护士与自然：绿色空间有影响吗？| J Clin Nurs

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Abstract

How we engage in and with nature is of growing interest in relation to our health and well-being. For nurses with stressful workloads that are contributing to fatigue, psychological burden, insomnia, and decreased coping strategies, interactions with nature or green space are essential as it has been demonstrated to facilitate better environments and outcomes for nurses. Evidence of the impact of nature is limited. However, the value of interactions with nature has been prioritised by the World Health Organization and so healthcare organizations should be considering overt and practical ways to ensure nurses, and other healthcare providers, are exposed to nature to contribute towards healthier environments.

What does the paper contribute to the wider global clinical community?

Interactions with nature, or green space, enhances clinical environments.

Nurses physical and psychological stress can be reduced through interactions with nature.

Implications for the profession and/or patient care

For nurses with stressful workloads that are contributing to fatigue, psychological burden, insomnia, and decreased coping strategies, interactions with nature, or green space, is essential as it has been demonstrated to facilitate better environments and outcomes for nurses.

No Patient or Public Contribution

Key points

1. Nurses are in stressful environments.

2. Nature and green space contributes to healthier environments.

3. Planning is required to overtly include access to nature and green space in healthcare.

A growing body of scholarship indicates that contact with nature is health-promoting. In a landmark study, Markevych et al. (2017) identified the domain pathways model, linking greenspace to positive health outcomes in people. By reducing harm, restoring capacities and building capacities, health outcomes are improved. Astell-Burt et al. (2022) updated the model to acknowledge that contact with nature and provision of green space enables loneliness to be reduced. These findings are significant when considering healthcare workers and those they care for in the current healthcare climate where large numbers of nurses are leaving or considering leaving the profession due to highly stressful settings and situations, and excessive demands that create stress and burnout, aggravated further by Covid-19.

With escalated workloads creating excessive fatigue, psychological burden, stress, insomnia, decreased coping strategies and information overload, these factors are often accentuated with shift work and not leaving, or even glimpsing, outside the healthcare facility for 8–16 h at a time. Coupled with an inability to work from home has meant an inability to access green spaces regularly for most nurses. This lack of exposure and access to green spaces has been shown in women to contribute to anxiety, stress and psychological impact, along with lower levels of social engagement (James et al., 2016). This is of particular importance since women make up approximately 88% of nurses globally.

Work to date with nurses and nature are generally small scale, hence the findings are limited in their transferability as well as their capacity to offer sound, statistically significant evidence that nature contact truly does have a measurable impact on well-being. However, from work that has been done, it seems that nature, or green space, creates better environments and outcomes for nurses. It has been identified that even a simple plant in a room can have a significant impact on stress and anxiety. Taking short breaks outdoors, or at a minimum ensuring green views, lowers stress. Access may include contact with an outdoor or sensory garden, with such connection demonstrating improved productivity and decreased clinical errors. Where higher levels of natural vegetation occur in workplaces, lower levels of staff sick leave are noted.

With growing evidence and appreciation around the importance of nature and green space in healthcare, it is important to take stock and consider why this is and what is it that supports health. The health benefits of being in contact with nature is evidenced in people being cared for in healthcare environments as far back as Hippocrates (460–370 BC) who ran a hospital with a garden and often prescribed forest walks to promote healing. Throughout history there are multiple references to nature promoting healing, for example, ancient Romans field hospitals were situated in nature, middle age European monasteries monks tended plants and vegetables whilst caring for the sick to balance rest and work, and in the 1800's philosopher Thoreau stating illness occurred when people moved away from nature. Key breakthroughs occurred in the 1970's and early eighties. Kaplan's (1973) work found interactions with nature to be of benefit psychologically, while Ulrich (1984) observed the effects of views of nature on people's recovery from surgery. Since then, several studies have demonstrated the positive impact of nature on both adults and children in outcomes of health. These include exposure to nature facilitating feeling better emotionally, promoting mental health, creating a sense of relaxation and lower stress levels, producing happiness and greater satisfaction with provision and quality of care (Nguyen et al., 2021).

1 PHYSIOLOGICAL IMPACT OF NATURE

Franco (2021) outlines the role nature contributes to physical well-being, having a protective effect on physiologic health. Nature has verified benefits of blood pressure reduction, lowered heart rate, decreased muscle tension, reducing the production of stress hormones, and decreased rates of diabetes, stroke, cardiovascular disease and even mortality rates (Franco, 2021). It has been suggested that nature can help to manage pain, particularly chronic pain; however, research is required to verify this assertion.

2 CHILDREN AND NATURE

It is not only adults who benefit from regular access to green space. When children have regular connection and access to nature, improved mental well-being, higher levels of physical health and cognitive development are evidenced, leading to improved attention, memory, competence, social engagement and stress reduction. Where children in hospital settings have access to green space, they have better recovery processes, decreased stress levels and greater happiness (McCormick, 2017).

