Flourish: Nature recovery for people living with severe mental illness

Foreword

Timeoutsideinnatureisoneoflife'ssimplepleasures;"…enjoyandconnectwithnature wherewelive,workandplay–benefiting our healthand wellbeing"1 . Whentime outsidewaslimitedduringtheCovid-19pandemic,itwasastarkreminderofthe importanceofaccesstoblueandgreenspaces -spaceslikeseas,riversandlakes, forests,parksandgardensthatare,quitesimply,goodforthesoul.

Forpeoplelivingwith severementalillness(SMI),accesstonaturecanbeallthemore important.

Peoplewith SMIaremorelikelyto experiencepoverty,homelessness,contactwiththe criminaljusticesystem,socialisolation andunemployment.Theyarealsomorelikelyto liveinlesssafeneighbourhoods,havelessaccesstohealthyfoodsand fewer opportunitiestobeinvolvedinhealthyactivities.Facingadversitylikethiscanmake accesstonatureachallenge,whenconfidence,vulnerability,safetyandexposurecan beveryrealbarriers.

Mentalhealthservicestouchpeople'slivesatthetimeswhentheyare mostvulnerable. ThisincludesservicesprovidedbytheVoluntaryCommunityandSocialEnterprise (VCSE)sector,localauthoritiesandtheNHS.Formanypeople,creativerecoverywhilst usingservices-nature, sports,arts-canbeasimportantastheclinicalcarethey receive.

AsanNHStrustandcharitycommittedtoprovidingtheverybesttherapeutic environment,thenewCombeValleyHospitalinEastSussex isauniqueopportunityfor ustodothingsdifferently.Itisahospitalthat hasthevoiceofpeoplewithlived experienceatitsheart. Flourishextendsthat approachbyexploringhownatureis incorporatedinthehospital.WorkingwithRecoveryPartnershasensuredthatthe researchisuser-led,givinguniqueinsightintohowpeoplewithmentalhealthproblems experiencenature,bothinhospitalandduringrecoveryinthecommunity.

1 NaturalEngland,NatureRecoveryNetwork

Whenwethinkabout amentalhealth inpatientstay,itisoftentimewethinkof. The timetakenfor anadmission,thetimespentin hospital,andthetimeittakesfor recovery.Throughoutthisresearch,peoplehavetoldushowchallengingtimein hospitalcanbe.Theimpactthatalackofaccesstooutsidespacescanhave.Theneed forthingstooccupytheirtime.Howmuchtimetheyhavetofill.

Flourishprovidesuswithatemplateforhowwecould workwith naturetosupport peoplethroughthattime.Peoplehavetoldusthattheywould likeaccesstonatureto beakeypartofaninpatientstay,that weshouldbeboldandcreativeinhowwework withnatureandthat,ifweget itright,itwillprovidelightandhopeduringincredibly difficulttimes.People wouldliketobuildhabitsinhospitalthatcan sustainthem when theyleave,andpartnershipswith ourlocalcommunitywillbekeytosupportingthis.

Inrespondingtothelevelofneedwithinour localcommunities,wemustensurethat weworkhand inhand withourNHScharitiestosupportthecreativerecoveryinour servicesthatissoneeded.Beingambitiousfor thefuturemeansweneedtothink differently,creativelyandboldlywithourpartnersaboutwhatsupportweoffertothe localcommunitiesweserveandhowweprovideit.

OurhugethankstoRecoveryPartners,NaturalEnglandourfundersfor thisresearch, andthemanyserviceuserswhogavetheirtime,thoughts,andideasenablingusto startthiswork.

DrJanePadmore ChiefExecutive SussexPartnershipNHSFoundationTrust

RachaelDuke CharityDirector HeadsOn

Introductionandacknowledgements

RecoveryPartnersisasmall, user-ledgrassrootsmentalhealthcharityworkinginEast Sussex.Established in2011byasmallgroupof peoplelivingwithmentalhealth challengeswhoweretrainedtobecomepeer supportspecialists,itbecameacharityin 2019.Aspeersupportspecialistsweoffersupport,understanding,insightandhopeto othersontheirmentalhealthrecoveryjourney.

Ourservicesincludepeer-ledartsformentalhealthrecoveryprojects,Expertby Experienceinvolvement,training,andcommunitydevelopmentprojectsworkingto improvetheinclusionofpeoplelivingwith severementalillness(SMI).

InAutumn2023wewerecommissionedbyHeadsOn,officialNHScharityforSussex PartnershipNHSFoundationTrust(SPFT)*,toundertakeuser-ledresearchintonature recoveryforpeoplewithSMI.TheresearchwasintendedtodirectlyinformhowNHS mentalhealthservicesincorporatenaturalrecoveryintotheirservices,includingthe newCombe ValleyHospitalinEastSussex.

Flourish:Naturerecoveryforpeoplelivingwithseverementalillness istheresultof thatcommissionandwasfundedbyNaturalEngland,HeadsOn andRecoveryPartners. Thisreportsummarises thefindingsoftheresearchundertakenbypeersupport specialistsduringtheperiodDecember2023-February2024,with51peoplewhohave livedexperienceasmentalhealthhospitalinpatientsinSussexwithin thelast10years.

Accompanyingthisreportisa‘zinebyalivedexperienceartistwhotookpartina1-2-1 interviewandfocusgroups,andwhocontributedtheimagesforthisreport.The‘zine willbeavailablebyrequestorcan beviewedviatheRecoveryPartnerswebsite www.recovery-partners.org.ukfromJuly2024.

*SussexPartnershipNHSFoundationTrust(SPFT)providesmentalhealth,learning disabilityandneurodevelopmentalservicestopeoplelivinginSouthEastEngland. SPFT'sservicesareforchildren,youngpeople,adultsofworkingageandolder people.AcrossSussex,SPFThavesixadultinpatientunits,threeofwhichareinEast Sussex.Eachyear861adultsreceiveinpatientmentalhealthcareinEastSussex.

Acknowledgements

Wewould liketothankallthepeoplewhogavetheirtimetotakepartinthisresearch; wearegratefultoallofyoufor sharingyourexperiences,yourinsights,yourstrengths andyourhumourwith us.Likeyouwehopeforever-betteropportunitiesforpeople livingwith mentalhealthchallengestolivewellinrecovery,with thesupportof communitiesaroundus,andasvaluablemembersofthosecommunities.

ThankyoutoNaturalEnglandforfundingthiswork,andtoourlead partnerHeadsOn.

CredittoRecoveryPartnerswhoconductedtheresearchand compiledthereport: AnthonyStevens,JoanneRhodes,Chenielle Jefferies,TracyHind,AnnaStratford

Livedexperienceartist: AndrewVoyce

Imagesthroughoutthedocumentarefromfocusgroups1and2unlessotherwise stated.

Reportsummary

Theaim ofthisuser-led researchisto enablepeoplelivingwithseveremental illnesstodirectlyinformhowNHSmental healthservicesincorporatenatural recoveryintotheir services.Thisincludes thenewCombeValley HospitalinEast Sussexplannedtoopenin2026,and howengagement with natural recoverycouldbesupportedto continueinthecommunityon discharge.

Theresearchinvolved251-2-1 interviewswith peoplewhohave hadexperienceasinpatientsin mentalhealthhospitals(the majorityinEastSussex),two focusgroups,andonlinesurveys completedby26peoplewith inpatientexperiencein mentalhealthhospitalsinEastSussex,WestSussexandBrighton and Hove.Fifty-onepeopleintotaltookpart;thisisasummaryofthefindings.

Naturalrecoveryinhospital:Keythemesfrominterviewsandsurveys

Participantswerefamiliarwiththebenefitsofspendingtimeinnature,andmany regularlyspendtime outdoorsincludingbeingbythecoast,inparks andwoodlands. Being‘handson’innature,gettingenoughsunshineandfresh airandbeingabletofeel theelements,werealldiscussedasimportant aspectsinmaintainingrecovery.

Accesstooutdoorspace

Accesstooutdoorspaceinprevioushospitalstayswasverymixed;themajorityof participantsdidnothavegoodaccesstosatisfactoryoutdoorspaces.Activitiesmost commonlyofferedtopeoplewhohadaccessincludedwalking,sensorygardens, gardeningandoutdoor exercise.Forthosewhohadbetteraccesstooutdoorspaces

thisincludedwoodlands,walks,outdoorcourses,viewsofnatureand gardenstospend timein.

Barrierstoaccessingoutdoorspace

Insufficientstaff,and lackofstaff availabilityarethemain barrierstopatientsbeing abletoaccessoutdoor spaceandactivities.Otherbarriersincludepeoplenotbeing permittedoutdoors,lockeddoors,andnotknowingwhenandhowtogainaccess.Low moodormotivationcouldbeabarrieraswell asthedistressorbehaviourofsome otherpatients.

Therapeuticandimaginativegardenspaces

Participantsmademanysuggestionsforhowspacescould bedesigned.Inspiring planting,viewsofnature,variedseatingand shelteroptions,well-maintainedspaces, colour,texture,waterandthesight andsound ofwildlifewereallimportant.Spaces wouldbevaried andaestheticallypleasing,somewitha ‘magical’elementtoinspireimagination,and thereare manyideasforhowtodesignspacestobeusedalone andwithvisitors.

Activitiesinnature

Beingabletotakepartingardeningandgrowing, creativearts,physicalactivityandquiet, contemplativeactivitiesareallmentioned. Varietiesofclassesand opportunitiesfor differentkindsofplaycouldbeprovided. Peoplewantpathsand trailsforwalking, meditationandrunning,andfor observationandengagementwithnature. Activitiesshouldbeled byqualified, experiencedpeople.

Gardeningandgrowing

Gardeningisoneofthemostpopular outdooractivitiesandtherearea rangeofsuggestionstoencourage peopletolearn,useandshareskills,including

growingindoorsaswellasoutdoors,andhavingchoices, includingto observeactivities ratherthantakepart.Havingpurpose-suchasgoals,and specificresponsibilities -was alsoimportant.Skilled andenthusiasticteachersareneeded,aswellasallthe equipmentandresourcesbeing provided.Patientswith practicalskillscouldmakeand buildthings– feelingcompetentbeingan importantfactorinrecovery.

Patientsafety

Patientsafetyisparamountandwouldofcourseinfluencethedesignofoutdoor spaces.Otherconcerns includehowtoensureenoughspaceandsafetyforpatients whereanotherpatient haserraticorconfrontationalbehaviour,thepotentialfor vandalismandtheft,andtheneedforstafftobevigilant.

Naturalrecoveryincommunity:Keythemesfromonlinesurveysandfocusgroup2

Participantsareclearaboutthebenefitstorecoveryofengagementwithnature-based communitygroups,includingsocialising,beingabletocontributetocommunity,andto feelincluded.Moreavailabilityofresourcesand accesstoinformationisimportant,as wellastheopportunitytobuildrelationshipsandmaintainconsistency.Participantsfeel naturalrecoverycould potentiallyreducetimespentinhospital,butsupportisneeded toengagewithcommunitygroupsuntilpeoplefeelmoreconfident.

Supportthedevelopmentofrelationshipswithcommunitygroups

Participantshavemanyideasforactivitieswhichcouldbeofferedbycommunity groupsbothinhospitalandcommunityanddiscussedtheimportanceofmatching inpatientprogrammeswithwhat isavailableinthecommunity,sothattherecould be continuityandsufficientsupportafterdischarge.

Personalisedapproaches,choicesandconsistencyofstaff/volunteers, allhelped developfeelingsofinclusionandbelonging.Transitionplanning,signposting,buddying andpeersupportareallsuggestionstohelpthesuccessofcontinued community engagement.

Awarenessofmentalhealthchallenges

Communitygroupsshouldhavetrainingandunderstandingaboutmentalhealth challenges,understand nature-basedapproachestorecovery,andhaveknowledgeand skillsinoutdooractivities.Smallerorganisationswith localknowledgeand

understandingoflocalissuesmaybebetterplacedtodothiswork and,wherepossible, withtheinvolvementofpeoplewithlivedexperience.

Accessingcommunitygroups

Barriersincludenotunderstandingwhatisonoffer,beingconcernedabouthavingto achievesomething,cost,nothavinganyonetogowith,andnotfeelingconfident. Offeringchoicestopeople,andaclearexplanationofwhatisonoffer areimportant. Peopleshouldbeabletorelaxinthespaceand justobserveactivitiesifwanted.Having apeersupportworker alsohelpedaccessprojects.

Staffingandfunding

Throughoutthisreport,participantshavefrequentlycitedstaffing levelsasabarrierto participationinnaturerecoveryduringinpatientstays,and wemust acknowledgethe ongoingpressuresontheNHS.Thereisanimportantopportunitytotestoutthe possibilityofworkingwithvoluntaryandcommunitysectorpartnerstodeliveraspects ofnaturalrecoveryatCombeValley,andforconsideringfundingforpartnerswhere thismaybeneeded.

Wehopetherecommendationsinthisreport willinformhowtomaximisethebenefits ofCombeValley’snaturalsetting for patientsandhelpinformNHSinpatientservices beyondCombeValley; showingtheimportanceofnaturetopatientrecovery,and whereimprovementscouldbemade tobetter enablethis.

Background

Forthisuser-ledresearchweworkedinpartnershipwith HeadsOn (SussexPartnership NHSFoundationTrust’s officialNHScharity) whichworkstosupportpeoplelivingwith mentalhealthchallengestofeelmoresupported 2andbemoreinvolved intheircommunities.This researchwasfundedbyNaturalEngland,the government’sadvisorybodyforthenatural environment,andisfrom SeedCornfunding forsmallscaleprojectswithintheSeaford toEastbourneNatureRecoveryProject.This covers12,000hectares oftheSouthDowns, anareathat thenewCombeValley Hospitalwillserve.The projectaimsto bothincreasehabitat forspeciesand increasepeople'saccesstonature.

NaturalEngland’sNatureRecoveryProjectsare areasfor focuseddeliveryoftheNatureRecoveryNetwork(NRN). TheNRNaimstobea single,nationalnetworkofwildlife-richplaces, whichwillbenefitpeopleandwildlifeby increasing,improvingandjoiningtheareasup acrossEngland.Itwillalsoenablepeople toenjoyandconnect withnaturewherewelive,workandplay,benefiting healthand wellbeing.ThisworkwasfundedunderObjective6 -Enableustoenjoyandconnect withnaturewherewelive,workandplay–benefitingourhealthandwellbeing.

