Why set up a Green Walk?
Green walks for mental health patients are nothing new. The value of time spent in natural spaces has long been recognised and championed particularly by occupational therapists. However, growing pressures on services have meant that wards are increasingly pushed to provide a minimum of care.
In their simplicity, walks in green space represent the effort to begin introducing more holistic ways of caring. Moreover, as we recognise the importance of green space in supporting wellbeing, it is apparent that those of us admitted to hospital should be afforded this as a basic right. Finally, in supporting the establishment of a new green walk, we allow ourselves to reflect on the sort of treatment we would want for ourselves, as much as those for whom we care.
- The Evidence Base
- Patient and Carer Perspectives
- Benefits to Physical and Mental Health
- National Recommendations
- A Model of Sustainable Healthcare
'Walking in green spaces as a new standard in mental health care responds to the need for a sustainable health service, and champions models of care which strive to be holistic and human while supporting our connection to the world around us.' - Dr. Adrian James, President-Elect, Royal College of Psychiatrists
‘We owe it to those whom we care for to adapt to the challenges placed on us to provide the highest standard of mental health care. Elegant in its simplicity, Green Walking is an important initiative which urges us to consider how we can safely provide the sort of care we would wish for ourselves.’ - Dr. Geraldine Strathdee, Co-founder, Zero Suicide Alliance & Non-executive Director, South London and Maudsley NHS Foundation Trust
‘Leisure has the potential to fulfil so many needs, particularly in acute mental health settings where boredom gives space and energy to introspection and isolation. Learning how to justify and use leisure to benefit those we support is the most important skill that healthcare providers can develop. This guide goes a long way towards doing that for Green Walking.’ - Dr. Tania Wiseman, Occupational Therapy Course Lead, University of Brighton
‘Scientific evidence strongly supports the common-sense notion that good access to green and natural space supports health in multiple, synergistic ways. The Green Walking Guide highlights that access to the natural world is a vital element in our wellbeing, perhaps particularly when we are at our most vulnerable’ - Professor Catharine Ward Thompson, University of Edinburgh
‘It was the most rewarding group. It was an intervention that got consistently positive feedback’ – Clinical walk leader, Green Beacon site, Kent
Walking groups are an established intervention in inpatient mental health settings – but they are currently under-used. Walking outdoors should be viewed as part of routine care, here is why:
Firstly, hospitals have a responsibility to provide a therapeutic environment which promotes mental healing and recovery. This is even more important where people are detained against their will under the Mental Health Act. Patients appreciate walks and staff have reported that the whole ward can feel calmer after a group has returned from a walk.
Secondly, time spent in green spaces and physical activity can contribute directly to people’s mental wellbeing and recovery. For some, it provides a connection to a time before they became unwell; for others, this may be their first experience of connecting with nature, which may become a relationship that sustains them through their recovery.
Thirdly, green walking can contribute to improving physical health in people living with severe mental illness, whose life expectancy is currently 10-20 years shorter than the rest of the population. At some of the Green Beacon sites, walkers with previously poor mobility have been seen to grow in confidence and balance as well as fitness.
Finally, as an intervention that consumes few resources and yet supports both recovery from a current crisis and resilience to future crises, green walking is a shining example of sustainable healthcare.
On reflection, the benefits of green walking can seem obvious, and it supports several national recommendations for mental health care. But not everyone is already on board. To help your case, we have compiled the research and policy evidence that follows, and in Learning from Green Beacons we share advice from wards that have successfully run their own green walks. This may seem like an overwhelming amount of evidence, and it is! This is a great thing – you can copy it into your own resource or funding proposal for high impact.
Studies of people’s experiences of inpatient mental health services have identified the importance of high-quality relationships with staff, reducing violence and the need for restraint, and providing meaningful activity as part of holistic care. Green walking can contribute positively to all of these.
‘Patients identified the importance of holistic care encompassing medical, psychological and occupational care. However, the review revealed that medical approaches were often the dominant treatment method during their inpatient stay. Rose (2001) also highlighted the paucity of activities and talking therapies in the inpatient environment.’ (Wood and Alsawy, 2016)
‘Patients suggested that inactivity slowed the in-patient care pathway, reduced self efficacy, exacerbated symptoms and was related to aggression and violence on the ward.’ (Staniszewska et al, 2019)
Observations and feedback from the Green Beacon sites corroborate published findings that patients enjoy walks and identify them as helpful in their recovery.
‘I really enjoyed that’
‘I like being out, I walk around my local park when at home’
‘Enjoyed that, getting off the ward and getting fresh air’
– Patients at Green Beacon sites
Walking together in nature offers a space for relationships with staff to develop. Both patients and staff at the Green Beacon sites found that walks were a good time to talk, with less of the healthcare professional-patient divide. In several cases, it was while on a walk that patients opened up for the first time.
