Research by the Centre for Sustainable Healthcare shows gardens and other green spaces at hospital sites have an important role to play in supporting staff wellbeing. CSH continued that research with a year long workplace wellbeing and green space study.

What is the Space to Breathe Study?

Our year-long study focused on three NHS sites that had taken steps to encourage their staff to relax and recharge in green space. Staff stress has long been a critical issue for the NHS, where in 2019 more than four in 10 staff reported feeling unwell as a result of work-related stress in the last 12 months. These problems have been greatly exacerbated by the Covid-19 pandemic, making staff wellbeing a greater priority now than ever. Our research shows that there is a strong appetite among health staff to take time outdoors – either for breaks or in the course of work – and points to a range of wellbeing benefits.

The study found

• At each of the sites a large majority of staff (83-89%) said they would like to spend more time in green space at their site than they currently did. Benefits described included feeling relaxed and calm, refreshed and re-energized and positive effects on mental and physcial wellbeing. A sizable proportion of staff (44-52%) said attractive green spaces were important to them in considering where to work – suggesting that this affects recruitment and retention. 
• Staff who said they regularly spent time in their sites’ green spaces during the working day reported significantly higher levels of wellbeing. The more ways in which staff said they spent time in green space at work, the higher was their reported wellbeing. 
• The most common way in which staff spent time in green space at work was taking a walk at the site during a break. This points to strong potential for encouarging informal walking, either alone or with others, an initiative that had already proved successful at one of the sites in the study. 
• While relatively few staff at each site had engaged in organised recreational activities at work, such as Qigong or gardening, those who had had slightly higher wellbeing scores than those who had not. At each site a sizable minority of staff (14-24%) expressed an interest in outdoor activities, with enthusiasm at all three sites for outdoor mindfulness.
• Staff who had face-to-face contact with patients spent less time in green space than those who did not. However, contact with patients was also found to predict wellbeing. This sugests that staff spending time with patients in green space enjoy a dual wellbeing benefit. 

Our study was carried out in collaboration with the University of Essex and with support from the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK. 

The research, conducted before the pandemic, explored staff experience of time in green space at work, including both benefits and barriers. For more details please see the summary briefing and full report below.

Outdoor wellbeing sessions

Following on from this work, CSH is working with the social enterprise Natural Academy to provide outdoor wellbeing sessions for health staff at five NHS sites around the country during 2021. At each site, further training will be offered for two staff to deliver these sessions themselves. We will be closely evaluating the sessions and their benefits for participants. The project is supported by the Green Recovery Challenge Fund, which is being delivered by the National Lottery Heritage Fund in partnership with Natural England and the Environment Agency. 

Experience at three NHS sites

The three sites in our study are part of our NHS Forest network, an alliance for health sites that are working to improve the therapeutic use of green space for the benefit of patients, staff and the wider community. Each site is different, allowing us to explore the value of green space for staff in contrasting settings. While each has a generous
amount of green space, their experience in making the most of this is transferable to other sites, including more urban ones working with different constraints.

Broomfield Hospital, Mid and South Essex NHS Foundation Trust

Broomfield Hospital in Chelmsford, run by Mid and South Essex NHS Foundation Trust, provides acute and community-based services, and has more than 5,000
staff. The hospital’s green spaces include woodlands, a fruit orchard, vegetable beds, a large lawn and a newly restored sunken dell garden.

Within the hospital building there are several green courtyards, attached to wards and the main atrium. In addition, staff have use of an outdoor Wellbeing Terrace,
with tables and parasols, sculptures, planters and games

For several years the Trust has run a Natural Health Service project: an initiative which invites volunteers, including staff, to help in creating and maintaining the
gardens and woodlands, while learning horticultural skills. It has been calculated that in the course of a year these volunteers gave 1,900 hours, worth £18,600 in
paid staff time. The Trust runs a programme of events and activities to promote its green spaces, which have included a Big Woodland Walk and a twilight bat tour.
It has also produced a walking map of the grounds showing seasonal wildlife. Our site-wide survey shows that the Broomfield Wellbeing Terrace is popular with
staff: 22% had sat there to relax or eat.