Theimpactofseverementalillnessonhealthoutcomes

Thefollowing informationisprovidedbyHeadsOn: Peoplelivingwithseverementalillness(SMI)facesignificanthealth inequalitiesand liveonaverage15to20yearslessthanthegeneralpopulation.People withsevere mentalillnessaremorelikelytohavehigherratesof:

• poverty

• homelessness

• contactwith thecriminaljusticesystem

• socialisolation

• unemployment

2 Imageby'Linda',fromPixabay.Source: https://pixabay.com/

Peoplewith SMIarealsomorelikelytoliveinlesssafe neighbourhoods,havelessaccesstohealthyfoodsand feweropportunitiesto beinvolvedinhealthyactivities. Atthesametime,acrossmultiplestudies,researchers haveevidencedthelinkbetween accesstogreen space,suchasfields,forests,parksandgardens,anda reducedriskofmental healthproblems,improved mood,andincreasedlifesatisfaction.Otherbenefits includereducedstress, increasedphysicalactivity, andbetterphysicalhealth3

ResearchersattheUniversityofYorkfoundthatpeoplewith SMIdescribedarange ofpositiveexperiencesandbenefitstobeing outdoorsandinnature,includingopportunitiesforrelaxation,timeawayfromeveryday stressfulexperiencesandthechancetotakepartinpurposefulactivity. However,they alsoidentifiedthat oneofthebiggestbarrierswasconcernsabout thesafetyofgreen andbluepublicspacesandtheimportanceofspacesbeing maintainedproperly,kept clean,well-lit andhavingwardensavailable. 4

Whenapersonisaninpatientinamentalhealthhospital,theyare attheirmost vulnerable,andthechallengeoftakingpartinnewexperiencescanfeel insurmountable.Wewanttousethisresearchtohelp identifywayswecan help supportpeoplethroughthis;puttingpeoplewithlivedexperienceattheheartof what wedevelopand sensitivelyovercomingthechallengespeoplemightfacewhilstthey areinhospitalsothat accesstonaturecan becomeahabitthat issupportedin hospital andabletocontinueupondischargeintheircommunities.

Theaimofthisuser-ledresearch

Theaim ofthisresearchistoenablepeoplelivingwithseverementalillnesstodirectly informhowNHSmentalhealthservicesincorporatenaturalrecoveryintotheirservices, includingthenewCombeValleyHospitalinEastSussexplannedtoopenin2026.

3 MentalHealthFoundationandWWF-UK,ThrivingwithNature,2020 https://www.mentalhealth.org.uk/sites/default/files/2022-06/Thriving-With-Nature.pdf

4 UniversityofYork,2023https://www.york.ac.uk/news-and-events/news/2023/research/green-spacesshould-feel-for-mental-health/

5InSeptember2023SussexPartnershipNHS FoundationTrust(SPFT)beganbuilding astate-of-the-artmentalhealth hospitalforpeoplefromacrossEast Sussex livingwith conditionssuchas psychosis,bipolardisorder, emotionallyunstablepersonality disorder(EUPD)andclinical depression.CombeValleyHospital willreplacetheinpatientunitat theDepartmentofPsychiatryin EastbourneonanewsiteinNorthEastBexhill.

Modern,bestpracticementalhealthcareemphasisesasafeand therapeuticsetting,naturallight,anddirectaccesstogardens.Thehospitalhasbeen designedinaparkland-likesetting.Accessand viewsouttonatureare oneofthemost importantelementsthatwillbeprovidedinthephysicalenvironmentforservice users. Thesitewillutiliseand protecttheexisting treesonsiteandsupplementthemwith newtreesandotherplanting.

SPFTwantstoensurethatthenaturalrecoveryopportunitiesthat are provided,both withinthehospitaland tosupportpeopleondischarge,areledbyserviceusers -who knowbest howtosupporttheirrecoverythroughnature.

SPFTwanttohearaboutthebarrierspeoplemightfacetoaccessingspacesinnature, whattheycandevelop withinthehospitalsite, andwhat supportpeoplemightwant andneedtoaccessnatureintheircommunity.

CurrentplansforthenewsiteatCombeValleyinclude:

• Thenewhospitalbeing builtisnestledintoanundulatinggreenfield,settothe backofthesiteandissurroundedbymaturetrees.

• Eachwardwillhaveexcellent linesofsightand directlevelaccesstoitsown wardgardensandviewsouttotheexistingmaturetreesthatsurroundthesite.

5 ImagebyKeirGroupPLCofthenewCombeValleyHospital.Source:sussexpartnership.nhs.uk/about-us/how-our-trustrun/organisational-plans/new-mental-health-hospital-bexhill

• Thewardgardenswillincludeavarietyofsoft landscaping – includingplanting shrubstocourtyardgardensandwildflower meadows.

• Therewillbeatherapy gardentoenableoutdoortherapyactivitiestotakeplace oneach ward.

• Allbedroomslookouttolandscapedgardenstogiveallclientsviewsoutto nature.

• Allbedroomcorridorshavebedroomsononesideonly –theothersideofthe corridorshavewindowsouttogardenspaces.

• Offward,thereisacommunalgarden‘village green’wherevisitsortherapeutic activitiescantakeplace.

• Therewillbe‘raingardens’andwaystohold waterinthelandscapeandincrease biodiversity.

• Aroundthebuildingisanextensiveperimeterofnaturetothewest,providing walkingandcycletrackstoprovideaccesstonatureinamorenaturalsetting outsideoftheformalgardens.

• Therewillbeinclusion ofoutdoorexercise spaces.

• Theremaybea‘wanderpath’thatloopsback totheward gardens.

RecoveryPartnersaskedwhatpeoplewith inpatient experiencewouldliketosee incorporatedintothenewhospitaltosupportnature-basedrecovery,andhowthey wouldlikethat supporttocontinueinthecommunityondischarge.Thisresearchwill informhowtomaximisethebenefitsofCombeValley’snaturalsettingforpatients.We alsowantedtoknowhowtobestconnectwithotherprojectsinthelocalcommunity astheaimisalsotoinformNHSinpatientservicesbeyondCombeValley;showing the importanceofnaturetoparentrecovery,and whereimprovementscouldbemade.

Recovery-basedapproaches

Wehopethat alldecisionsmadeaboutthedesignandprovision ofservicesarenot onlymade inpartnershipwithpeoplewhousethoseservices,butthattheyare also madeinrelationtorecovery-focusedapproaches.Whileeveryone’srecoveryjourneyis uniquetothem,thekeyprinciplesofmentalhealthrecoveryinclude:

• Hope

• Dignity

• Choice

• Personalresponsibility

• Self-advocacy

• Support

Thisappliesinallmentalhealthservices,andthereisgreat opportunitytowork with recovery-focusedapproachesinnature-based work.

Althoughmoreresearchisneeded,some evidencedoessuggestusingthe5Waysto Well-being,particularly inthecontextofpromotingpatientchoices,alsoappearsto improvementalwellbeingandimportantly,hope,amongpatientswithSMI.

Methodology

InpartnershipwithHeadsOnweagreedthat wewouldaimtoconductin-depth1-2-1 interviewswith upto25peoplewithmentalhealthhospitalinpatientexperiencein EastSussex,withinthelast10years. 25peopletookpartofwhom24 hadEastSussex in-patientexperience.Someofthepeoplewetalkedtohavemanyexperiencesof beinginpatientsovertheyears,bothinEastSussexandelsewhere,andwhilethe majorityhaveexperienceofNHSprovision,somealsohaveexperienceofprivate provision.Somehaveveryrecentexperience, beingdischargedwithinthelast12 months.Thismeanstheybringparticularlyvalidcurrentexperience.

Wealsowantedtoincludeawiderrangeofvoices so,withthesupportofHeadsOn, wecirculatedanonline surveyaimedat anyadultswith inpatientexperienceinthelast 10yearsinWestSussex, EastSussex andBrightonandHove.Wesetthetargetat30 questionnairesandextendedthedeadlinetwicetotrytoachievethis.Wereceived26 intotal.

Weconductedtwofocusgroupswhichweranaspeer supportedartsworkshopswith integratedfocusgroup sessions.ThefirstfocusgrouptookplaceinNovember2023at TheFriends’MeetingHouseinEastbourne and fivepeopletook part.Participantswere showntheaims oftheresearch,andtheproposalsfortheCombe Valleyhospitalsite. Wediscussedtheroleofnatureinrecovery,drawingonpeople’sownexperiences. Togethertheyidentifiedwhattheythoughtwouldbethemostimportantquestionswe shouldask people,inlinewiththeaims oftheresearch.

Thereweresomanypotentialquestionstoask thatwedecidedtofocusthe1-2-1 interviewsmainlyoninpatientexperienceand todiscussnaturerecoveryincommunity (afterhospitaldischarge)inthesecondfocusgroup,withonespecificquestionabout thisaddedtotheonlinesurveyquestionnaire. Thesecondfocusgroup tookplacein February2024 atDeLa WarrPavilion,Bexhill.Fivepeople,whohad alreadycompleted 1-2-1interviews,tookpart.

TheRecoveryPartnersteamwhoconductedthefocusgroupsand1-2-1interviewsare highlytrained andexperiencedPeerSupportSpecialists, withyearsbetweenthemof supportingindividualsandgroupslivingwith mentalhealthchallenges, including peoplelivingwithseverementalillness.Priortointerviewsstarting,theteamtookpart

intrauma-informedinterviewpracticetraining, andwedevelopedspecificprotocolsfor aftercareordebriefifneeded,bothforintervieweesand ourteam.

Wedesignedallmethodologieswiththeintentiontoavoidtoomuch focusonanyone’s personalhistory,but weacknowledgethatrecalling andtalking about inpatient experiencecanbedifficult.

Allinterviewsareanonymousandwhereanyindividualorstaffmemberisidentified, wehaveredactedthat information.

All1-2-1interviewswererecordedandtranscribedusingOtter.ai,Inc.Informationwas analysed using anadaptedformofFramework Analysis,amethoddeveloped specificallyfor analysingqualitativedataattheNationalCentreforSocialResearch6 Thisinvolvedcreatingaspreadsheettotabulatetheinterviewandsurveyresponses andenabletheteam to identifyemerging themesandpatterns,aswellaskeypoints forinclusion.

Pleasenote

Whileparticipantsareveryaware ofthe potentialrisksofharminoutdoor spacesforsomepeoplewhoare very mentallyunwell, andsometimesthisis referredto,wedidnotaskpeopleto specificallythinkabout riskandwe didnotwantthem tolimit themselveswhen imaginingwhat naturalspacescouldbelike.Risk assessment isofcoursetherole ofthehospital.

6 Galeetal,2013;Ritchieetal,2014

Naturalrecoveryinhospital:Key findingsfrominterviewsandsurveys

Asidefromonequestionintheonlinesurveyaboutnaturerecoveryincommunity (responsestowhichhavebeenincludedwithsection6),inthis section wehave summarisedthekeythemesandnoteworthyfindingsfromall25 1-2-1interviewsandall 26onlinesurveyresponses.

ARespondents’previousaccesstooutdoorspaceswheninhospital

Accesstooutdoorspaceinprevioushospitalstayswasverymixed,withfewerthan a quarterofallrespondentshavinggoodaccess tosatisfactoryoutdoor spaces.Somehad noaccesstooutdoorspacesatall,othershad accessonly‘rarely’or‘sometimes’, and thiswasinsomecases asmall,concreteorpavedoverspace,notgenerallywell maintained,mostlyusedforsmokingorvaping.

‘Therewaslikeaconcreteoutsidebitwithafewbenches.Andthat'sjustwherethe peopleusedtogoandsmoke.So,therewasneveranyaccessibilitytoanythingnatural orscenic,itwasverymuchlikeaprisonenvironment.’

‘SothelasttimeIwasinhospital….theyhadaquoteunquote,gardenthatwasmostly paved,andhadlikeareallytallwallwithamuralonit,butitdidn'thaveanylike,plants orflowersor,youknow,anythinglikethat.Itjusthadalittlebitofgrassandpavingand acoupleofbenches,soitwasn'treallyrestorativeornicetobeinbecauseitwas basicallyjustthreebrickwalls.Green,painted,andsomepavingandatinybitofgrass. Likeitwasn'tverysortofnicetobeinitwasjustkindofthere.’

Somepeoplesaid itwasgoodjustbeingableto‘seeplantsgrowingandseethesky’ wheninanoutdoor space,asoftentheviewsfromindoorspaceswerenotinspiring. Otherssaidtheyweregratefulforanybitofoutdoorspace:

‘Therewasagardenareaand ,wheneverIcould,Iwouldspendasmuchtimeas possibletherebecausebeingwithinalockedenvironment,youwanttobeinthekind ofpartwhichfeelstheleastlocked.Thefencewaswiresoyoucouldseethroughit. Youknow,anditwasopentothesky,anditwasinakindofruralsettingsoyoucould seesquirrels,theoddrabbit,severalcatsusedtovisitaswell.’

BActivitiesinnaturethatpeoplewereofferedinhospital

Thefollowing activities werethosemostofferedtopeoplewhohad accesstothe outdoors:

• Walking/woodlandwalks

• Sensorygarden

• Gardening

• Leavetogointotownandwalkaround,gotowalkbytheseaorin parks.

• Barbecuesinthegarden

• Boardgames

• Outdoorexerciseincludingyogaandtai chi.

Oneformerpatienthad experienceofseveraldifferenthospitalsthat includedboth NHSandprivatehospitals.Hefoundthatthetwoprivatehospitalsofferedmoreinthe wayofengagement withnature,whichhefelt madeadifferencetohisrecovery:

‘I'vebeenin(namesof privatehospitals)andtheyhavelikeabigforestandareallybig outdoors.Theyhavelikeareallybigfield,andtheyhaveagardenlikeasensorygarden andfruittreesandallthatkindofstuff.Butthatwasreallynicebecausetheyhadlike gardeninggroups.Theyhadguidedwalkinggroupslikemeditationintheforest.AndI knowobviously,NHShospitalsdon'thaveasmuchroomasprivatehospitals.Iwasinas anNHSpatientbutthedifferencewasquite- likeIdon'tfeellikeIrecoveredaswellin theNHShospitalsforanumberofreasons….youwerejustkindofstuckinsidethose surroundedbyotherillpeopleratherthanbeingoutsideandhavingsometimefor yourselforhavingthosekindofexerciseormeditationorpositiverecoverythingstodo innature. ’

C Participants’experienceofoutdoorspacewhentheyhadaccess

Forthosewhohadgoodaccesstooutdoorspacesthattheyfeltwerebeneficialto spendtimein,thisincludedplaceswithwoodlands,walkstogoon,coursesthatwere runoutdoors,viewsofnature,gardenstheyspendtimein,wandering,potteringor simplybeingabletobeoutside.

