Connecting with the natural health service
Spending time in nature is not only beneficial to patients’ health but is restorative for general practice nurses, and may be an antidote to the stresses of a busy working life
Earlier this year, twenty-two nurses from GP surgeries across South Yorkshire swapped stethoscopes for binoculars for a day of experiential learning at RSPB Old Moor nature reserve near Barnsley. The day focused on how connection to nature can benefit health and wellbeing. The day was part of the Practice Nurse vocational training scheme (VTS) with the South Yorkshire Primary Care Workforce and Training Hub.
A practice nurse clinic typically involves many patient encounters, multiple streams of electronic communication, constant task switching, complex risk assessment and decision making. ‘It’s a busy job,’ explains Nurse Educator Sarah Newton. ‘The workload on general practice teams has been intense and unrelenting for years; you frequently reach the end of the day physically and mentally depleted. Burnout is a problem in general practice as much as anywhere in the NHS, that’s why clinical supervision is a core element of the South Yorkshire’s Practice Nurse VTS. The model we follow is normative, formative and restorative. Today was about the nurses turning their attention to their wellbeing and taking restorative peer support out of the classroom and consultation room and into nature.’
Led by nurse educators from the Training Hub, the day began with a look at how the body and mind respond to time in nature and the growing evidence and theory emerging to explain this. The nurses were quick to identify the potential mechanisms and benefits of spending time in so-called blue (water) and green space for patients. These include impacts on physical activity, weight, stress, blood sugars, and vitamin D, and reducing isolation and loneliness, improved mood and sleep quality.
During the session the nurses were invited to recall and share their sensory memories and meanings of connection to nature from childhood before reflecting on when and where they encounter nature now as adults. Common in the recollections were themes of play, freedom, inquisitiveness and exploration. Then it was out into the reserve with the opportunity to try a selection of nature connection activities in between visiting the hides: a mindful, sensory walk; meeting a tree blindfolded; and cloud spotting.
Old Moor is an 89-hectare wetland nature reserve created in a post-industrial mining landscape in the heart of Dearne Valley, outside Barnsley. Wetlands are the UKs most important habitat in terms of biodiversity, supporting a host of migratory and wading birds along with a range of small mammals, insects and plant species. Through a process of decontamination and regeneration Old Moor has achieved recognition as a Site of Special Scientific Interest for its importance to nature recovery and has been the model for wetlands restoration at other sites across the UK.
Back in the classroom the nurses were tasked with mapping the blue and green spaces in proximity to the GP surgery that are available to them and their patients. ‘South Yorkshire does not do badly for access to the scenic national parks, but it is the green and blue spaces much closer to home that stand to have much greater impact on our wellbeing,’ Nurse Educator Heather Jones says. ‘That’s something I took from lockdown when I cycled daily from Sheffield to Rotherham to work as a practice nurse, following the River Don. That ride was precious, there was something about being alongside the steady flow of the river that helped still my thoughts and process feelings. I often saw a heron, twice glimpsed a kingfisher and once saw a grass snake, all while gradually witnessing the seasons change. I have always noticed and appreciated nature but now I go to these places with intention, not to just pass through, but to be present.’
The session closed with discussion of ways that, as nurses, they might enhance their personal connection to nature. Suggestions included reintroducing awareness of the seasons through food and rituals, observing the phases of the moon, logging in to online wildlife cameras, listening to nature soundscapes, or finding a regular spot to sit and practise mindfulness.
Reflecting on her day, practice nurse Sam Hirst said, ‘Being able to focus on our wellbeing somewhere as beautiful as this, the insects, birds and wildlife, the tranquillity here... spending time with colleagues outdoors, in a situation that was not work focused, allowed us to get to know each other better and build our friendships. In nursing we are constantly told the importance of [developing] personal wellbeing and building resilience, but rarely given an opportunity to do so. Today was a literal breath of fresh air. ’
‘This session was as much about empowering the nurses to discuss benefits of time in nature with patients as it was for them to explore what it offers them as space for respite, reflection and restoration,’ explains Nurse Educator Clare Jones. ‘There are places like Old Moor, accessible to communities up and down the country, which are managed by the RSPB, local Wildlife Trusts, the Woodlands Trust and others, to support wildlife and develop a nature recovery network.’
Heather Jones adds: ‘There is something that happens in natural settings. I know it in myself and have felt it in the presence of others; that hectic human tempo can give way to one that is more universal, communal and ancient. The truth is I think we, health care professionals and patients, need nature every bit as much as nature needs us.’
EVIDENCE FOR HEALTH BENEFITS OF NATURE
So how can connection to nature affect health and wellbeing ? Let’s look at the evidence.