‘I really enjoy spending time with staff and peers away from the ward as it’s good to be able to talk about random things and not things to do with the ward or our illnesses.’ - Patient at Green Beacon site
Green walking, through strengthened relationships with staff, together with the calming effects of physical activity and time spent in natural spaces, can help people to feel supported, relieve anxiety and reduce the need for restraint.
‘One of the service users is quite chaotic on the ward and more challenging. They seemed to calm down quite a lot being off the ward and spoke of their garden at home. It also helped in building a therapeutic relationship with this individual.’ – Clinical walk leader, Norfolk
In addition, whether simply walking, engaging in conversation, observing wildlife or sketching the view, green walking can be a meaningful activity, which connects people to their life before the crisis and, possibly, to an imagined future.
‘I loved it. Being in the green space and getting fresh air, being in nature is so grounding. I’m a very spiritual person and I need those connections.’
‘It’s good to have something to do with my time, what other exercise can I do?’
‘They’re my favourite trees, reminds me of a park I used to go to.’
– Patients at Green Beacon sites
There are now many reviews and summaries that provide overviews of research on specific aspects of the relationship between physical and mental health:
- The robust evidence base showing that exercise in the natural environment has many therapeutic benefits, for both mental and physical health, is summarised in the Natural England briefing : Links between natural environment and mental health evidence briefing (July 2016).
- A review of nature-based interventions for mental health care (Feb 2016), also by Natural England,  shows that taking part in nature-based activities helps people who are suffering from mental ill-health and can contribute to a reduction in levels of anxiety, stress and depression.
- A lot of the medical literature on the relationship between nature and wellbeing looks at psychological health in particular. Dan Bloomfield’s evidence report for NHS Forest, A Dose of Nature: Addressing chronic health conditions by using the environment (2014), is a useful resource.
There is a wealth of published research, much of which is referenced in the above overviews. Hartig et al. (2003) have demonstrated that nature can have a ‘restorative and therapeutic effect on the mind’. Pretty et al. (2005) found that taking part in green exercise led to improved self-esteem and a reduction in feelings such as depression and anger.
Reports in 2004 and 2007 by William Bird found that benefits from contact with the natural environment included reductions in obesity, heart disease, diabetes, cancer, stress, ADHD, aggression and criminal activities, among others.
In 2013, the Green Exercise Research Team at the University of Essex published a report evaluating the charity Mind’s ecotherapy programme (Bragg et al. 2013). It presents three mechanisms for how green space may confer healing effects: a possibly innate “dependence on, and desire to connect with, nature”; , the importance of nature in restoring attention; and the value of nature in reducing stress, which by default brings other benefits to individuals. This report also discusses the importance of interacting with green space through physical exercise and its benefits to mental wellbeing.
Green Exercise has been well-researched and proven to be a great way in which to improve fitness and enhance mental health and confidence. Studies demonstrate numerous correlations between exposure to nature and different indices of health and wellbeing, and an overview by Hartig et al. (2014) shows that the evidence regarding these benefits is strong.
Good evidence for Green Prescriptions, whereby a healthcare practitioner prescribes an activity in green space, comes from research done on a programme run by the New Zealand Ministry of Health. , That study, published in the British Medical Journal, found that a Green Prescription increases physical activity levels and improves quality of life over 12 months, without evidence of adverse effects. It also reported that for every ten Green Prescriptions written, one person achieved and sustained 150 minutes of moderate or vigorous leisure activity (using up an additional 1000 kcal) per week, and a 20–30 percent risk reduction in all-cause mortality (Elley et al. 2003). Such prescriptions were also shown, via a randomised control trial, to be cost effective at three different quality-adjusted life year thresholds, for adults who were previously inactive (Leung et al. 2012).
There is epidemiological evidence that is strong enough to support calls for nature-assisted therapies to be part of care. Significant improvements were found for varied outcomes in diverse diagnoses including schizophrenia (Maller et al. 2006). To be effective this means bringing together health and environmental management sectors (Annerstedt and Währborg 2011).
Greenspace also has proven therapeutic value within healthcare environments, facilitating good recovery and improved physical and mental health (for example Marcus 2005).
In 2005, some interesting research was carried out by the Mental Health Foundation (Halliwell)) which tried to understand why GPs do not refer patients to exercise for treatment of mild to moderate depression. It found that 42% of GPs would try exercise as one of their top three strategies if they themselves became depressed, but only 5% prescribe exercise to their patients.
Green Walking embodies and helps to take forward a number of national recommendations in mental health:
2011 NICE Clinical Guideline [CG136], Service User Experience in adult mental health: In acute mental health care, the guidelines call for a broad range of social, group and physical activities as essential elements of the service provided.
2011 DEFRA Natural Environment White Paper, The Natural Choice: securing, the value of nature: This report highlights that “nature is sometimes taken for granted and undervalued” and sets out the need to strengthen the connection between people and nature, to build “prospering communities and personal wellbeing.”
2014 NHS England Strategy Report, Sustainable, Resilient, Healthy People & Places: This report outlines a vision for developing a health and care system that is financially, socially and environmentally sustainable.