‘IfoundwhatreallybenefitedmewhenIwasinhospitalwas,wewentonawoodwalk everysingledayandthatwouldliterallybethemostexcitingthingofmydayandI thinkyou'renot,untilyou'reinthosesettingsandstuckinahospitalthatyoulike,you'll justbelike,oh,whyaretheysoexcitedtogoforawalkbutitliterallyitmeanssomuch andit'sjustthehighlightofyourday…Itfeelslikeyou'relockedupandyoufeelvery distantanddetachedfromtherealworld.Ithinkitenablesyoutoevenjustgetasmall

senseof,ofnormalityandreality.So,itwasanicewaytoregulateaswell.Iyeah,Ithink onceagain,Ithinkit'sbringingbackthatsenseofrealityandmakingyounotlookatthe samefourwallsfor24/7.’

Manyofthosewhohad accesstogood outdoorspacestalked aboutthebenefitsof beingoutdoorsfortheirmentalandphysical health,thatitimprovedtheirmoodor helpedthemfeelcalm.

‘Itallowedmetofeelconnectedto something,andtoseecoloursand breathefreshair,makingmefeellighter duringaverydifficulttime.’

Beingabletoadmirenature/looking atandsmellingplantsandherbs

Beingabletoexercise(particularlywalking,running)

• Meditation

• Bettermobilecoverage

• Gettingawayfromnoise/peopleinbusyenvironment

DBarrierstoaccessingoutdoorspacesinprevioushospitalstays

Manypeoplementionedthelackofstaff asakeyreason theycouldnotaccess outdoors,aswellaslackofstafftimeand availabilitytoaccompanypeopleoutdoors. Onepersonsaid,'thewayitwasmanagedwith stafffeltlikedog-walkingattimes'.For severalpeople,notbeingabletogooutdoors wasverydifficultforthem.

‘AlthoughIwasnotsectioned,thereweretimesIwasnotabletogooutalone.Ihadto haveanursewithme.SometimesIwouldhavetowaituntilsomeonewasavailable,

whichmeansyoucouldn'tgooutwhenyoumostfelttheneed.Icouldn'tstandbeing insidesometimes.’

‘Ifounditverydifficulttoaccessitbecausehalfthetimetheyjustwouldn'tletmeoff thewardandthenwhentheydoletyouoffthewarditiswithamemberofstaffand thenthelackofmembersofstaffwouldbeyouknow,theywouldn'thavethecapacity toletyougoout.So,we'reprettymuchlockedinalotofthetimebecauseofshortages ofstaffreally,orthedemandsofcertainpatients.’

Otherbarriersincluded peoplenotbeingpermittedoutdoors,andlockeddoors preventingpeoplegoingoutside.Acoupleofpeoplesaidtheydidn’tknowthatgoing outdoorswasapossibilityasno-onetoldthem aboutit,and thatcommunicationwith staffaboutoptionshad been limited.

Somementionedhavingverylimitedoutdoortimeallocation.Onepersonsaidthey werenotallowedoutsideforquitealongtime,eitheraccompanied orunaccompanied. Anothersaidit‘felt likebeingpunished’ when youwerenotallowedoutdoors,andthat everyoneshouldhavetherighttosometimeoutdoors.

Afewrespondentssaid disabilityaccesswasanissue,particularlylack ofwheelchair access,and lackofstaff toassist.Onepersoncouldn’tgooutsideiftherewerenostaff availabletopushtheir wheelchair.

Being‘checkedon’bystaffwhenoutsidewasalsonotrelaxing. Someoutdoorspace waslockedduringcertainhours,whenpeoplewouldhavelikedtousethespacebefore andaftertheopening andclosingtimes.

EBarrierstousingoutdoorspacesinprevioushospitalstays

Forthosewhodidn’tsmokeorvapetheyoftenavoidedtheoutdoor spaces(which weresometimestheonlyoutdoorspaces)and someofthosewhodid usethespacefor this,alsofounditunpleasant.

‘Theonlyoutdoorspacewasbasicallyasmoker’squad.Thefewplantpotsatthefront ofthebuildingweresadandovergrown.’

Acoupleofpeoplementionedthemainbarrierbeingtheirownlowmoodor motivationwheregoingoutdoorsdidnotfeelpossible,ortheyfelt vulnerableifthey did.Anotherpersonmentionedavoidinggoingoutdoorsoutofchoice, but thathaving choicewasimportant:

‘Iamquiteanavoidantpersonsoifsomeonetoldmesomethingwasgoingonoutside, itwouldprobablymakemenotwanttogooutandIfeelalotofpeoplewouldfeelthe same.So,Idon'tknowwhatitcouldbelikeformetogoouttherebutgivingsomeone choice,Ithink,Idon'tknowifthisisdifferentfromthequestionbutIthinksomeone beingabletojustgraduallygetusedtoitislikethemostimportantthing.’

Afewpeoplementionedthatotherpatients’distressoruninhibitedor challenging behaviourwasabarrier,andthattheywouldavoidbeing outdoorswhenotherpeople werethereinastateof agitationorwhenpeoplewerestillveryunwell. Ensuringthere areenoughdifferentspacesforeveryonetobein,ortohaveabookingsystemtouse spaces,weresomesolutionstothis.

Lackofsuitable,inspiringandengagingoutdoorspaceinmentalhealthhospitalswas alsoabigbarrier.Spacesthatarenotwell-maintained,visiblyunkempt andunplanted, arealsonotonlydrabanduninspiring,butcanaffecthowpatientsfeel.People mentionedthattheycouldseesometimesthat ‘therewasnotenough fundingto maintainspaces.’

‘Therewasa‘wanderloop’whichwouldhavebeenagoodideaalthoughinthiscaseit lookedlikelotsofplantsweredyingsoitdidn’tfeelgreattome.’

Afewpeopletalked abouttheneed forwelcomingspacestobemaintained,andthe needforthinking about long-termfunding;ifplantingtrees,what wasthespacegoing tolooklikein20-30years?Wouldfundingbesufficienttomaintain thisspace?Would therebethestafftomaintainthespace?

FActivitiesinnaturethatwouldbenefitpatients

Physicalactivity,exerciseclasses,relaxationandgardeningwereallbeneficialfor people.Participantssaidactivitiesshouldbeoutdoorsasmuch aspossible,eitherledby staff,volunteers,peersupportworkersorpatientsthemselves.Someactivities couldbe self-directed,sono-onewasneededtofacilitateorsupervise.

‘Relaxation,TaiChiclasses,havingaccesstoyogamats.Also,regularexercise.Having structuredexercisegroupsledbyaninstructor.Somethingforpeoplethatphysically needtodosomethingtogetridofallthatenergythatcanleadtoanger.Somepeople needotherpeoplearoundthemandlotsofactivityandsomepeopleneedquietspace, somewheretobebythemselves.’

Beingabletosit anddojigsawsoutdoorsaswellashavegentleactivitiesthatpromote socialinteraction werealsomentioned.

Observationandinteractionwith wildlifeispopular,includingbird watching,andbird andinsect identification(including‘charts’tocheckoffsightingsagainst).Having wildlifeorganisationscomingtodowalksand talkswasoneidea.

Participantsalsosuggestedmeditation/mindfulnessoutdoors includingwalking meditation,followingpathsandlabyrinths.Thesecould befacilitated sessionsaswellas paths/areasthat weredesignedforpeopletodowithoutassistance – especiallyif peopleareshownthem aspartoftheirintroductiontothehospitalor whentheyare wellenoughtoengage.

‘WhenIwasreallyunwell,Ilikedtopacealot,soIfeellikehavingpathwaysthatloop around.’

Participantsfeltthattherapeuticsessionsthat usuallytake placeindoorscouldbe movedoutdoors,especiallyifthere weresheltered/coveredareas.Thisincludes occupational therapy(OT)sessions,talkingtherapies,massageand physicaltherapies.Othersuggestionsincluded introducingaromatherapysessionsandsound baths.

Therearemanysuggestionsformovingoutofanarts andcraftsroomindoorsandundertakingcreativeand artisticactivitiesinnature,includingweaving,flower arranging,drawingandpaintingnaturalsettingsand foundobjects,naturephotographyandwriting or journaling

‘WritingclasseswouldbereallycoolbecauseIthinkyoucanuseallofyoursenses whenyou'reinagarden.Ithinkthat'squiteimportantinrecovery.Actually,when you'rekindoflearningwhoyouareagain,likejustgoingbacktobasicsandwhatyou canseeandsmellandhowyoudescribethat.’

Bushcraftand‘campingactivities’arealsorecommendedbypatientsforbringing peopletogetheroutdoorsandpromotingasenseofpurpose,adventureandfun.

GSupportandactivitiesthatcouldbeofferedtoencouragepeopletolearn,use andsharegrowingandgardeningskills

Gardeningandgrowingisverypopular.Manypeoplearekeenongardeninggroups beingsetup,whereskillsandknowledgecanbebuiltup,especiallywithintroductory sessionswhereeverythingis‘veryachievable’.Beingabletoseequickresults,having theopportunitytocareforplantsand growthingsinyourownroomareallimportant.

Askingpeoplefortheir interests,whattheywanttodo,andwhat theymightwantto learnisalsokeytoengagingpeople:

‘Maybeaskingthemtheirideasandwhattheywant,whatwouldliketoachievefromit. So,ifthey'reintermediate,andthey'vedonesomebefore,maybethere'ssomething theywanttolearnspecifically.Ifthey'reabeginner,maybethere'sacertainareathat they'reinterestedin,thattheywanttoengagein,otherareasthey'renotsointerested in,soyoucanfindthatinformationout.’

Havegrowingspace(vegbeds,allotmentareas,greenhouses)and beingabletogrow foodisinspiring,particularlyifyoucanprepareandeat ityourself or shareitwith others.It’sgoodtofocusoneasy-to-growand productivecropslikerunnerbeans, sunflowers,saladvegetables.

‘Gardeninggroup.Vegetablesandthingslikethat.Thingswecaneat.Ireallylikedthe gardeninggroupwhereyougettotendvegetablesandflowersandwateringthe plantsduringthesummer,basicallythat'sniceenoughtodoforme.’

Havingskilledand enthusiasticteachersisneeded,aswellallequipmentbeing provided,andbooksandotherresourcessothatpeoplecan‘taketheirinterest where theywant ittogo’and dosomeoftheirown researchandplanning.

Somepatientswillhavegardeningknowledge andexperiencethemselves,anditcould behelpfultotheir own recoveryiftheywereencouragedtotakepartandsharewhat

theyknowwith others. Thisalsofollowsfor patientswith practicalskillswhocould makeandbuildthings– feeling competent isanimportantfactorinrecovery.

Forpatientswhoarenotabletogo outside,havingworkshopsforindoor planting(makingtheirownterrarium,for example)andbeing abletogrowherbs andflowersindoorscouldbereally beneficial.Theywould beencouraged tocarefortheplantsthemselvesbut couldalsohavehelpwiththis.

Offeringchoices,and stayingpatient andflexiblereallymatters,aspeople oftenfeeldifferentlydaytoday:

‘Soit'sabout,keeptryingwithpeopleandona differentday,differenttimesyoucouldgetadifferentresponseandalso well,youcouldhaveforpeoplewhoarealittlebitunsure,youcouldhaveamemberof staff,maybejusttakethemnottodotheclass,butjusttowatchtheclassandsee whathappensandmaybethentheymighttakeaninterest.’

Acoupleofpeoplelikedtheideaofhavingsettaskstodo,forthesenseofpurpose, andhavingaclearrole:

‘Likeifitwasoutside,likegiveusIwouldsaygiveusgardeningduties.Like,volunteers arelikehavingatask,right?Eachdayforexample,liketodaylikemyjobistotrimthe bush.

Therearemanyrecommendationsrelating togardeningandgrowing;seesection 8.

HHowoutdoorspacecouldbedesignedforpatientswantingtobealone Therearelotsofsuggestionsfor‘niches/nooks’thatallowpeoplenottobeseenfrom allangles,andtohaveseveralprivateareassothatmorethanonepersoncanbealone atatime. Thereare somereallyimaginativeideasincluding‘swingseats’,‘egg-shaped seatswithcushionson’,'nookssetintowalls' andavarietyofbenches and‘beachhuts’.

Itisimportanttoletothersknowwhenpeoplewanttobealone,sotherecouldbe signsinforming othersnotto‘intrude’.Theneedtoensuresafetywasacknowledged; peoplementionedthattheremightneedtobesecuritycameras,or staffnearby,for veryvulnerablepatients.Being‘alonebut with astaffmember’wasalsosomethingthat shouldbedesignedfor –soasecludedspacethatcouldstillhaveastaffmember nearbyandinsight,but wherethepatientalsohadthesenseofsolitude.

Thereareideasforseparatingoutspaceswithintheoverallgardens,sothatpeople havechoicesandcan bealoneindifferentpartsoftheoutdoors.Benches,hedges, woodentrelliseswithclimbingplants,hedging andtreesandwallscan beusedto createprivateandquietareas.Therecanbelittleshelteredareasthatareinharmony withthenaturalsetting:

‘Buildawickersheltersoitlookssafe,andtheybundlethemselvesintherewithsome blankets…tuckyourselfaway.’

‘Createsafespacesthatarealittlebitsecludedbytrees…itwouldneedtobe surroundedbynaturalthings.Asmallwaterfeaturewouldbenice.Iliketobenear water;itmakesmefeelpeaceful.Aniceseatingarea.’

IIdeasforspacestobeoutsidewithvisitors

Mostpeoplesuggesthavingseveral‘visiting areas’somorethanonegroupcanbe outsideatatime.Ideas forthesekindsofspacesinclude:

• Areaswhereyoucan playaroundandbesociable.

‘Firepit,roastmarshmallows,prolongtheoutdoorspacetobeusedatnight-gather round,singing,notfeellikeyouhavetogoinbecausethesunhasgonedown,orit's gottoocold.’

• Colourful,abundantlyplantedareasmakepeoplefeeluplifted onthevisits:

‘Imean,coloursareabigthing,youknow?Thebrighterthecolour,thehappieritseems tomakepeopleyouknow…smellisveryimportant…thesmellofnice,freshflowersisa greatthinginthemorning.So,Ijustthinkthey'vejustgottobevibrantflowers.Ifyou wantittolookgoodbuythespecificbulbsforthattimeofyearandifyoucan'tbuy seasonalplantsfillthingswithgreenerythatwilllastallyearroundsothatyoucanput theplantsinthemiddleofit.’