Air and noise pollution are known to be associated with increased incidence of cardiovascular disease; recent research has thrown light on the pathology.1,2 Particulate matter and exposure to chronic noise pollution can cause oxidative stress and damage to the inner lining of blood vessels and other tissues, and dysregulate the nervous system’s control of the heart and blood pressure. Other research points to nature providing a lower-stimulus, restorative space that can bring respite from cognitive and emotional overload.3 City planners have long recognised the importance of providing parks and green infrastructure for alleviating the intensity of urban living by offering urban dwellers spaces for rest and relaxation.3 This research proposes that our affinity to nature may be in part about counteracting the internal dysregulation that can arise with urban environments and modern living.
Efforts to build the evidence base for the incorporation of nature-based therapies in healthcare have been bolstered by a recent evaluation of their use to support people experiencing mental health challenges.4 Over 8,000 patients were referred to a range of nature-based activities through a green social prescribing programme. Nature-based activities could focus on conservation, wilderness, gardening, farming, sport, creativity, and talking therapies in the outdoors. Analysis of outcomes found statistically significant improvements across self-reported happiness, physical activity, life satisfaction, feeling life was worthwhile and reductions in anxiety. Importantly, the evaluation calculated a social return on investment of £2.42 per £1 invested.4
It may be early days for green social prescribing in the UK, but health care professionals in Japan have been referring patients to the ‘Natural Health Service’ for decades. Shinrin-yoku, the practice of mindful walks in ancient woodlands, is a national prescription to alleviate work stress with consistent evidence of positive effects on cardiovascular health, immune function and inflammatory processes from both Japan and South Korea.5
Shinrin-yoku, or forest-bathing, is now taking off in the UK. A recent study conducted in ancient woodlands in Sheffield offers clues to the medicine beneath the trees. It is well-known that trees absorb carbon dioxide and emit oxygen. However, analysis of air samples taken from under the tree canopy of a species-rich ancient woodland reveal that besides oxygen, an array of organic chemicals with known anti-inflammatory, antioxidant, antimicrobial and neuro-protective properties, are being emitted.6 It is proposed that the abundance and diversity of these chemicals in ancient woodlands could be significant in terms of the health benefits of spending time in such environments.
Another theory on how connection to the living landscape enhances wellbeing is nature’s capacity to influence focus, thoughts and feelings.7 Awe is an emotion that can be distinguished from other emotional states by facial expressions, behaviours and thought patterns, and physiology. Awe-inducing experiences have been shown to prompt release of oxytocin, the hormone that promotes trust and bonding and tempers fight or flight neural and inflammatory responses. Studies of psychology and cognition in the emotional state of awe suggest that focus on self and feelings of entitlement can shift towards a sense of common humanity, meaning and purpose, while studies of behaviour observe humans are more likely to share, co-operate and sacrifice. These are thought patterns and behaviours which are protective against feelings of depression and despair.
CONCLUSION
In summary, we may know by intuition that time in blue and green spaces can help us feel better. The positive effects nature can have on health and wellbeing are not just physiological but increasingly understood to be psychological, social, emotional and spiritual, effects which are now being utilised in the form of green social prescribing programmes. Practice nurses may want to consider how regular nature connection may may support them manage the emotional demands of the job, enhance reflective practice and peer support and be a resource for personal wellbeing along the lifespan of their careers.
REFERENCES
1. Al-Kindi SG, Brook RD, Biswal S. et al. Environmental determinants of cardiovascular disease: lessons learned from air pollution. Nat Rev Cardiol 2020; 17, p. 656–672
2. Münzel T, Sørensen M, Daiber A. Transportation noise pollution and cardiovascular disease. Nat Rev Cardiol 2021; 18, p. 619–636
3. Poulsen MN, Nordberg CM, Fiedler A, et al. Factors associated with visiting freshwater blue space: The role of restoration and relations with mental health and well-being. Landscape Urban Planning 2022; 217
4. Haywood A, Dayson C, Garside R, et al. National Evaluation of the Preventing and Tackling Mental Ill Health through Green Social Prescribing Project: Final Report Briefing. January 2024. Department for Environment, Food and Rural Affairs London
5. Park BJ, Tsunetsugu Y, Kasetani T, et al. The physiological effects of Shinrin-yoku (taking in the forest atmosphere or forest bathing): evidence from field experiments in 24 forests across Japan. Environ Health Prev Med. 2010 ;15(1) p.18-26.
6. Walker H, Jena A, McEwan K, et al. Natural Volatile Organic Compounds (NVOCs) Are Greater and More Diverse in UK Forests Compared with a Public Garden. Forests. 2023; 14(1):92
7. Monroy M, Keltner D. Awe as a Pathway to Mental and Physical Health. Perspect Psychol Sci.2023; 18(2): p. 309-320.