3 NURSES' HEALTH AND NATURE

Most green space in healthcare settings focus on patients and community wellness, neglecting healthcare providers well-being. This needs to change to be a priority to counter the burgeoning stress and burnout in healthcare professionals noted earlier.

In highly stressful healthcare environments, workloads often lead to poorer health in nurses. Since green space has been associated with physical and/or psychological health benefits, especially for reducing stress levels such as perceived stress and job stress, views of green spaces should be prioritised. Not only this, but exposure to green space has been associated with improving sleep, which is extremely important for nurses on varied and long shifts. A key consideration is how to enable nurses to spend more time in green spaces during breaks, amidst workload and environmental systems. To make this a feasible option, healthcare organizations need to provide support systems to counter the sense of being overwhelmed and halted with responsibility so many nurses report.

4 GREENING HEALTHCARE

The World Health Organization in 2013 recognised that adopting a ‘healthy settings’ approach positively impacts health promotion and should be organisationally established. This approach of a healthy setting must embody the health benefits associated with contact with nature, including awareness, accessibility and use of green space. In particular, trees and leafy plants, natural light and exposure to elements have been identified as consistently contributing to health outcomes (Nguyen et al., 2021).

Healthcare systems must invest in green spaces and ensure they are invested in the workforce being able to use green spaces regularly. There is growing interest and investment in greening healthcare facilities, with rationales of green space highlighted as being ‘calming’, ‘promoting healing’, ‘inviting’ and other positive outcomes such as ‘heightening spirits’. Internationally, some hospitals and healthcare centres are adding green spaces to site. However, these green spaces are generally in lobby's or outside the healthcare facilities where staff and patients cannot readily see or access them.

Some evidence of investing in green spaces can be seen sporadically, for example, a large hospital site in Western Sydney, Australia has been planting more than 3000 trees since April 2021 with a focus on what the chief executive has stated will create a beautiful environment for patients, visitors and the local community to relax within and enjoy. In the United States, a hospital in Michigan established a large green wall and vertical garden of edible vegetables and herbs for patients, families and staff. Similarly, a hospital site in London, Canada, established a living wall and healing garden outside the building for patients, visitors, staff and the community to enjoy.

But what do nurses have to say about green spaces, about using them and about retreating for moments of restoration to continue with intense workloads? These are questions that have not been addressed in depth to date and are critical in planning innovative ways to strengthen support for nurses, to manage the ongoing array of stressors in the workplace in a safe manner for their physical, psychological and emotional health.

全文翻译（仅供参考）

摘要

我们如何与自然互动，与我们的健康和福祉有关，这一点越来越受到关注。对于压力大的工作量，导致疲劳，心理负担，失眠和减少应对策略的护士，与自然或绿色空间的互动是必不可少的，因为它已被证明有利于更好的环境和结果的护士。大自然的影响的证据是有限的。然而，与自然互动的价值已被世界卫生组织优先考虑，因此医疗保健组织应考虑公开和实用的方法，以确保护士和其他医疗保健提供者接触自然，为更健康的环境做出贡献。

该论文对更广泛的全球临床社区有何贡献？

与自然或绿色空间的互动，增强了临床环境。

护士的身体和心理压力可以通过与自然的互动来减少。

对专业和/或患者护理的影响

对于护士与压力的工作量，有助于疲劳，心理负担，失眠，减少应对策略，与自然或绿色空间的互动，是必不可少的，因为它已被证明有利于更好的环境和结果的护士。

无患者或公众贡献

关键点

1. 护士处于紧张的环境中。

2. 自然和绿色空间有助于健康的环境。

3. 规划需要公开包括在医疗保健中获得自然和绿色空间。

越来越多的学术研究表明，与大自然接触有助于健康。在一项里程碑式的研究中，Markevych等人和nbsp;（ 2017）确定了域路径模型，将绿色空间与人们的积极健康结果联系起来。通过减少伤害、恢复能力和建设能力，卫生成果得到改善。Astell-Burt等人& nbsp;（ 2022）更新了模型，承认与自然接触和提供绿色空间可以减少孤独感。在当前的医疗环境下，大量护士由于高度紧张的环境和情况而离开或考虑离开职业，以及过度要求造成压力和倦怠，并因Covid-19而进一步加剧，当考虑到医护人员及其护理人员时，这些发现具有重要意义。

随着工作量的增加，造成过度疲劳、心理负担、压力、失眠、应对策略减少和信息过载，这些因素往往随着轮班工作而加重，并且一次8-16小时不离开或甚至不瞥一眼医疗机构。再加上无法在家工作，这意味着大多数护士无法定期进入绿色。这种缺乏接触和获得绿色空间的情况已被证明会导致女性焦虑，压力和心理影响，沿着较低的社会参与水平（James et al.，& nbsp; 2016 ）.这一点尤为重要，因为女性占全球护士的88%左右。