• Curvedtablesandcurvedseating– playful,notjustpicnicbenchesandtablesas theyare‘dreary’.Tableswiththingscarvedintothem,interesting‘points’.

• Designsfortalkingpoints,givingpeoplethings todoandtalkabout ‘ratherthan makeawkwardchat.’

‘Itneedstohavesomethingthatyoucantalkabout,reallybeautifulflowerbeds,maybe somefishinapond.Havingsomethingelsetofocusonratherthanyourmentalhealth canbereallyuseful.Peoplefeelawkwardsometimes,theydon'tknowwhattosay.A beautifulenvironmentcanhelpdistractfromthis,especiallyifyoudon'tgetonwith yourfamily.Ithelpstomakeyoufeelmorerelaxedanddistractedfromyourproblems.’

• Gamestoplaylikegiantchessandcheckersgames,bowls,hopscotch, activities forgroupstoengagein,forallagegroupssochildrenarealsokept engaged.

• Areastowalktogether in,sowideenough paths,labyrinthstowalkround,so youcan ‘walkandtalk’ratherthanhavetosit down.

• Roundshelteredareassoyoucanbeoutdoors inallweather

‘Ithinkhavingshelteredspacewouldbeimportant….Likeyoucanhaveacolourful canopy.’

• Naturalsurroundings,livingwillow,yurtandgazebotypespaces, wherepeople caneattogether.

• Trailsand activities(likecollectingthings, outdoorquizzes,checklists) thatyou coulddowithguests,tohavefuntogetherratherthanjusttalkabout problems.

‘Weusedtohavebirdfoodthatwetookoutasawaytoencouragethemtocomeand likethatwaslikeareallyexcitingactivity.’

• Visitors’areasshould bedesignedtobe‘soothing’andprovidenaturalstimuli:

‘RockingchairsaresoothingImeantheycouldevenmirrorit(therockingmotion) maybewithsomeoftheplantingarounditkindofthingslike,Idon'tknow,likebroom shrubs,thatkindofjustswayanddifferentgrassesthatkindofmovewithyouasyou're rockingasthewindgoesthroughthem,thatjustthatkindofripplingfeathery whisperingeffectthat’sjustsoftandgentle.’

JPatientsafety

Severalpeopletalkedaboutpatientsafety,andhowthat wouldimpactthedesignof theoutdoorspaces. Theneedtoavoidthepotentialforvulnerablepatientstoself-harm isparamount,andatthesametime,somepeoplefeltmoreofabalancecouldperhaps

beachieved,throughtheuseofindividualised care planningandindividualisedresponses:

‘Ultimately,becauseitisahigh-riskenvironment thinkingaboutmakingitsafeisimportant,butI thinkthere'sabalancewiththat.Because peoplecanbesoriskaverse.Isupposethe priorityisthewellbeingofpatientsbutatthe sametime,ifyoutakeawayanyelementof trustandIdon'tknow,it'ssortofifpeople feeltheycan'tbetrusted.Idon'tknowhow toexplainit.’

Otherconcernsincludedhowtoensure enoughspaceandsafetyforpatients wheresomeonehaserraticor confrontationalbehaviour,thepotential forvandalismandtheft,andtheneedfor stafftobevigilant.

KWhatelseinspireshopeandrecovery?

Somepeopletalked aboutmakingthingsoutdoors,usingtheirhands –including makingdreamcatchersandnaturalsculptures.Onepersonspokeindetailaboutthe benefitsofbeing‘handson’innature:

‘Allthetouching….youknowtheplanting,thefeelofthesoilyouknow,addingsand andthings…Thesoilofferssomanydifferentkindsoftextures,you'vegotthefeelof thesoilandthenyousuddenlyyou'regoingtocomeacrossasmallstoneorasnailshell or,youknow,maybeevenaworm,there'salldifferenttexturesinonepieceofsoil.Just alltheselittlethingsarethingsthatweneedtolookfor.Butwedon'tneedtogoand spendsomuchmoneydoingthings….Ifyou'relookingtodoitoutside,everything's therealready.’

Othersspokeabout theimportanceof‘gettingenoughVitaminD’and thatbeingable tobreathefresh airand feeltheelementsis‘invigorating’.Afewpeoplespokeabouta deeprelationship with thesea,andhowmorecouldbemade ofproximitytothesea to promotethisaspect ofnaturerecovery:

‘There'sadeepconnectionbetweenpeopleandthesea.That'swhypeoplearesokeen tomovetoandlivesomewherenearthesea,becausethere'sadeep-seatedconnection there.Ithinkifitwassomethingthatwasoffered-anditcouldhavebeenoffered duringthetimeIwasinhospital-awalkdowntheseafrontsomethingIdefinitely wouldhave,wouldhave,wouldhavedone100%.Again,itwasn'tmadeavailableand it'ssomethingthat'srightthereonthedoorstep,somethingthat'ssohealingand therapeuticthat'snotevenbeingaccessed.’

Manypeoplealsomade statementsalongthelinesofnaturebeing enoughtoinspire hopeandrecovery,andthatpeopleshouldhavesufficientaccessand opportunitiesto engagewith nature.

‘Forme,oneofthemostimportantthings,Iwouldthinkitisformostpeople.People shouldbeencouraged.Naturecanberelaxingandstimulating,itcangiveyouwhatyou need.’

‘Naturehasalltheingredients.’

‘Naturehelpstoquietthevoicesinmyhead.’

‘Walkingandengagingwithnature,initsmanyforms,buildshopeandfeedsour spirits…see,smell,hearandtouchtheoutsideworld.’

Naturalrecoveryincommunity:Key findingsfromonlinesurveysand focusgroup2

Intheonlinesurveyand inthesecondfocusgroup,weaskedhowpeoplecanbe supportedtocontinueengagingwith natureandnaturalrecoverywhentheyleave hospitaland areback livingincommunities.

Thefollowing aresummarypointsfromthe26onlinesurveys.

Reflectivegroup/reflectiveactivityinordertoplancontinuation

Onesuggestion istoworkwithpeopletoseehowbeing innaturehasbenefitedthem duringtheirstayinhospitalandmakeaplantocontinue –anindividualplan aspartof theirtransitionfromhospitalback intocommunity.Thiscouldbea‘beforeandafter’ exercisetoseehowthepersonfelttheybenefited(ornot,andifnot,whynotand whatcouldbelearnedfromthis?).

Developconnectionstocommunitygrowingprojectswhileinhospital

Suggestionsweretoinvitecommunityprojectsintothehospitaltomeetpeopleandto runsomegentleintroductorysessions,explaininghowtobecomeinvolvedinvarious projectsandwhat,ifany,specificsupportisofferedforpeoplelivingwithmental healthchallenges. Theremightnotneedtobeanyspecialist supportaslong aspeople werewarmlywelcomedandincluded,andvisitsto buildconnectionandtrustwouldbe partofthis.

Signposting

Afewpeoplefelt Itwouldbegoodtohaveahandbook/resourcesignpostingpeopleto projectsandplacestoconnectwith inthecommunitytheylivein.Thisincludesfinding outiftherearelocalparks,communityallotments,communitygrowingprojectsandif thereisanyparticular supportforpeoplewhomayneed it – i.e.,theremaybe therapeuticcommunitygardens,and‘buddy’schemes.Acoupleofpeoplesuggested socialprescribingwouldbeuseful,tohelppeopletofindvolunteeringopportunities thatmightbenefitthem.

Organisevisitsandtripswhenpeoplearestillpatients,sotheycanbeintroduced toplacesandpeople

Wherepeopleare abletoleavethehospitalforperiodsoftimebeforedischarge,it wouldbehelpfulifstaff,peersupportworkersorotherscould accompanypeopleto placeswhereengagementwithnaturecanhappen –thisincludesvisitinggardens, parksandprojectsbut mayalsoincludeaccompanyingpeopletotalksoreventstohelp themconnectwiththingstheyarespecificallyinterestedin.

Havecoursestaughtinhospitalthatpeoplecancontinuewithwhendischarged

Thisincludesgardening/horticulture,woodcraft,etc.Itwouldbehelpfultohave a resourceforadulteducationclassesandonlinelearning;identifyingpotentialcourses andlearningopportunitiescouldbepartoftransitionplanning.

Comingbackasagardenvolunteertothehospital

Afewpeoplementionedthisasagoodopportunityforpeopletoengageintheirown recoverybyhelpingothers.

Peersupporttoconnectincommunity

Theremaybe peer-supportedgardeningandgrowingspacesandpeer supportfor peopletoaccesscommunityresourcesandaccompanypeopletothingslikeHealth Walks,untiltheycan buildtheirconfidenceto goindependently.

Givepeopleresourcestocontinuegardeningandgrowing

Thisincludesdonationsofequipmentandfundstobeabletobuypeopleequipment theyneedtokeepgrowing–tools,compost, seedsandplantsetc.Thiscouldalso includebooksand alist ofgood internetresources. Peoplecouldgohomewithahouse plantondischarge,oraplant(s)theyhavebeenlooking after,asasymbolofhope.

Accesstonaturalandoutdoorspacesthatarenormallytooexpensive

Oneideawastoask placesliketheNationalTrustandprivategardenstooffer discountedaccesstopatients,forexamplewithin6monthsofdischarge.

Bringingtheoutdoorsin

Halfadozenpeoplesuggestedpatientscould begrowingplants,flowersandherbs indoorsandonwindowsillsintheirown rooms,andthatthiscouldencouragepeople tocareforsomethingaswellasforthemselves.

‘Plantingthingscouldbebeneficial,alsoinpotsthatpatientscantaketotheirroomto seesomethinggrowwhiletheyrecover.’

‘Franklyjusthavingmyownplantpottowaterwouldhavebeensomething.’

Severalpeoplesuggestedhavingterrariaindoors,withpeopletakingonresponsibility forlooking afterthem. Suggestionsforworkshopsfor makingyourownminiterrariumwerealsomade, withpeoplebeing abletotakethesehomewith them.

Findingsfromfocusgroup2

Anartworkshopwith integratedfocusgroup washeldattheDeLa WarrPavilioninBexhill inFebruary2024.There werefiveparticipants, allofwhomhadtakenpartin1-2-1interviews previously,andallofwhomhadEastSussex mentalhealthhospitalin-patient experience(some also hadexperiencein otherlocations).

Currentorpreviousexperiencewith communitygrowingorgardening projects

Allfivepeoplehadpreviousexperienceaseither participantsorvolunteerswithgrowingorgardeningprojects, includinggreengyms,woodlandactivitiesor volunteeringonretreats(asagarden volunteer).Twoarecurrentlystillinvolvedwith projects.

Theydescribed thebenefitsoftakingpartas:goodexercise,beingoutintheopen, learningnewskills,contributingor‘puttingsomethingback’ -whichtheyknewtobe beneficial.Socialising, meetingnewandlike-mindedpeople,andfeelingincluded,were otherbenefits.

Currentlythreepeople havelittleornoinvolvementingrowingorgardening.Twoof thefivesaidtheylivedinflatsandhadnooutdoorspace.

Currentexperienceofinvolvementwithnature-basedgroupsandprojects

Twopeopletalked aboutthegroupstheytook partin.Onepersonattendedagroup aimedatcombattingisolation,that successfullyincludespeoplewhoare neurodivergent.

‘Ithinkthattherewerenopreconceivedexpectations,itwasjustcomealongandsee howyougeton,ifyoulikeit,youcancomebacknextweek.Andpeoplewhowere quiteshygottoknoweachother.Oneoftheguyswhojoinedhewasreallyshyand nowheworksforthem.Itjustallowspeopletobe,togoattheirownpace…thatmakes themfeelliketheybelong.’

Anothertalkedabout goingoutfor walkswith acameraclub,which is‘veryinformative andrelaxed’.

Participantsknewofseveralothergroupsfor walkingandcreativeartsoutdoorsintheir localareasofEastSussex,andmostwereinterestedinbeingabletodosomething againandto‘get involved’atsome point.

Whenaskedwhatwouldmakeitmoreinviting orappealingtoattend groupsinnatural settings,participantssaidmoreinformation,availabilityandaccessibletimesofthe week(particularlyiftheywereatwork)wereimportant.

Whatparticipantsthoughtaboutcommunityprojectsrunningworkshopsin hospital

Participantsdidnothaveverymuchexperienceofcommunitygroupscominginduring theirownhospitalinpatientexperiences,and theywereverymuchin favourofthis. Severalpeopletalkedabouthowmostactivitiesare‘OT-led’and itwouldbegoodto havecommunitygroups,particularlyiftherewereoccupationaltherapistswhodidnot haveskillsor interestsingardeningorgrowing.

Therewasadiscussion abouthowthiscouldbemutuallybeneficialforpatientsand communitygroups;patientswould learnskillsandtherewouldbebenefitstothe communitygrouptogain‘insightintotheexperiencesofmentallyillpeople’,challenge theirownperspectivesandultimatelybreakdownsome ofthestigma andlackof understandingthatstillexists.

Someparticipantsalso feltsomecaution aroundtheidea:

‘Ifyouhavegotpeoplecomingin,sometimespatientscanbealittlebiterratic.Itcould wellbethatyouputalisttogetherofpeoplewhowouldbenefitandcouldcopewith workingwithanoutsidegroup.Butitcouldbechallengingpractically.’

Beingabletobuildrelationshipsmattered,and consistencywasimportant:

‘Havingconsistencywiththepeoplecomingin.Youmightjustgettoknowthem,and theyleaveandsomeoneelsecomesin.YoucanlosesomethingthereIthink.’

Participantsfeltit wasimportantforanycommunitygroupcoming intohospital,tofind outwhatpatientswereinterestedin andwhat theywerealsocapable of,intermsof theirownskillsandexperiences:

‘It’sabouttakingthetimetofindoutaboutpeople,isn’tit…?Somepeoplearereally capableofdoingsomegreatwork,youknowlikebricklaying,layingpaths,weeding.It’s surprisingwhatpeoplecandowhengivenachance.Theycanshinewiththeskillsthat theyhavegotwiththemalready.’

