A pilot programme evaluated the use of outdoor activities in green spaces adjacent to hospitals as part of rehabilitation services for cardiac patients
Evidence suggests that green spaces next to hospitals can be used to promote health. This article reports on a pilot study to determine how hospital green spaces can be used for patients with cardiac problems and their rehabilitation programmes. Over a six-week period, patients spent one hour per week taking part in activities, including tai chi, photography and willow sculpting, as part of their rehabilitation programme. Patients showed improved physical health, less social isolation, a better overall mood and increased positivity. They were also more likely to choose to exercise than at the start of the rehabilitation programme, and valued the new skills and knowledge that they gained.
Citation: McNish H (2014) Using outdoor activities in cardiac recovery. Nursing Times; 110: 19, 12-14.
Author: Hugh McNish is health adviser at Central Scotland Conservancy and leads on the delivery of the Forestry Commission Scotland’s Health Programme.
- This article has been double-blind peer reviewed
Cardiac rehabilitation has a central role in reducing the recurrence of cardiac events such as myocardial infarction, and increasing cardiac patients’ general fitness and confidence. It is usually provided in community or hospital settings.
In 2011, the Arts and Humanities Research Council and the Scottish Funding Council were awarded funding for a knowledge-exchange partnership to develop and test a community engagement process to encourage greater use of a green-space project.
The partnership involved the University of the Highlands and Islands (UHI), Forestry Commission Scotland (FCS), NHS Forth Valley and NHS Highland. NHS Forth Valley and FCS had already joined forces with Central Scotland Forest Trust and Falkirk Council to transform the woodlands surrounding Forth Valley Royal Hospital into a green oasis for staff, visitors and local people.
The work is also supported by the Green Exercise Partnership, which encourages local health boards to get involved in improving hospital grounds for health and wellbeing purposes. We decided to pilot the use of the woodland in our cardiac rehabilitation programme.
Forth Valley Royal Hospital, in Larbert near Falkirk, is carrying out the latest in a series of projects in Scotland to improve the provision of and access to green space and woodlands within and near hospital grounds; projects have already been completed at Ninewells Hospital in Dundee and Lawson Memorial Hospital in Golspie.
The aim of creating these peaceful surroundings is to encourage people from hospitals and their wider communities to make greater use of woodlands to enjoy physical activity, recreation, recuperation and relaxation.
Work started in the Larbert woodland in 2011 to make it more accessible and enjoyable for all who use it. New trails have been constructed throughout the woodland, along with an outdoor classroom for local schools to use. The woodlands were thinned to open them up and allow light to penetrate to the forest floor, while a loch-side viewing platform and seating area provides a focal point for visitors.
A ranger was appointed by FCS to manage the development of the site and the hospital partnership; this was the first role to be jointly funded by the commission and a health board.
Developing the programme
The programme development phase involved a range of stakeholders to ensure its content was appropriate to patients’ needs and would motivate them to attend the sessions.
Workshop and service-user input
As part of the engagement process, UHI researchers designed and carried out workshops with cardiac staff and patients with cardiac problems at Forth Valley Royal Hospital to identify their needs and desired outcomes (Munoz and Nimegeer, 2012). This approach follows one of the seven standards for cardiac prevention and rehabilitation recommended by the British Association for Cardiovascular Prevention and Rehabilitation (2012). Surprisingly, workshop participants did not want to carry out parts of their existing cardiac physical rehabilitation programme in the woodlands, but saw the outdoor programme as having the potential to address the effects of cardiac incidents on mental health, which are generally less discussed. This demonstrates the value of engaging patients and health professionals in setting their own priorities and choosing activities that fit in with them.
As part of its investigation into the impact of green space on health, a team from UHI developed evaluation techniques to determine the success and outcomes of the pilot.
Input from FCS
FCS offers outdoor skills programmes throughout the year to a wide range of user groups and ages. It used its existing programme, Branching Out - which offers adults using mental health services in Scotland three hours of activities per week in a woodland setting - as a template for the cardiac pilot. The commission worked with NHS Forth Valley staff to develop a programme of activities to be delivered over the six-week pilot period. They aimed to select activities that would appeal to patients and take into account their aims, as expressed in the research phase.
The cardiac rehabilitation team at NHS Forth Valley offered the outdoor sessions to their patients as part of their rehabilitation programme; 20 patients were interested in taking part and were offered a place on the pilot. Participants who volunteered were at least six weeks into their rehabilitation programme, which meant it was around 10-12 weeks since their cardiac incident; this allowed the team to assess and educate them on exercise and pacing as well as to allow patients to build up their confidence and exercise tolerance. The group also included patients who were members of Healthy Hearts, a phase 4 maintenance group for patients who have completed the early rehabilitation classes and whose cardiac event had occurred 12 weeks or more previously.
The programme was delivered in hour-long sessions run weekly over six weeks; these were led by FCS rangers and NHS Forth Valley staff. Participants were offered a range of activities including:
- Health walks;
- Tai chi;
- Conservation activities, such as clearing rhododendrons;
- Bushcraft skills, such as building shelters and lighting fires;
- Creative activities, including photography and making willow sculptures.
The BACPR (2012) recommends this type of menu approach to achieving clinical effectiveness and sustainable health outcomes.