迄今为止，与护士和大自然的工作通常规模较小，因此研究结果在其可转移性以及提供可靠的统计学显著证据的能力方面有限，即大自然接触确实对福祉产生了可衡量的影响。然而，从已经完成的工作来看，大自然或绿色空间似乎为护士创造了更好的环境和结果。已经确定，即使是房间里的一棵简单植物也会对压力和焦虑产生重大影响。在户外短暂休息，或者至少确保绿色景观，可以降低压力。访问可包括与户外或感觉花园的接触，这种连接证明提高了生产力并减少了临床错误。在工作场所自然植被较多的地方，工作人员请病假的比例较低。

随着越来越多的证据和对自然和绿色空间在医疗保健中的重要性的认识，重要的是要进行评估，并考虑为什么会这样，以及支持健康的是什么。与大自然接触的健康益处在医疗保健环境中得到照顾的人中得到了证明，早在希波克拉底（公元前460-370年）就经营着一家带花园的医院，并经常规定森林散步以促进愈合。纵观历史，有多处提到自然促进愈合，例如，古罗马野战医院坐落在自然中，中世纪欧洲修道院僧侣照顾植物和蔬菜，同时照顾病人平衡休息和工作，并在19世纪的哲学家梭罗说，疾病发生时，人们远离自然。关键的突破发生在20世纪70年代和80年代初。Kaplan（1973）的研究发现与自然的互动对心理学有益，而Ulrich（1984）观察到自然观对人们手术后恢复的影响。从那时起，一些研究已经证明了大自然对成人和儿童的健康结果的积极影响。这些包括接触大自然，促进情感上的感觉更好，促进心理健康，创造放松感和较低的压力水平，产生幸福感和对护理的提供和质量的更大满意度（Nguyen等人，& nbsp; 2021 ）.

1自然的生理影响

Franco  （ 2021 ）概述了自然对身体健康的作用，对生理健康具有保护作用。大自然已经证实了降低血压、降低心率、降低肌肉紧张、减少应激激素的产生以及降低糖尿病、中风、心血管疾病甚至死亡率的益处（Franco， 2021）。有人认为，大自然可以帮助管理疼痛，特别是慢性疼痛;然而，需要进行研究来验证这一说法。

2儿童与自然

不仅仅是成年人从定期进入绿色空间中受益。当儿童经常接触和接触自然时，可以证明心理健康得到改善，身体健康和认知发展水平提高，从而改善注意力，记忆力，能力，社会参与和减轻压力。在医院环境中的儿童可以获得绿色空间，他们有更好的恢复过程，降低压力水平和更大的幸福感（麦考密克， 2017）。

第三章护士的健康与性格

医疗环境中的大多数绿色空间都专注于患者和社区健康，忽视了医疗保健提供者的健康。这需要改变，成为应对医疗保健专业人员迅速增长的压力和倦怠的优先事项。

在高度紧张的医疗保健环境中，工作量往往导致护士健康状况较差。由于绿色空间与身体和/或心理健康益处相关，特别是用于降低压力水平，例如感知压力和工作压力，因此应优先考虑绿色空间的视图。不仅如此，暴露在绿色空间中还与改善睡眠有关，这对各种长时间轮班的护士来说非常重要。一个关键的考虑因素是如何使护士在休息期间花更多的时间在绿色空间，在工作量和环境系统中。为了使这成为一个可行的选择，医疗保健组织需要提供支持系统，以对抗许多护士报告的不堪重负和责任感。

4绿色医疗

世界卫生组织在2013年承认，采用“健康环境”的方法对健康促进产生积极影响，应该在组织上建立。这种健康环境的方法必须体现与自然接触的健康益处，包括认识、可及性和绿色空间的使用。特别地，树木和多叶植物、自然光和暴露于元素已经被确定为持续地对健康结果有贡献（Nguyen等人，& nbsp; 2021 ）.

医疗保健系统必须投资于绿色空间，并确保他们投资于能够定期使用绿色空间的劳动力。人们对绿化医疗设施的兴趣和投资越来越大，强调绿色空间的理由是“平静”，“促进愈合”，“邀请”和其他积极成果，如“提高精神”。在国际上，一些医院和医疗中心正在增加绿色。然而，这些绿色空间通常在大厅或医疗保健机构外部，工作人员和患者不能容易地看到或访问它们。

投资于绿色空间的一些证据零星可见，例如，自二零二一年四月以来，澳大利亚西悉尼的一个大型医院场地已种植超过3，000棵树，重点是首席执行官所说的将为患者、游客和当地社区创造一个美丽的环境，供其放松和享受。在美国，密歇根州的一家医院为病人、家属和工作人员建立了一个大型的绿色墙和垂直花园，种植了可食用的蔬菜和草药。同样，加拿大伦敦的一家医院在建筑物外建立了一个生活墙和康复花园，供患者、访客、工作人员和社区享用。

但是，护士们对绿色空间、对使用绿色空间、对休息片刻以继续繁重的工作量有什么看法呢？这些问题尚未得到深入解决的日期，是至关重要的，在规划创新的方法，以加强对护士的支持，以管理在工作场所的压力源在一个安全的方式为他们的身体，心理和情绪健康的持续阵列。

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