Whenaskedifanyonehadenquiredabouttheirinterestsand skillswhentheywere inpatients,noonecouldrememberanyoneaskingthem.Severalpeoplespokeabout theirexperiencesofbeing‘keptbusyandover-fed’:

‘Theactivities,itwasjustlikecakebaking,therewasn’tanythingtheredesignedto makeyougetoveryourmentalhealthproblem,itwasalmostlikeitwasaloadof activitiesthatweremadeuptojustkeepyoubusy.Justgoingthroughthemotions.I meanhowismakingcakeswhenyouaredepressedhelpful,youjusteatthemandput onweightandfeelevenworseaboutyourself.Iputontwostonesinhospital. ’

Participantsdiscussed someoftheapproachesandactivitiesthatwouldbenefit patients,includinghavingminibustripstotakepatientsout‘atleast afewtimesa week’,andbeing abletogoforwalksoffsite. Oneparticipantsaidthatatonestage duringhishospitalstay,avolunteerfromacommunitygrouptookpatientsoutand ‘had alltheinformation abouttheplaces,soyouwerelearning atthesametime.’Hethought

lackoffundinghadput astoptoit.Havingthe opportunitytobetakenoutoffsitewas reallyimportant:

‘It’sgoodtohavepeoplecominginbutit'salsogoodtohavepeopletakingyouout. Youneedtomixitupalittlebit.Beinginhospitalallthetime,it’sjustsouldestroying anditdrainsyourblood.Awalkinggroupthatcomestoactuallytakepeopleoutwould beagreatidea.Thereareloadsofplacesaroundherethatyoucangoonawalk.’

Thegroupagreedthat‘yourrecoverywillbequicker’for‘gettingsomehelpand stimulustodrawyourselfout’,andthat thepatternof‘staringatfour walls’andbeing ‘fedstodgyfood’is‘just holdingyouback from improving,thereforekeepingyouin hospitallongerandcostingeveryonemoremoney’ - andsomadebothaveryhuman andaneconomicargumentforengagingpatientswith thingstheyareinterested in.

Thisincludedcommunitygroupsnotonlycomingintoteachandsharegardeningand growingskills,butalsooutdooryogaand exerciseclasses.Someparticipantshad experienceofunskilled/untrainedpeopleleadingactivities.

‘Itissoimportanttohaveaccesstothepeoplewhocanactuallydothesethings,who knowwhattheyaredoing.Theactivitiesworkersat(nameofhospital),blessthem,they weredoingtheirbest,buttheydidn’tseemtohaveanyrealtraininginanyspecific area.Itjustseemsthattheywereputinajobandtoldthisisyourroleandtheychurn thingsout,buttheywerenotexpertsinwhattheywereteaching.So,ifyouarebeing offeredactivities,youactuallyneedsomeonewhoisproperlytrainedinthatto facilitatethatsession,becauseitmakesitlessmeaningfulfortheparticipantsifit’sjust someone‘givingitago’.

Onemajorconcern,asitisthroughoutthisreport,wasthelackofhospitalstaffto supervise.Participantsfeltthat ifcommunitygroupsweredependent onhospitalstaff tosuperviseactivities,thentherewasarealrisktheactivitieswouldnotbeableto happen.

Oneparticipantspokeabouttheneed tounderstandthemain differencesbetween secureandacutesettings,andtheimpacton whatactivitiescan takeplace,bothinside andoutsideofthehospitalsetting,andagain,theimportanceofadequatestaffing levels:

‘Frommyexperience,oneofthemaindifferencesbetweensecureandacutesettingsis inasecureenvironment,thereismoreofasetstructureforpeopletofollow.Acute wardscanbeverychaoticspaces,andthishasaknock-oneffectofhowandwhat activitiescanbedeliveredbothinsideandout.Peopledon’treallyknowwhattodo withthemselvesduringtheday.Thereisahighturnoverofpeopleallthetime,this changesthingsquitequicklyonthewardandcanrefocusstafftimeandresources.This makesstructuringthedayverydifficult,sohavingsupportivegroupscominginand thatyoucangoto,isveryvaluable,butitallcomesbacktostaffinglevels.’

7Whatparticipantsthoughtabout visitingcommunitynature-based projectsfromhospital

Allparticipantsagreed thatiftheyhad beenofferedthechancetogoout intoanaturalenvironmentfor gardening,walking,yoga,taichi, photographyorothercreativearts, thattheywoulddefinitelyhave takenthatup.

Peoplefelt itwasreallypositiveto beencouragedtogooutfrom hospitalonvisitswhen wellenough, andto‘startdoing thingsforyourself again’. Having differentcommunitygroupscoming intothehospitaltorunactivitieswould beimportantaspatients‘becomepartofit,get usedtotheactivityandthepeople runningitbeforetheyevenleavethehospital.It’seasiertocontinueoutsidethen.’They suggestedthiscouldallbepartofeachindividual’sdischargeplan.

Howpeoplecouldbesupportedtoengagewithcommunitynature-basedprojects afterleavinghospital

Beinggiveninformationaboutwhatisavailableinthecommunityand howtoaccessit iskey. Thiscouldbealeafletorlistsofcontactspatientsare given,asnoteveryonewill

7 Imagecredit: JurgenPollefromPixabay.

knowwheretolookon theinternettofindthings,orperhapswon’thaveaccesstothe interneteasily.

Havingpeersupportworkerstohelppeopleengagewouldbeimportanttoo –includingaccompanyingpeople,atleastinitially. Onepersonsuggestedeveryonecould beofferedapeer supportworkerforsixweekspost-discharge:

‘Twiceaweekforthefirst3weeksandonceaweekforthelastthree.Itreallyhelped metointegratebackintothecommunity. ’

Thegrouptalked about howimportantpost-dischargesupportis,‘otherwiseyouare lefton yourown’and‘thechancesare youwill thenfallback again’andtheydiscussed theeconomiccasefor offeringmorepeersupporttohelppeopleavoidre-admittance tohospital,aswellasthewell-beingcase.Again,therewasconcernthatcutsto fundingmeanthereare notenough staff,andthatmorefundingwasneededto increasestaffingandresources.

Therewasstrongagreementthatthetrainingofmoreprofessionalpeersupport workersinTrustsandinthevoluntarysectorwasareallypositivedevelopmentin supportingpatientsbothinhospitalandthecommunity.

Thebenefitsofpeer-supportedandpeer-ledactivities

Participantsagreedthatwhenpatientsaredischargedand‘it’sleftup toyou’then manypeopledonotengage;supportisneededuntilpeoplefeelmoreconfident,and peopleneedtobe‘easedoutofhospital’.Theydiscussedtheideaoftherebeinga transitionalsupportmodel;forexample,sixweekswith apeer supportworker,firstly workingwiththeperson1-2-1andthenafurtherthreeweeksbeing inasupportivepeer grouporgoingtogroupswiththepeersupportworker.

Whenaskedwhatthe1-2-1supportmightlook like,thegrouptalkedaboutthepeer supportworkertaking averypersonalisedapproach;startingsupportwhilethepatient isinhospital,gettingtoknowthem andwhat theylike,whattheirstrengthsare,and whattheymaybeinterestedindoing.

‘Thenyoucanbesupportedtofindoutwhatisoutthere,orsignpostedastheysay nowadays.Afterthat,thesupportcanbeofalessernatureandamountoftime,maybe reviewhowyouaregettingon.’

‘Youcouldalmostdoitfromwhenyouareinhospital.Startmeetingwiththem,they couldgotoinpatientgroupswithyou,sotheyfindoutwhatyouareinterestedin beforeleaving.Itissuchashockgoingoutintotheworldagain.Becauseitis regimentedinhospital,mealsatthistime,lunchatthattime.Itishardafterwards.’

Whatactivitiesinnaturecommunitygroupscouldoffer

Participantshadlotsofideasforactivitieswhichcouldbeofferedbygroupscoming intohospitaltorunthem,aswellasofferingtheminthecommunity.Theyare listed here:

• Gardeninggroupstolearnhowtogrowfruit,vegetables andflowersinbedsandpots,bothindoorsand outdoors,as noteveryonehasgardenoroutdoorspaceattheirhomes. Learninghowtoidentifydifferentspeciesofanimals,trees andplants.Thesearetransferableskillsandknowledgethat wouldencouragegoing outandaccessingnaturewhen backinthecommunity.

Haveopendaysatthehospitalwherepatientscan sellplantsandraisemoneyforgardeningprogrammes andotheractivitiesand materials.Thiswouldgive peoplepurposeandhelpwithconfidenceand interactingwith the‘outside’worldagain.

• Learningtouseplantwasteforcompostingor makingthings(naturaldyes,dreamcatchers,charcoaletc.)

Relaxation.Howtodothisproperly.Learninghowtouseitbefore thingsgettoostressful. Differentkindsofmeditation(as‘noteveryoneissuited tomindfulbreathing’). Mindfulwalkingmight bebetter,orTaiChi.Nothingtoo complex,sothat itcan belearnedeasilyandusedregularly.

• Noteverythingneedsmoney,andmanypeoplewon’t havemuch. So,when inan outdoorareathathasbeencreatedtohelppeoplewith theirrecovery,startby identifyingplants,recognisingplants, learning aboutthem,what insectsthey mightattractandhow theywork intheir environment:‘Thingsthat youdon’t

reallythinkabout that makeyoustarttothink abitdeeper,aboutthecycleof things.’

• Foodpreparation,healthyeatingandhowfood affectsmood.Thenutritional contentoffood.Thiscouldbeassimpleasgrowingthingslikecress‘forthose thatcan’tgooutor wantaquickresult.’

• Growingsomething‘safeandgreen’tobrightenownspace.‘Youcanquicklyget asenseofachievementfromthis.’

● Haveaccesstoaminibusfororganiseddaytripstobeabletogoforlonger walksandindifferentspaces/landscapes.This wouldalsohelpwith awareness ofwherepeoplecould gointheirlocalareas.

● Haveorganised walksalongtheseafront.Thiswouldhelppeopleget intothe habitofdoingsomethingaccessibleandfreeoncetheyareoutofhospital.

● Haveaccesstoagym (indoororoutdoor)oractivitieslikeaerobicsclassesrun bytrainedteachers.

8Thegroupdiscussedtheimportanceof matchinginpatientprogrammeswith whatisavailableinthecommunity,so thattherecouldbecontinuityand sufficientsupportafter discharge.This wouldhelpkeepupthemomentumfor peopleandenablethemtoexpandany intereststheyhavedevelopedand buildonanykillstheyhavelearned andhelpwith re-orientationback into community.

‘Beinginhospitalcanbereallybadfor yourphysicalhealth.Beingabletoseeandaccessan activityprogrammeandunderstandingwhocanhelpyouattendisreallyimportant.’

Participantsalsofelt itwasimportanttohave thesame activityleadersandpeer supportworkersforbothinpatientandoutpatientinvolvement,ideallythosewhohad alsohadhospitalexperience.

8 Imagecredit:Drawingscreatedfromthe MakeYourMarkpopup atthe HeadsOnWalkforWards event2018

‘Continuityofpeopleisimportantforbuildingconfidencebackup.Thiscouldbeagood roleforpeersupportworkerswhohavehadinpatientexperiencethemselvesand understanddirectlythechallengesofleavinghospital.’

Howimportantisitthatcommunityactivitiesinnaturearerunbymentalhealth organisations?

Fourpeoplefelt itwasquiteimportant,andonepersonthought itwasveryimportant. Therewasgeneralagreementitwasimportant forpeoplerunning activities/initiatives tohaveknowledgeand understandingabout mentalhealthchallenges,but‘therehas gottobesome inputfromelsewherefrompeoplewhounderstand aboutnature-based work,forthewholethingtowork.’

Mostpeoplefeltthat itshouldbesmaller organisationswith localknowledgeand understandingoflocalissueswhowouldbebetterplacedtodothiswork.

‘Youneedtoconsiderlocalissueswhichmightgooutthewindowwithalarger organisation.Iwasn’tthinkingofalargeorganisation,morelikesmallgroups….towork quitecloselywiththehospital.Ithinksmall,organisedgroupsthatarepeerled,peerdesigned,workwell.’

‘Ithinkthingsgetdilutediftheyarerunonalargerscale.Andthereisthedangerofbig organisationsmakingcutbacksandnotputtingfundingwhereitismostneeded.’

Howimportantisitthatstaffandvolunteershavementalawarenesstraining?

Fourpeoplefelt thatknowledgeandtrainingwereveryimportant,andoneperson thoughtitwasquiteimportant.Somethought thathavingexperienceofworkingin the mentalhealthsystemwasabonus.

Howimportantisitthatstaffandvolunteershavetheirownlivedexperience?

Fourpeoplefelt itwasveryimportantthatstaffandvolunteersincommunityprojects hadtheirown livedexperience–thiswouldbe‘fantastic’.Onepersonfeltit wasquite important.

Howimportantisitforanaturalrecoveryprojecttobeaimedatpeoplelivingwith SMI?

Fourpeoplefelt itwasveryimportant.Onepersonfelt itwasquiteimportantbutthat ‘it’sdifficult tosay.Ihavebipolar,butIdon’t considermyselftohave aseriousmental illness.’Thissparkedadiscussion about whetherpeopleconsideredtheirillnesstobe severe.Twopeopledid (onepersonlivingwith severebipolarillnessandoneperson livingwith schizophrenia)andonepersonsaid‘whenIamunwell,I wouldconsidermy symptomstobesevere.Certainly, inmyyoungeryearsIwasseverelyunwell.’

Therewasgeneralagreementthatwhen peopleareseverelyunwell,they‘kind ofget druggeduporlockedup’andthatiftheywerebroughtintoactivitiesattheirown pace inasupportive1-2-1peerrelationship tostart with,thenintosmallsupportivegroups, ‘theywouldfarealotbetter’.

Howimportantisitforanaturalrecoveryprojecttobeforanyoneinthe community,regardlessoftheirmentalhealth?

Twopeoplefelt itwasveryimportantthatprojectswereaccessibletoeveryone.Three peoplefelt itwasquite important.Onereasonforsupportingfullaccesstoeveryone, wastopreventdeteriorationofsomeone’smentalhealth,ratherthanonlyoffering supporttopeoplewho werealreadyseverelyunwell.

‘Ifyousaysevere,it’sasortofspectrumofdifferentlevelsofseverityandthereforeit shouldbeaboutmeetingwhatneedseachindividualhas.’

‘Ithinktheseverityofthingsaswell,it’sapersonalthing.Someonemaydeem themselvestohaveaseverementalillness,butclinicallyitisn’tconsideredso.It’sabout howitimpactsyourlife.Notatickboxprocess.’

Whatmightgivepeopleasenseofinclusionandbelonging?