Results of the pilot
The team from UHI evaluated the pilot using several tools, including longitudinal mixed-method questionnaires with validated questions from the EQ5D health outcome questionnaire (www.euroqol.org), the Warwick-Edinburgh Mental Wellbeing Scale (tinyurl.com/NHSScot-WEMWBS) and the Connectedness to Nature Scale (Mayer and Frantz, 2004).
Participants completed the questionnaires at the start and end of the programme, as well as short evaluation forms after each session. Interviews with them and observations were also used during evaluation. Improvement was noted in the following four key areas:
- Physical health;
- Mental health;
- Skill development (reported by most participants in their evaluation forms in response to “Have you experienced any other positive or negative impacts of taking part?”);
- Physical exercise (most participants reported in evaluation forms that they had increased the amount of exercise they took and were more likely to use the outdoors for exercise as a result of taking part).
Overall levels of mobility and levels of pain (self-assessed by participants) remained the same.
Participants were asked to score their health out of 100 using a visual analogue scale (EQ5D VAS validated measurement tool). Their scores at the end of the programme were an average of seven points higher than before it started.
Using qualitative feedback, participants reported experiencing decreased stress, improved mood, less social isolation and a general increase in positivity. The Scottish Intercollegiate Guidelines Network (2002) confirms that psychological factors - such as those shown to improve over the programme - can have a significant positive impact on cardiac-related recovery and associated costs.
Participants valued learning new skills and gaining knowledge, in terms of both outdoor activities such as woodland maintenance and strategies to cope with stress, such as continuing to use tai chi in their daily lives.
Those who completed the course undertook an average of 0.78 more exercise sessions per week than at the start.
The cardiac team felt that incorporating forest walks into the programme gave patients a “real-life” activity as part of their rehabilitation, which increased their confidence about walking without being with the group. This meant they were not associating rehabilitation with a gym environment only, but with everyday activity.
The programme has enabled NHS Forth Valley to increase the range of cardiac rehabilitation activities available to patients. Academics and clinical staff involved in the project have attributed the successful outcomes of the pilot, in part, to involving patients in setting their own priorities and choosing their own activities. Patient feedback from the early planning stages did not match staff assumptions about the type of activity they might like to do; this underlines the value of user engagement.
During interviews, the cardiac team reported that being in an outdoor environment helped their relationships with patients, which meant they were able to offer more valuable support. Staff felt they knew their patients better after going through the programme; they got to know their personalities, needs and abilities and felt better able to connect with the patients, motivate them and provide them with tailored support.
The woodland project highlights the importance and effectiveness of considering more options to support patients through their rehabilitation programme. In particular, it provides significant evidence for the positive impact of lifestyle-related activities in addressing the mental health effects of having a cardiac incident. Patients showed signs of improvement in physical and mental wellbeing, with real improvements in their positivity.
The natural environment helped to deepen relationships between patients and staff and enabled nurses to get to know patients better, demonstrating the benefits of making use of informal settings outside the ward and hospital environment. The green-space setting also varied the delivery of the rehabilitation programme, with forest walks incorporated into the education sessions.
Patients were inspired to walk in the woodland by themselves as a result of the pilot; before taking part, many had been unaware of its existence. After the pilot, they also showed signs of increased confidence and exercised more, helping to improve longer-term health benefits.
Although this project used green space next to a hospital, it has implications for nursing practice at hospitals with no woodlands or green space nearby. Improved awareness among nursing staff of woodland and other outdoor areas close to the hospital and patients’ homes would give patients and their families options to support their rehabilitation with woodland-based recovery. Better knowledge of local groups and activities, such as walking groups and tai chi classes in local parks, would further enhance options for patients.
The pilot study was developed and delivered through a collaboration involving FCS, NHS Forth Valley and UHI. Other hospitals should consider existing partnerships and initiatives in their local area to support similar programmes, and establish collaborations with organisations that are likely to have common health objectives.
NHS Forth Valley, FCS and the UHI recommend that this programme should be rolled out on a permanent basis for patients with cardiac problems at Forth Valley Royal Hospital.
SIGN (2002) acknowledges that psychological factors - such as those shown to improve over the course of the programme - can have a significant impact on cardiac-related recovery and associated costs.
The potential to pilot it with other patient groups should be considered, including patients with cancer and stroke, who may also benefit from many of the outcomes.
- A growing body of evidence suggests that using green spaces next to hospitals can improve health outcomes
- Using a woodland-based cardiac rehabilitation programme, combined with regular cardiac rehabilitation activity, can boost recovery
- Engaging patients in setting priorities and taking responsibility for maintaining their health improves outcomes
- Outdoor rehabilitation can improve physical and mental health, develop skills and increase exercise participation
- Other patient groups, including people with cancer or who have had a stroke, may benefit from green-space or woodland-based recovery methods
British Association for Cardiovascular Prevention and Rehabilitation (2012) BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012.
Mayer FS, Frantz CM (2004) The connectedness to nature scale: a measure of individuals’ feeling in community with nature. Journal of Environmental Psychology; 24, 4: 503-515.
Scottish Intercollegiate Guidelines Network (2002) Cardiac Rehabilitation: a National Clinical Guideline.