2014 NHS England, The NHS Five Year Forward View: This planning document cites concern with the ‘factory model of care and repair, with limited engagement with the wider community’ that is sometimes in evidence in the NHS, and strives for a ‘radical upgrade in prevention and public health.’
2016 Commission on Acute Adult Psychiatric Care, Old Problems, New Solutions: The Commission advocates for ‘a philosophy of care which is holistic, person-centered, facilitates recovery and which is underpinned by humanity, dignity and respect.’
2016 NHS England, The Five Year Forward View for Mental Health: The strategy calls on Commissioners to ‘emphasise early intervention, choice and personalisation and recovery’ and to consider physical health needs in tandem with mental health.
2018 Independent Review of the Mental Health Act, Modernising the Mental Health Act – summary version: The review recommended the introduction of ‘four new principles’ to inform the Mental Health Act in future, which are: ‘choice and autonomy, least restriction, therapeutic benefit and the person as an individual.’ The following recommendations are also particularly relevant:
- No. 82 notes that the CQC should develop new criteria for monitoring the social environment of wards.
- No. 84 highlights the need for improvement to inpatient wards.
- No. 154 states that NHS England should consider implications of the evidence linking staff morale and patient experience.
2018 RCOT, Getting my life back: occupational therapy promoting mental health and wellbeing: Recommendations include improving the physical health of people with serious mental health problems by incorporating and promoting healthy occupations.
2019 RCPsych, Standards for Inpatient Mental Health Services 3rd Ed: These core standards for inpatient mental health services are revised by the Royal College of Psychiatrists’ College Centre for Quality Improvement (CCQ). The following standards are helpful to reference:
- No. 6.1.6 states that every patient has a seven-day personalised therapeutic/recreational timetable of activities to promote social inclusion, which the team encourages them to engage with.
- No. 6.1.11 insists that patients have access to safe outdoor space every day.
- No. 21.1 notes that the ward/unit actively supports staff health and well-being.
- Guidance: For example, providing access to support services, providing access to physical activity programmes, monitoring staff sickness and burnout, assessing and improving morale, monitoring turnover, reviewing feedback from exit reports and taking action where needed.
2019 RCPsych, Standards for Acute Inpatient Services for Working Age Adults (AIMS-WA) 7th Ed: Fulfilling the following standards will help your ward to reach accreditation through the AIMS scheme:
- No. 46 identifies the importance for patients to have access to weekly activities which focus on accessing green spaces.
- Guidance: The manner in which the green space is engaged can include a range of activities from a basic group walk but also include interests which can be supported by staff and reflect interests of patients such as photography, drawing, mindfulness etc.
- No. 74 states that patients have access to safe outdoor space every day.
- No. 150 observes that staff recognise the benefit of using natural settings or green spaces to enhance the therapeutic potential of the ward environment and make patients aware of those benefits.
2019 NHS England, The NHS Long Term Plan: The planning document offers the observation in point 3.102 under the Inpatient Care section that ‘for people admitted to an acute mental health unit, a therapeutic environment provides the best opportunity for recovery. Purposeful, patient-orientated and recovery-focused care is the goal from the outset.’
This evidence is powerful, but it is equally important to see how it is working in practice. Learning from Green Beacon sites focuses on the experiences of places that have successfully introduced Green Walks. This is also evidence, but of a different kind, taking us from theory into practice.
The current global ecological crisis threatens to irreversibly alter the conditions under which human civilisation has evolved. Within the decade, the whole world – including healthcare – must change to become sustainable. We now need to reshape health services to provide the best health outcomes for patients and populations from the wisest use of environmental, social and financial resources:
Green walking applies the principles of sustainable clinical practice
In mental healthcare, sustainable value may be achieved through:
- Prioritising prevention, thereby reducing the need for health care in the future.
- Empowering individuals and communities, improving mental health resilience through self-management and independent living, social networks and employment.
- Delivering the right intervention, at the right time, to the right person.
- Considering the carbon impacts of interventions and models of care to enable design of carbon efficient services.
In the right circumstances, Green Walking embodies all of these principles: contributing to prevention of future ill health, offering a means of self-management, improving resilience and enhancing the inpatient pathway, all at a minimal environmental cost.
Green Walking and the ‘triple bottom line’
Green Walking scores well across the ‘triple bottom line’ of environmental, social and financial resource use:
Environmental: Green walking makes use of an abundant, low carbon, natural resource with potent therapeutic value: green spaces. By spending time in and noticing what is around us, we can actually benefit the environment by developing our connection with nature, learning to cherish and protect it.
Social: Green walking strengthens social connections and restores social capital - including among staff, who not only benefit directly from the activity itself, but also take satisfaction from developing meaningful connections with patients and witnessing their steps to recovery.
Financial: Finally, green walking is inexpensive, relying primarily on the time of existing salaried staff, with few additional costs. Meanwhile, it contributes to patients’ recovery and, potentially, their resilience to future (expensive) mental health crises.