Thegroupdiscussedtheimportanceofpersonalised approaches,and going‘slowand steady’,with smallgroups,makingiteasierfor everyonetoget toknoweachother, withconsistencyofstaffandvolunteers.

Staffandvolunteersshouldactivelyincludepeoplebased ontheirneeds,offer encouragementandbe interestedin eachindividual.Peopleshould havetimetothink

abouttasks,abouthowtheymight beabletoachievethem(asthis is differentforeach individual)andtotrythemoutwithoutanypressuretohavetoachievethem.

Participantsdiscussedhowharditistobeinterestedindoingsomethingifdepressed orinanegativestateofmind,andtheimportanceofnotpressurisingpeople,aboutnot givinguponthem,abouttryingagainanother time,‘andthinkingwell ofpeople’.

‘It'ssoimportanttohavepeoplewhowillkeeptryingwithyou,whetheryouareinor outofhospital.Whenyouarereallydepressed,it’ssoeasytosaynothing,ifyouget askedaboutwhatyoulikedoing.Butifpeoplekeepcomingbackandgentlykeep asking,itdoesgetthecogsgoingagainandyoustartthinkingagainaboutwhatyou enjoy.’

Whatwouldhelppeoplefeelsafewhenvulnerableorexperiencingsymptomsof severementalillness?

Participantsdiscussedhowdifficult thiscouldbe;sometimespeopledon’tknow themselveshowvulnerabletheymightbe. Thisiswhereknowledge,trainingand experienceforstaff andvolunteerswouldbesovaluable. Thegroupfeltitwas importantthatcommunitygroupswouldbeabletobeflexibleandofferchoices.

‘Isupposeit'saboutgivingpeopleoptions,soit’snotasetregime,soit’spersonalised, say,youcanjustcomefor10minutesandseehowyougeton.So,youhaveachoice andopportunitytocontinueornotonanyparticularday.Justsoitdoesn’tfeelclosed orregimentedandlikeaschooltimetable.’

Otherssaidthat justbeingabletoexercise,togoforawalk withsomeone,makinga planwith someone,or‘justbeing abletosit down’,wouldbeanimportantpartof offeringsomeonechoices.

‘Justletthemgotothegroup,don’tforcethemtotryit,justletthembethere.You mightfindthatthistriggerssomething,oh,thatlooksinteresting,or,yes,Ihad forgottenIlikethat.’

What

thebarriersmightbetoaccessingacommunitygroup

Participantssaid onecommonbarrierwasnothavingclarityorreallyunderstanding whatisonoffer.Oneexamplegivenwasofbeingreferredtoan‘artgroup’ –which

didn’texplainwhat areasofartarecovered,whatskilllevelwasrequired,andif equipmentwasprovided.

Anotherexamplewasgivenaboutassumingnatural recoveryisalwaysaboutfocusingongardening, whenitcanincludesomanyotherthings likeyoga, outdoorpainting,taichietc.

Beingconcernedabout ‘havingtoachieve something’wasabarrier,asopposedtojustbeing abletobeyourself inthespace.

Otherbarriersincludingpossiblecost(includingfor anytransportneeded), nothavinganyonetogowith, andnotfeelingconfident.

9Overcomingbarriers

Thegroupsaidthatthemostimportantaspect was aboutofferingchoices topeople,andclear explanationofwhat isonoffer.Oneparticipanthasa friendwhoranagreen gymand‘incorporated allkindsofdifferentexercisesaspartof it’.Peopleneedtobeaskedwhattheyliketodo,andgroupscouldofferseveral differentthings–gardening,artinnature,exerciseinnature.Thisneedstoallbe made clear.

Thereshould alsobethechoicenottosocialise,andtojustbeabletobealone,torelax inthespaceand alsotojustobserveactivitiesifpreferred.

‘WhenIusedtogotothegreengym,Ihadaterribledepression,butIwasabletoget myselfthereandIwasallowedtojustfindacornerandwatch,becauseIdidn’treally wanttosocialise.Buttheyunderstoodthat,andIwasstillpartofit.’

Oneparticipantsaidtheywereputofftryingsomething(taichi)becausetheythought itwas‘somethingonly womendid’but whenitwasintroducedtothem,theytriedit

9 Photocredit:HeadsOn,photographof theGreenGyminstalledatMillViewHospital.

outandlikeddoing it.Oneotherpersonsaidtheywereallowedtocomeandobserve anoutdoorclassuntiltheyfelt readytojoin in.

Knowingthat outdoortimeisalsosocial(barbecueswerementioned) andcanbeabout playaswellasabout doingactivitiesishelpful.Funactivitieslikegeo-cachingwere mentioned,alsotreasurehuntsandhide-and-seek.

Finally,having apeersupportworkerwasalsokeytofeeling abletoaccessresources, particularlywhen notfeelingabletodoitalone.

Considerationsand recommendations:Staffingand fundingactivities

Throughoutthisreport,participantshavefrequentlycitedstaffing levelsasabarrierto participationinnaturerecoveryduringinpatientstays.Weneedtoacknowledgethat nationalpressuresfacingtheNHS,includingtheongoingchallengefollowingthe Covid19pandemic,meanthat thesepressuresarelikelytocontinuefortheimmediatefuture.

Wealsounderstandthatmentalhealthhospitalscareforpeopleattheirmost vulnerableandsafetyisoftheutmostimportance.Thiscanmakethedeliveryof activitiesoraccesstooutdoorspacesandnaturechallengingtofacilitateasstaffwill alwaysneedtoprioritisepatientsafetyoverandabovedeliveryofactivities.

ThenewCombeValley Hospitaloffersauniqueopportunityto considerandtest innovativewaysofdeliveringnaturerecovery,withintheparameters ofexisting staffinglevels, withthepotentialforrolling outtoothersettings.Forexample,ifnature recoveryactivitiesweredeliveredbytrained voluntarysector partners thishasthe potentialtoreducetheburdenonNHSstaffing. Naturecouldbeincorporatedinto existingactivityprogrammestobroadenopportunitiesandofferpatientschoiceof creativerecovery.NHS Trusts'ownvolunteeringprogrammescouldplay akeyrolein enablingnaturerecovery.

Byconsideringandtestingsome ofthesethings,inthecontextofcontinuingpressures ontheNHS,SussexPartnershipmaybeablepilotresponsestomanyofthe recommendationsinthisreportwhilst maintainingsafestaffing levelsandbeing mindfulofadditionalcost.

Keythingstoconsiderfromtheresearchinaddressingthechallengeofstaffingfor natureactivitiesare:

1. Ensureactivitiesare ledbypeoplewhohaveexperienceand/or training.

2. Considertheroleofpeersupportersinthedeliveryof activities.

3. Some‘entrylevel’activitiesshouldn'trequirestaffing -forexamplegiving patientsasmallplanttogrowandtakecareofintheir bedrooms.

4. Naturerecoverycanbeincorporatedintoexistingactivities -forexamplean onlinemap ofthenaturalfeaturesonawander loopforpeopleto spot.

5. Peoplearekeen foractivitiestobebothbroughtintohospitalandfor peopleto betakenoutofhospitalonvisits;partnershipswiththevoluntarysectorwillbe keytoachievingthis,howeverthismayhavecostimplications.

"Researchtellsusthatcreativerecovery,includingnaturerecovery,playsanimportant roleinpeople'sjourneysthroughmentalhealthproblems,bringinghopeandoptimism forthefutureandconfidenceinourabilitiestobemorethanwefeelinourhardest moments.

Atthesametime,buildingcreativerecoverywithinNHSservices,especiallyinthe currenteconomicclimate,canbeanongoingchallengewithNHSbudgetsunder sustainedpressureanditisclearweneedtothinkdifferently.AsanNHScharity,Heads Onhasastrongtrackrecordofsupportinginnovationandchange,bothwithfunding andthroughworkinginpartnershipwithourlocalcommunities.Ifwearetodeliveron therecommendationsofthisreportinSussex,itisvitalthatwefullyharnessthe potentialofHeadsOntopilotnewwaysofworkingthatembedcreativerecovery withintheDNAofhighquality,effectivementalhealthservices,buildingthecasefor sustainedinvestmentintothefuture."

Rachael Duke,CharityDirector,HeadsOn

Conclusionsandrecommendations

Conclusions

It’sclearfromwhat participantstoldus,thatnature-basedrecoveryplaysakeypart in people'srecoveryjourneys,bothasinpatientsandinthecommunityfollowing discharge.Researchshowsthat‘interventionswhichfacilitatenatureconnectionshave thelargestand mostsustainedpositiveimpacts’forphysicalandmentalhealth;see Naturemattersinmentalhealth10 andalsoEffectofnatureprescriptionson cardiometabolicandmentalhealth,andphysicalactivity:asystematicreview.11

Respondentshaveagoodunderstandingofthebenefitsofnatureinrecovery,and somepeopledidmentiongoodpriorexperiencesinhospital.

12Respondentshavemanyideasfor whattheyfeelshouldbeofferedin therapeuticnaturalspaces,andsome imaginativeproposals. Thisincludes beingabletoseeandhearwater, observeandengagewithwildlife, haveavarietyofcolour,texture andplanting.

Peoplewantsensorygardenswith herbs,pollinator-attractingplants andareasforattractingwildlife, differentfloweringplants throughouttheseasons,largeshrubsand treestocreatespaceanddimensions,andcreationofspacesfor privacyandreflection, aswellasgroupgatherings.

10 Roberts,RandFisherT(2024),NatureMattersinMentalHealth .Availableat:https://www.rcpsych.ac.uk/news-andfeatures/blogs/detail/sustainability-blog/2024/03/06/nature-matters-in-mentalhealth#:~:text=Good%20for%20patients&text=A%202023%20systematic%20review%20of,as%20lowered%20blood%20pressure1 0.(AccessedMay2024)

11Astell-Burt,T, Feng,X.,Nguyen,P-Y., Rahimi-Ardabili,H.Effectofnatureprescriptionsoncardiometabolicandmentalhealth,and physicalactivity:asystematicreview .Availableat:https://researchmanagement.mq.edu.au/ws/portalfiles/portal/228808323/Publisher_version_open_access_.pdf (AccessedMay2024)

12 Imagecredit:JasonfromPixabay

Outdoorfurniturecouldbemade ofnaturalmaterials;therecouldbeorchardsand berrybushes,theabilitytobeoutdoors inallweathers.Outdoorgamesandactivities arepopularandprovideafocusforwhenbeingwithvisitors.

Gardeningandgrowingfood,throughtaughtcourses,groupsandclubscould include patientswhohavegrowingexperiencebeing encouragedtosharetheirskills.Beginners canbeintroducedtosimpleandachievabletasks,andquick-growingplants,sothey canseeresults.

Havingchoicesisveryimportant;particularlyforpeoplewhoareveryunwellandlack motivation.

Beingabletointeract with,becuriousabout andlearnfromthenaturalspaceswasalso important;particularlywhenpeoplearemoreabletoengageandtakenoticeoftheir surroundings.Havingchecklistsforspottingnature,beingabletolook upinformationor beprovidedwithinformationthroughsignsor infosheets,can providebothentertainmentandpurpose.

13Observingandinteractingwithanimalsofallkindsis therapeutic.Thiscouldincludegoingfornaturewalks withsomeonewhocan pointoutwhatthefloraand faunaareorhavingchecklistsorquizzes.Being able tocreatehabitatsfor wildlife,andattracting wildlife,createsanotherwayofbeing alongside nature.Interactingwith therapyanimalsis beneficial,andtherearesuggestionsforanimals livingonsiteincludingdogs,catsandchickens.

Respondentssuggesta varietyofrestingand seatingareasincludingswingsand living willowspaces,forsolitudeandgroupspaces, andalsotoallowviews ofsky,trees,flowers, woodlandareas.It isimportanttohavespaceto

13

Image by Langley Green Hospital. 'Brandy' visiting therapy dog. Source - Twitter.

breathe,toreflect,tobequiet.Manypeoplementionedmeditationandmindfulness outdoors.

Peoplewantspacesfor playandforcreativeartsandcrafts;thisincludesworkshopsto beheldoutdoors insteadofindoors,butalsospecificoutdooractivitiesincludingusing naturalmaterials,found objects,naturephotography,writing.Playincluded giant outdoorgameslikechess,spacesforplayingbadmintonandtabletennis,andtreasure huntsandgeo-caching.

Bushcraftandoutdoor activitiesassociatedwith‘wilderness’orcampingarealso popular,includingmakingfiresandhaving singsongs,toastingmarshmallowsandother activitiesaroundafirepit.

Intermsofphysicalactivity,thereshouldbespacesforbothsoloand groupexercise includingwalkingandrunning,gentlestretching,yogaandtaichi,and exerciseclasses outdoors.Activitiesshouldbeledbypeoplequalified orexperiencedinrunning them.

Respondentssuggestthatthereshouldbeavarietyofspaceswherepeoplecanbe aloneoutdoors,includingspacethat canbebookedinadvance,andthatitshouldbe somehowindicatedwhensomeonewantstobealoneandhasthespacetothemselves.

Forthosewhowanted company,oneideaisa‘buddybench’areawhereconversationis invited.Groupsshould alsohaveavarietyofspacesawayfromquiet areas,whetherthis isforvisitorsorclasses wherenoise/musicisapartofit.

Thereshouldbespace wherepeoplecansmokeorvapeawayfromothers. Smoking/vapingisanimportantpartofhowsomepeoplewith SMIcope,andthere wasconcernthatsmoking/vapingwouldnotbepermittedonhospitalpremises – as thisdeprivespeopleoftheirchoice.

Gardeningandgrowing

Therearemanysuggestionsmade aboutintroducingpatientstoeasy, gentlegrowing activities,includingstartingindoorswithplantsonwindowsillsandshowingpeople howtocareforthem.Simpleandquick togrowfoodlikesaladvegetablescanbe growninpolytunnelsandraisedbeds,sothat peoplecan see(andeat)quickresults whichfeelspositiveandencouraging.Beingabletogrowfoodthat patientscan eat

(anddrink,withherbalteas)isverysatisfyingforpeople,andagood waytoengage peoplewith gardening.

Beinggivenaspacetocarefor,orparticularplantstogrow,isalsoattractivetopeople, whileatthesametime somepatientswillstrugglewith motivationor abilitytoachieve taskswhileveryunwell, soarangeofchoicesisneeded,includingthe choicetojustsit andobserveothersgardening.

Somepatientswillhavegardeningandgrowingexperienceand should beencouraged tosharetheirknowledge,supportingandevenleadingactivitieswheretheyfeelable to.

