially stood out revolved around the perception that Spectrum Health as an organization understood that respite and rejuvenation was important and provided a break room atmosphere that promoted re-energizing and readiness to resume work. The pattern of not taking meals and breaks continued from pre- to post-surveys, which may reflect increases in patient acuity and ongoing nursing staff unit cultural issues.


Recommending a holistic approach
The process used to develop the design principles and this study were informed by research that discusses the correlation between stress, fatigue, unsafe work, and social and emotional needs of healthcare staff.

What is little understood is the nature of rest and rejuvenation in healthcare settings; specifically, how often staff are taking breaks, how staff uses the break rooms they have, what principles can be used to better support rest and rejuvenation, and how universally applicable these principles are for different departments within an organization. 

Because there are many issues that impact the ability for staff to take a break, which therefore results in whether they feel rested and rejuvenate, it is likely that a multifaceted strategy may be required to help staff members change their behaviors around meals and breaks. 

A break roommakeover without an underlying culture thatsupports break-taking will have limited impact. Likewise, a poorly designed and maintained break roomwhich is used will have limited impact on the quality of the break-taking of healthcare staff.

Quality break-taking thatresults in staff feeling rested, rejuvenated,and ready to resume work can help contribute to better experiences and outcomes for staff, patients and healthcare organizations.

Caroline Kelly, EDAC, MID, is a senior design researcher at Steelcase Inc., and can be reached at Karyl King, BAS, PMP, is a project manager and can be reached at Karen J. Vander Laan, PhD, MSN, RN, is senior nurse researcher at Spectrum Health and can be reached at