Guide Lodge, Lancashire and South Cumbria NHS Foundation Trust

Guild Lodge, run by Lancashire and South Cumbria NHS Foundation Trust, is a medium secure mental healthcare hospital on the edge of Preston, with 500 staff and 164 service users. Staff say the site is ‘wrapped around in greenery’ thanks to its rural location. The hospital’s Grow Your Own Project supplies the hospital kitchens with organic produce and helps both service users and staff to learn horticultural skills, with activities that include staff team-building days.

Both staff and service users participate in Guild in Bloom – an annual site-wide competition to foster pride in individual ward gardens.

The Trust’s Workspace Walking initiative aims to promote staff wellbeing by creating a positive ethos around informal walking at work. The idea is that, where feasible, staff should feel free to take a short walking break, either alone or with others, during the
working day.

Staff have taken ownership of the concept. In our site-wide staff survey, 39% said when taking a break from work they regularly walk outdoors and notice the
gardens and green spaces while 26% had taken informal site walks arranged with other staff.

Mount Vernon Cancer Centre, West London

Mount Vernon Cancer Centre in Northwood, West London, is a regional specialist centre with 500 staff, run by East and North Hertfordshire NHS Trust. Historically a tuberculosis hospital, the centre’s main green space is a large lawn, overlooked by the
sanatorium terraces where patients once received ‘open air treatment’. In our site-wide survey, 56% of staff said they had used this area to relax and eat, emphasising its importance to the site and its identity. The idea of using the site’s outdoor areas for health and wellbeing took hold when the Community Engagement Manager attended a talk about green gyms and realised, what their site lacked in indoor space, it more than made up for in outdoor space. A consultation found staff wanted activities that they could complete in half an hour, which were low in cost and would not make them sweat.

In the last three years the hospital has piloted outdoor lunchtime sessions for staff and volunteers that include a walking group and Qigong, a system of movement,
breathing and meditation. At the time of our study the centre was also refurbishing a garden area and had plans to create a woodland walking trail.

Watch the recording from the launch event on 22 October 2020

https://www.youtube.com/embed/6W8vMW2srEs?feature=oembed>Research outline>

The research explored staff experience of green space at work using qualitative and quantitative methods, including:

• In-depth interviews with green space leads at each hospital to understand the initiatives that had taken place there
• One-to-one interviews at each hospital with staff who regularly spend time in green space at work, and staff who do not (34 across all sites)
• Consultative workshops at one site
• Site-wide staff surveys at each hospital (981respondents in total, with response rates of 12.5% at Broomfield, 22.8% at Guild Lodge and 48% at Mount Vernon)

What are the benefits of time in green space at work?

Much previous research has shown the benefits of being in green space for reducing stress and boosting mood. This is strongly reflected in this study which points to
positive effects for staff themselves and for their work with patients.

Benefits for staff wellbeing

Both interviewees who regularly spent time in green space at work and those who didn’t were enthusiastic about the personal benefits of this. When asked how
they found the experience, the most common response was ‘relaxing’ or ‘calming’.

Those who did regularly spend time, especially, spoke about breathing deeply or
freely, fresh air, a sense of space and a clear head. They also talked of enjoying the beauty and variety of nature.

Interviewees from both groups said being in green space made them feel happy and positive and helped to reduce stress.

Many interviewees described feeling refreshed, recharged and re-energized and thought they worked better on returning to work. There were interviewees
from both groups who saw time spent in nature at work as time to themselves, and an opportunity for reflection, with some connecting being in nature to spirituality.
Green space was widely viewed by interviewees as good for wellbeing, with the stronger emphasis on mental wellbeing than physical wellbeing

Some interviewees described how outdoor walking and talking with colleagues could facilitate more difficult conversations and help with problem-solving. The vast
majority of interviewees said they would like to spend more time in green space than they currently did though some felt this was not realistic. Our site-wide surveys at the three hospitals also show staff enthusiasm for spending time in green space at work:

• 83-89% said they would like to spend more time in these areas of the site than they currently did
• 65-78% said being in green space at work made them feel calmer and more relaxed.
• 54-68% said it made them feel refreshed and re-energized
• 48-59% said it would make them more effective when they returned to work
• 74-80% enjoyed the beauty of their site’s green spaces and garden areas
• 44-52% said the availability of attractive garden areas and other green spaces at a hospital site was important to them in considering where to work – suggesting that this could be a factor in recruitment and retention.