Beingaskedwhat youwanttodo,and whatyourinterestsare,isimportantfor engagement–choices, again.

Connectionstocommunitygardenandnatureprojects

Connectionstocommunityresourcesshould ideallybemade whilein hospital.This includescommunityprojectscoming intothe hospitaland runningactivities,so patientscan becomefamiliarwith peopleand whatisonoffer.Buildingsecure relationshipsandhavingconsistencyofpeopleisimportanttobuild upconfidenceand trust.

Beingabletogooutofthehospitaltovisitprojectsisalsorecommended,forexample goingfororganised walksbytheseaandin woodlandandvisiting othernatural settings.

Itwouldbeidealifthe staff/volunteersintheseprojectshadlivedexperience themselves.Itshouldbenotedthatmanycommunityprojectsaredeliveredby volunteersnotpaid staff,soconsiderationneedstobegiventoprovidingvolunteers withtherighttrainingandsupporttoworkwellwith peoplelivingwithSMI.Funding forcommunityprojectsisanotherimportantconsideration;participantsdidreference somegood initiativescomingtoanendbecauseoflackoffunding.

Peersupportandpeer-lednature-focusedactivitiesareimportant.Severalsuggestions weremadeabout havingindividualpeersupportforseveralweeksor monthswhile transitioningfromhospitalback intocommunity,thenpossiblymovingtogrouppeer support.Thiswouldhelppeopleregainconfidenceandthepeer(s)couldsupport

someonetoengagewiththeirwidercommunity,withthelikelihoodthatsomepeople willnotonlybecomeactiveparticipants,butalsobecomevolunteersthemselves.With supportandtraining,othersmayalsochoosetobecomepeersupporters.Having formerpatientsaspeer supporters(especiallyifcomingback intothehospitalthey havebeeninthemselves)modelshopeandrecovery -twokeyvalues ofpeersupport.

Recommendations

Muchhasalreadybeen designedfortheCombeValleyHospitalsite,butwehopethese recommendationswilldeveloptheplansfurther,fromalivedexperience perspective. Theseare alsopotentialkeyconsiderationsfor allmentalhealthhospitalsites.

1Designinspiringoutdoorspacesthatinviteengagementwithnature

Participantswantoutdoorspacesthatare inviting,inspirational,imaginativeandwellmaintainedsothatpatientshaveasenseofoptimismandwant tospendmoretimein nature.Therearemany variedanddetailedsuggestionsfortherapeuticoutdoorspaces, andtheseare listedbelow:

• Well-maintainedsensorygardens

Peoplearekeen tosee, smelland touchplants, flowersandherbs.Manyfeelthat gardensshouldbewell-maintained,notallowedtoovergroworbecome unkempt.Theyshould bedesignedtobelow-maintenanceandeasyto maintain.

• Colourfulbrightplantsandflowers

Itisveryimportantfor participantstobeingreenspaces,but peoplealsowant tohavethegreeneryinterspersedwithbrightcolouras‘itcheerspeopleup’and addsinterestanddiversityandbeauty,notjust insummerbutthroughoutthe seasons.

• Gardenswithpollinators,nativeplantsandedibleplants

Peoplewantplantsthatattractbees,butterfliesandotherpollinators.Forafew peopleitisimportantthattherearenativeplants,andotherswant fruitand otheredibletreesand bushessothattherecanbesome harvestingofleaves andberries;‘foraging’thatwouldbebothfun andengaging. Amini-orchardis oneideaforlow-maintenancegrowing.

• Water

Lotsofrespondentstalkedaboutwaterbeinganimportantfeature.Peoplewant

tobearoundwaterand tohear watertrickling, asthisfeelstherapeutic –so littlewaterfallsandfountains,butalsoponds, whichincaseofrisk couldbe smallershallowponds, birdbaths,andlittle‘boggardens’thatare safeand wouldstillattract wildlifeincludingfrogsandtoads.

• Treesandlargerplants

Manypeoplewanttobearounddifferenttypesoftrees,particularlytobeable tositundertreesforshadeandforagreatersenseofthe‘wonder’ofbeingin nature. Beingabletoreadorpicnicunder atreeisveryrelaxing,butalsojust beingableto‘sitand feelandobserve’.

Thereismuchavailableevidenceofthementalhealthbenefitsofbeing closeto trees:

https://www.woodlandtrust.org.uk/trees-woods-and-wildlife/britishtrees/health-andwellbeing/#:~:text=Nature%20alleviates%20stress%2C%20stabilises%20blood, and%20accelerate%20recovery%20from%20surgery

https://www.treesforstreets.org/how-trees-support-our-mental-health/

https://nhsforest.org/blog/happy-to-be-outside-mental-health-and-nature/

• Walksandpaths

Manypeoplewantdesignatedwalking areas, withpathways,andtohave ‘destinations’for‘pacingwithpurpose’,aswellastheabilitytowanderandto explore.Havingsignsandmapsarepracticalsuggestionssothatpeoplecan walkwithoutsupervision.Forwheelchairusers, flatandwidepathsare essential, andothersmentioned needingtoensureequalaccessforallphysicallydisabled people,sothatmightincluderailingsand lotsofwell-spaced-outseating/resting options.

• Accesstonaturalspacesasoftenaspossible,atdifferenttimesandinall weathers

Offerasmuchsafe,openaccesstonaturalspacesasispossible – including night-timeaccessforstargazing.Ensurethat assoonasfeasibleafteradmission, patientsare introducedtotheoutdoorspaces, towhat isavailable,andknow whenandhowtheycanaccessit.Thismaybeawrittenguidetothespaceanda guidedinduction/introductiontotheoutdoor spaces,whichcouldalsobe

conductedbyotherpatients.Provideshelteredspacessopeoplecan be outdoorsinallweather.

• Creativeartsspaces

Respondentswantspacesandequipmentforpeopletobeabletodrawand paint,writeanddotheirowncreativeprojects,includingusingnatural resources likeplants,leaves,woodandstonetocreatethings.Naturephotography,murals, mosaicwereallmentioned,aswellasareaspeoplecould paintover(i.e.,change thesignageormessagingoncommunityboardsasand when,ideallywith inspiringandcomfortingmessages).

• Variationofspaces

Severalpeoplehadvarioussuggestionsforthedifferentcharacterofeachspace, includingdifferentheightanddepth,placesfor lightand placesforshade,open spaceandshelteredspace,stillandrunning water,differentcolours,shapesand textures.Areaswherepeoplecan smokeorvapeawayfromothers.

• Aestheticallypleasing/magicalspaces

Suggestionsincludewindchimes,artwork,murals,mosaics,sculptures,useof naturalmaterialsasmuchaspossible, livingwillowareasanddesigningfor ‘intrigue’andimagination.Pondswithwaterlilies.Crystalsand stonesarounda garden/smallpond. Afewpeoplesuggestedspacesfortreasure huntsand outdoorstorytelling,andthecreation ofsmallcalminggardenspacesor‘zen gardens’.Offerimaginativeand‘magical’spaceswitharangeofheights,depths andtextures;wherepossiblecreate‘wilder’spaces,with livingwillow,high grassesandtrees.

2Designspacesandopportunitiesforgardeningandfoodgrowing

Manyrespondentswanttoseeareasforgardeningandgrowing,including:

• Differentspacesforgrowingfoodandflowers

Thisincludesproviding raisedbeds,polytunnelsandallotmentareas,spacesfor gardeningcourses,groupsandclubs,andforindependentgardeningor ‘pottering’.

14Growingownfood

Peopleliketheideaofthegrowingofherbsand plantsforfood,whichcanalsobepickedandused incooking/saladsonsite.Again,theseshouldbe welldesignedandmaintained,aspeoplefindthe growingoffood‘hopeful’and‘grounding’.

• Classes/clubs

Offeravarietyofgardeningclassesandclubs thatenablechoicesfor peopletogrow,learn andshareskills,and alsotosimplyobserve activities.Offersimple, accessibleactivities thatencourageplant care,andthegrowing andmaintainingofplantsindoors,inown roomsandcommunalspaces.

• Engagepeople’sinterests,knowledgeandskills

Findoutwhat interests, knowledgeandskillspatientsmayhaveandbe willingtoshare.Offerpatientstheopportunitytosupportorco-lead activitiesin ordertogrowconfidenceandprovidepurpose.

Thereweremanysuggestionsfor thetypesofgardeningandgrowingactivitiesthat couldhappen,including:

• Communitygrowingplot

• Patientherbandvegetablegarden

• Agardeningclubwithbeginnerandintroductoryandtastersessionstoo

• Gentlesessionsfortendinggardens(aloneor withothers)

• Propagationofplants; growingplantsand flowersforplantingout

• Helpingmaintainthegarden/choosingwhatplantstogrow/helpingdesign it.

• Digging,weeding,sowing

• Educationsessions, includingthoseledbypatientswith growingexperience.

• Learnaboutgerminationandgrowth

• Pickingandharvestingandbeingabletousethese(i.e.,incooking/foodprep)

• Plantingtohelpwithgrieforother issues, wherefloweringplantscouldbepart ofacare plan.

14 ImagebyHeadsOn.AllotmentspaceatAmberstoneHospital.Source:HeadsOn

• Beingtaughtaboutplantcare,differenttypesofplants,feedingandunderor over-watering.

• Howtogrowfromseed

• Makingyourowncompost

• Howtoplantandmaintain

• Gardendesignskills

• Generalgardeningskills -which toolsdowhat

• OTandvolunteergroupstocome andhelp educate.

• Horticultureskills

• Miniallotmentbedswithfastgrowing plants,easyto tend.

• Polytunneltoextendthegrowingseason andrunsessionsinduringbad weather.

• Beingpartofateam withparticularresponsibilities,soyoufeel ownership.

• Fruitgrowing/orchard

• Peer-ledgroups

• Plantingsomethingthatgrowsquicklysoyouseequickresults – i.e.,growa cresshead.

• Plantstogrowandtakewith youwhenyougo home.

• Learnaboutthementalandphysicalhealthbenefitsof gardening.

• Howtomakeabirdbox/birdfeeder

• Howtomakeabughotel

• Learninghowtomakegreenroofsandliving walls

3Designplacesforrest,solitudeandsocialising

Peoplewantthechoicetobeabletobealoneandwithothers(other patients,staff, visitors)andsuggest differentareasare createdtoenablepeopletousethemat differenttimes.

• Benches/seating

Havingseating isveryimportant,andtohaveavarietyofseating areas.There wereideasforsinglechairs/restingspacesforpeopletobealoneinthe outdoors,aswellasdesignated‘buddybenches’whereyoucangoandsitwhen youwant someonetocomeandchat.

Groupsofbenchesare goodforvisitorsandforcoursesorgroupsoutside.Ideas werealsoofferedforshelteredcanopyareas,livingwillowareasand‘nichesor nooks’wherepeoplecouldsit inslightlyenclosedspacesforprivacy.

Havingseating madeofnaturalmaterialswasproposed,including‘curvy’and ‘wavy’seating.Havingcushionsandsofterseatingforgoodweatherwasanother ideaforcomfortandbeingabletoaccessblanketsforwhen itwaschilly,so peoplecould stillbeoutdoors.Onepersonsaid hewouldbehappywith‘tree stumps’toperchon,as longastherewasvarietyforpeople’sdifferentlevelsof comfort.Swingseatsandseatingcarvedintotreetrunkswerealsosuggested.

• Quiet,safespacestobealone/areasforpeacefulcontemplation/reading spaces

Also,veryimportanttopeopleistheabilitytobeawayfromothersinquiet spaces;whethertosimply‘be’and‘watch clouds’ortosit,toread,towriteordo soloactivitiessuchascraftingorgroupmindfulness/meditationsessions.Several peoplesuggestedthat quietareasshouldbeclearlydesignatedand labelled/signedassuch sothatpeoplewantingtotalk orplaymusic,knewnot togothere.Quietspacescould alsopotentiallybe‘bookable’inadvance.

• Placestochat/havediscussiongroupsandworkshops

Theoutside‘offer’shouldalsoincludeplaceswherepeoplecan gather,whether withvisitors,staff,otherpatients,oraspartof courses,classesordiscussions. Theseneedtobeaccessibleinallweatherssobeingabletohaveshelterorput onacanopy(possiblearemovableone) forbadweatherandforshadeinhot weatherarealsoimportant.Theseplacesneed tobefarawayfromthequiet space(s).Suggestionsforavisitorbookingsystemwerealsomade sothat peoplecould accessspacewhen needed.

4Provideopportunitiesforobservationofnatureandinteractionwithwildlife Itisimportanttomanypeopletobeabletoobservenature;theywant tohear birdsong,insectnoisesandotherwildlifesounds.

• Createwildlifehabitats

Thisincludeshaving(or making)birdboxesandfeeders,squirrelfeeders,bat boxes,ponds,insect-attractingplants,bughotelsand areasthat mightprovide shelterforanimalspassingthrough.Provideopportunitiestoobserveand interactwithwildlife, throughnaturewalks,floraandfaunaidentification.

• Views

Severalpeoplesaidhowdispiriting itistohavenoviewofnaturewhenin hospital.Beingabletoseetrees,daylight,skyandtoseeandhearbirds,uplifts people. Suggestionsincludebeing abletohave various‘viewing’ pointswith differentperspectives–i.e.,viewsofgarden,of sky,ofwoodland,offlower beds,oflargetreesetc. Thesecouldalsobehighlightedor‘mapped’forpeople, sotheyknowwhatisthere(informationabouttheflowers,orthewoodlands –typesoftreesetc.).Patientscould alsobeintroducedtotheideaof‘sit spots’ whichcan reallyencourageobservationandinteractionwith naturein areally calmway.

• Interactiveinformation

Severalpeopletalkedaboutfindinginformationoutabout theonsiteplantsand creatures. Oneintervieweesuggestedcreatinganinteractivemaptobeusedon atabletorphonesopatientscouldreadandhearaboutplantsand wildlifeand beencouragedtospot wildlifeandlearnaboutit.

• Animalsonsite/therapyanimals

Provideopportunitiesforengagementwith therapyanimalsbothonandoffsite andconsiderthepossibilitiesforhavingdomestic/low-maintenanceanimals onsite.

5Provideopportunitiesforoutdoorphysicalactivity,exerciseclassesandplay

Respondentsareveryknowledgeableabout thebenefitsofexerciseandmovementon mentalwellbeing,and wantavarietyofchoice,withtrained/experiencedfacilitators whenclassesortaught activitiesareonoffer.