Benefits for patient care

Interviewees at all three sites were appreciative of the therapeutic benefits of green space for patients. This was especially so at Guild Lodge, the mental health unit.
Here more than 18% of staff said they regularly spent time in green space when working with patients and visitors.

• Some interviewees felt that being outdoors together – simply sharing the experience of nature – was helpful in reducing power disparities between staff and service users.
• A health assistant described the positive effects of going out into the grounds in calming a troubled patient and reflected that he had also felt safer personally as a result, despite being away from the support of his colleagues.
• In our site-wide surveys 51-70% of respondents said they found the site’s garden areas and green spaces helpful in meeting the needs of patients. However, at two of the sites the proportion of staff who regularly spent time in green space in the course of working with patients and visitors was very low (1.3% at Broomfield and 2.5% at Mount Vernon).
• At other sites, interviewees described the benefits of garden areas as private places for holding sensitive conversations with patients and relatives, for instance, when imparting news or talking through anxieties

Recommendations for good practice

Our research indicates that helping staff to spend time outdoors contributes to wellbeing and suggests ways of tackling the barriers that prevent this. NHS sites wishing to encourage staff to spend time in green space need to focus on both physical and cultural issues.

Green space close to work

To maximize opportunities for a green break, it is important to locate green spaces close to where people work – ideally providing all buildings with garden areas. In this research staff especially valued outdoor areas next to staffrooms or offices. In new-build hospitals such access should be designed-in from the outset.

Green space for restaurants and rest areas

Hospital canteen facilities and rest areas should have access to outdoor space with chairs, tables and adequate shade (e.g. parasols or awnings) so that staff can spend time in green space in the warmer months and look out on green views all year. None of the restaurant areas in the study had such direct access.

Privacy for staff outdoors

In locating green outdoor seating areas close to work areas, it is important to consider staff privacy and to avoid locations that are readily overlooked or where
staff feel that their conversations cannot be private. Sites should explore the scope for designated outdoor staff areas that provide a degree of screening as well as weather protection in sun and shade – for example gazebos or other types of outdoor shelter, or seating with tables and umbrellas or awnings in areas effectively screened by greenery.

Green walking routes

To encourage staff to take green walks in the hospital grounds – either during a break or more incidentally in the course of their work – sites should develop attractive, well-signed and well-delineated green walking circuits, enabling those moving about the hospital to experience a pleasant green route, that is not dominated by parked cars or moving vehicles.

Supportive working culture

Encouraging staff to make use of outdoor amenities also requires a supportive working culture, in which staff feel permitted to take time out in green space, either alone or together, as opportunities arise, for instance, to reduce stress or to talk through an issue with a colleague. To achieve this it is recommended that senior staff explicitly endorse such activity and promote the benefits of workspace walking, including by their own example.

Outdoor activities

Offering organised recreational activities – such as a led walking group, gardening or games – not only creates an opportunity for staff to engage in green space but helps
to communicate organisational support for this. Surveys at the three sites in our study highlight enthusiasm for outdoor mindfulness sessions.

Green space for patient care

Staff should be encouraged to find more opportunities to help patients enjoy the therapeutic benefits of their site’s green spaces, an activity that could also enhance
their own wellbeing.

Guidance on clinical clothing outdoors

Managers should clarify whether there are conditions in which it is permissible for staff to sit in scrubs in outdoor space, providing they also wear a protective plastic
gown.

If infection control requires that staff moving from their immediate surroundings for their lunch break must change out of clinical clothing, then this change should
be accommodated within their work time.

Other resources

The research was supported by the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and healthcare for people in the UK. Thank you to all those who contributed to the research.