• Movement

Thisincludeswalkingandrunning(solo,groupsandclasses),spacesforgroup ‘keep-fit’andteamgames,aswellasquietspacesforpeoplewhowant to practiceyoga,taichi, Pilates,breathingand stretchingandtoningexercises. Suggestionsalsoincludedcreatinga‘naturalgym’,havinganoutdoor gymasin manypublicparks,outdoorfitnessclasses,placestosetupbadminton andtable tenniswithlow-maintenanceandsafeequipment.

Pétanqueandother‘gardengames’werealso mentioned,aswerewalking sports(i.e.walkingfootball),outdoortabletennisandbadminton.

• Spacesforplay

Afewpeopletalked abouttheimportanceofplay,oftenforgottenforadults. Thismight includesmallandlarge(‘giant’)gamesofchess,draughts,Connect4, Jenga,etc.aswellaslargebouncyballsand largeandsmall‘fidgettoys’,butalso groupgamesthatdon’t needmuchequipment.

• Bushcraftand‘wilderness’activities

Thisincludeswoodcraft,foraging,buildingsheltersandotheroutdoor activities thatencouragecommunalgathering andcollaboration.

6Developconnectionstocommunitygardenandnatureprojects

Seeearliersections6and7fordiscussion aroundthebenefitsandpossibilitiesof workingwithcommunityandvoluntarysector partnerstodelivernaturalrecovery activitiesbothinhospitaland inthecommunity.Furtherrecommendationsare:

• Explorethepossibilitiesofworking withvoluntaryandcommunitysector partners,buildingrelationshipswithlocalnature-basedandgardening projects; communitygardens,nature/well-being projects,walk-and-talkprojects,wild swimminggroups,communityallotmentsetc.

• Identifywherefundingmaybeneededtoenablecommunityprojectstowork withthehospitalbothonandoff site.

• Ensurestaffandvolunteersareprovidewithtrainingand supporttoworkfor supportingpeoplelivingwith SMI.

• Provideopportunitiesforpatientstogoonoffsitetripsandvisitstonatural settingsincludingparks,NaturalTrustsites,coastalsitesand woodlands

• Workwithpeersupportproviderstodeveloptheopportunitiesforpeopleto engagewith naturalspacesand outdooractivitiesbothonand offsite,andin the communitylonger-term.

• Involvepatients(andformerpatients)inco-productionofinitiatives.

Appendices

AInterviewschedule

(30-40mins)

Theinterviewyouarekindlytakingpart inwill enablepeoplelivingwithmentalillness todirectlyinformhowNHSmentalhealthservicesincorporatenaturalrecoveryinto theirservices,includingthenewCombe ValleyHospitalinEastSussex plannedtoopen in2026.

TheNHSwanttoensurethatthenaturalrecoveryopportunitiestheyprovide,both withinthehospitaland tosupportpeopleondischarge,areledbyserviceusers,who knowbest howtosupporttheirrecoverythroughnature.

Everythingyoutellus willbecompletelyanonymous,andweremoveallnamesand anythingthat couldpotentiallyidentifysomeone.Theaudiorecordingwillbe transcribed,thentherecordingwillbedeleted.Keyfindingswillbewrittenupand informthereportthat wewriteforourfunders.

Youare welcometoseeacopyofourreportsummaryandwillbeaskedifyouwant this.

Inthisinformalinterviewwewillfocusonyourthoughtsabout hownaturalrecovery canhelppeopleinhospital.Ifwegoofftrack, wemayneedtogently steerthe conversationback tothequestions;thisisnotinanywaytominimiseyourexperiences.

Youcan stoptheinterviewatanytime,andyoucanchangeyourmindabouttaking partupuntiltheendofJanuary,meaningyoucanasktowithdrawyourinterviewup untilthatpoint.

Doyouhaveanyquestions?

Areyouhappytoproceed? Areyouhappyfor ustostartrecording?

SectionAOwnrelationshipwithnature.

Guide:5minutes

Firstofall,Iamgoingtoaskyouaboutyourownrelationshipwithnatureand naturalsettings. Bynature,wemeanparks,allotments,gardens,thesea,thecoast, woodlands,hills,downlandsetc. –naturalfeaturesofplants,animals,landscapes, water,etcasopposedtohumancreationslikebuildingsandtownsetc.

1Howimportantisitforyoutospendtimeinnature?

2Whatdoyouliketodowhenyouareinnaturalsettings?

BThepotentialfornaturalrecoverytosupportpeoplewhilestayinginpsychiatric hospital

Guide:20-30minutes

I’mnowgoing toask youtothinkaboutwhenyouwereinhospital,andyour engagementwith naturethen. Ifyoudon’t wanttoanswerthisoryoudon’tremember thatwell,pleasesayso, it’sfine,andwewillmoveontodifferentquestions.(Noteto interviewer;ifparticipantdoesn’trememberordoesn’twanttotalkaboutit,please moveontoQ5)

3Whenyouwereapatientinhospital,wereyouabletoaccessthenaturaloutdoor spaces,andifso,whatdidyouliketodointhosespaces?

4Wherethereanybarrierstoyoubeingabletousethenaturaloutdoorspaces?

Thankyou.I’mnowgoingtoask about yourthoughtsaboutthedesignofthenatural settingforthenewCombeValleyhospital.Thereisaproposed‘therapygarden’for clientsinthenewCombeValleyhospital.

5Whatfeaturesdoyouthinkatherapeuticgardenspacecouldhaveina psychiatrichospital?

6Whatkindsofactivitiesdoyouthinkcouldhappeninatherapeuticgardenthat wouldbenefitpeoplestayinginhospital?

7Whatkindsofinteractiveactivitiesmightencouragepeopletoexplorethe naturalsetting,whetheraloneorwithothers?Whatmightsparkinterestand engagement?

8Howcouldoutdoorspacebedesignedtobenefitpeoplewantingtobealone?

Prompts:Whatcouldhelppeopletofeelsafe?Whatcould aspacelikethislooklike? Howcan weachievebothprivacyandsafety?

9Whatcouldanoutdoorspacelooklikeforpeoplewhowanttobeoutsidewith visitors?

Prompts:Whatfeaturesdoesthishave?Maybethinkaboutseating/shelter/privacy.

10Whatkindsofsupportandactivitiescouldbeofferedtoencouragepeopleto learn,useandsharegrowingandgardeningskills?

11Whatmightbeyourmainconcernsabouttheoutdoorspaces?

Prompts: Whatmightbebarrierstousingtheoutdoorspace,andwhat mightput peopleoff?

12Howmighttheseconcernsbeaddressed?

13Isthereanythingmoreyoucanthinkofthatcouldparticularlyinspirepeople stayinginthehospitaltoengagewithnature?(Pleasedrawonyourown experience)

Thankyouforallyourideasandyourcomments,thiswillreallyhelp. Wearecoming towardstheendoftheinterviewnowandhavejusttwomorequestions.

14Isthereanythingelseyouwouldliketosayaboutnatureandnaturalrecoveryin hospitalsettings?

15Andfinally,whenyouthinkaboutwhatinspireshopeandhealing,whatkindof naturalspacecometomind?Maybetakeamomenttothinkaboutthis. Thankyouverymuch. Wearegoing tostoprecordingnow.

Informtheparticipantaboutwhentoexpectvoucherpayments.

Askthemiftheywouldliketoseethereportsummary(itwillmostlikelybeonthe RPwebsitesowewouldsendthemadirectlink)

BOnlinesurvey

RecoveryPartners:Naturalrecoveryinmentalhealthhospitals

RecoveryPartnersisasmall,user-ledmentalhealthcharityworking inEastSussex.We areundertakingaconsultationfundedbyHeadsOn.HeadsOn isthecharitablearmof SussexPartnershipNHSFoundationTrust,whichworkstosupportpeoplelivingwith mentalhealthchallengestofeelmoresupportedandbemoreinvolvedintheir communities.

Whoareweaskingtocompletethissurvey?

Anyoneover18whohasbeen anin-patientinanNHSmentalhealthhospitalinthelast 10years,inanyoftheselocations:

● EastSussex

● WestSussex

● BrightonandHove

Whatisthissurveyabout?

Thesurveywillenable peoplelivingwithmentalillnesstodirectlyinformhowNHS mentalhealthservicesincorporatenaturalrecoveryintotheirservices,includingthe newCombe ValleyHospitalinEastSussex plannedtoopenin2026. TheNHSwanttoensurethatthenaturalrecoveryopportunitiestheyprovide,both withinthehospitaland tosupportpeopleondischarge,areledbyserviceusers,who knowbest howtosupporttheirrecoverythroughnature.

Howlongwillittaketocomplete?

Weestimate10-15minutes,althoughitmaytakealittlelongerifyouwanttogiveus moredetailinyour answers.

Whatwillwedowiththeinformationyougiveus?

Alloftheinformation thatyouprovidewillbetreatedasconfidentialandwillonlybe usedforresearchpurposes.Yourcommentswillnotbeidentifiedasbelongingtoyou, insteadtheywillbecombinedwiththosegatheredfromothersurvey participantsand

willbeanalysedaspart ofagroup.Wedonotuseanyoftheinformationyouprovide fordirectmarketingor othernon-researchactivities.

Ifweask youforpersonalinformation thatenablesyoutobeidentified -e.g.,your name,IDnumbers,e-mailaddress,wewillclearlystatewhyweare askingforitandfor yourpermissiontouseitforthatpurpose.Forexample,itmightbetoinformthe winnerofaprizedrawortocontactyouabout sharingourresearchfindingswith you.

Yourparticipationisvoluntary.Youare entitled toask thatpart,orall, oftherecordof yourinvolvementinthesurveybedeletedordestroyed.

Keyfindingsfromallthesurveyswillbeincludedinthereportthatwewritefor our funderHeadsOn,inMarch2024. Thiswillmakerecommendationsbasedonwhat peoplewith livedexperiencetoldusaboutnaturalrecovery. Youare welcometoseea copyofourreportand willbeaskedifyouwantthis.

Onlinesurveyprivacystatement

RecoveryPartnerstakesyourconcernsabout privacyseriouslyandwemakeevery reasonableefforttorespectthis.Weare committedtoprotectingyourpersonal information,suchasanydetailsthatmight enableyoutobeidentified,suchasID numbers,emailaddressetc.Wetakeallnecessarystepstoensurethat personal informationyouprovideisprocessedfairlyand lawfully.

Onlyauthorisedstaffhaveaccesstopersonalinformation,andtheyare obligedto respectitsconfidentiality.Wedonotsell,rentorexchangeanypersonalinformation suppliedbyyoutoany thirdparty.Nordoweuseanyoftheinformationyouprovide fordirectmarketingor othernon-researchactivities.

Wemonitorourinternalproceduresregularlytoensurecompliancewiththerelevant statutoryrequirementsinallthat wedo,includingtheDataProtection Act1998

Contactingus

Ifyouhaveanyquestions,please emailAnnaona.stratford@recovery-partners.org.uk

Prizedraw

Allsurveyrespondentscanchoosetobeenteredintoadrawtowinoneoftwo£25 Love2ShopvouchersattheendofFebruary2024.

Section1:Yourin-patientexperience

Q1Howlongagowereyouanin-patientinanNHSmentalhealthhospitalsetting?

AWithinthelasttwoyears

B2-5yearsago

C5-10yearsago

Q2Wherewasyourlasthospitaladmissionasanin-patient?

AEastSussex

BWestSussex

CBrightonand Hove

Section2Natureandmentalhealthrecovery

Q3Howimportantisitforyourmentalhealthrecoveryforyoutospendtimein naturalsettings?

AVeryimportant

BImportant

CQuiteimportant

DNot important

Q4Whatdoyouliketodowhenyouareinnaturalsettings?Canyousayhowyou feelthishelpsyou?

50-wordlimit

Q5Whenyouwerelastapatientinmentalhealthhospital,wereyouabletoaccess naturaloutdoorspaces?

AYesoften

BYessometimes

CYesbutrarely

DNo

Q6Ifyes,whatdidyoufindwasbeneficialforyou?

50-wordlimit

Q7Pleasedescribeanybarrierstoyoubeingabletousenaturaloutdoorspacesin hospital,andwhatyouthinkcouldhavehelpedovercomethese.

50-wordlimit

Q8Whatfeaturesdoyouthinkatherapeuticgardenspaceinamentalhealth hospitalshouldhave?

50-wordlimit

Q9Whatkindofactivitiesdoyouthinkcouldhappeninatherapeuticgarden spacethatwouldbenefitpatients?

50-wordlimit

Q10Whatkindofsupportandactivitiescouldbeofferedtoencouragepatientsto learngrowingandgardeningskills?

50-wordlimit

Q11Whenyouthinkaboutwhatinspireshopeandhealing,whatkindofnatural spacecomestomind?

50-wordlimit

Q12Howdoyouthinkpeoplecanbesupportedtocontinueengagingwithnature andnaturalrecoverywhentheyleavehospitalandarebackintheircommunities?

50-wordlimit

Section3Equalitymonitoringquestions

1Howoldareyou?

A18-25

B26-35

C36-54

D55-64

E65+

2Howdoyoudefineyourgender?

AFemale

BMale

COther(pleasesay)

DPrefernottosay

3Howdoyoudefineyourethnicity?

10-wordlimit

4Areyouphysicallydisabled?

AYes

BNo

CNot sure/don’tknow

DPrefernottosay

5Howdoyoudescribeyoursexualorientation?

ALesbianorgay

BBisexual

CHeterosexual

DOther(pleasesay)

EPrefernottosay

6Doyouhaveadiagnosisoflivingwithaseverementalillness(SMI)?

AYes

BNo

CNot sure/don’tknow

DPrefernottosay

7Areyoucurrentlyengagedwithanyofthese:

APrimaryhealthcareservices(GP,Health inMind,Well-Beingservice)

BSecondaryhealthcareservices(hospitals,psychologicalwellbeingservices,crisisand hometreatmentteams)

CNot sure/don’tknow

DPrefernottosay

Finally

Areyouhappytobeenteredintoadrawtowinoneoftwo£25Love2Shopvouchers?

Yes/No

Ifyes,pleaseenteryouremailaddressbelow.Wedonotshareyouremailaddresswith anyoneelseandwillonlyuseitforthepurposeofcontactingyouifyouwinoneofthe vouchers.

Doyouwanttobecontactedtoseethereportwhen itiscompleted?(Spring2024,the reportmaybehosted onourwebsite)Yes/No

Ifyes,pleaseenteryouremailaddressbelow.Wedonotshareyouremailaddresswith anyoneelseandwillonlyuseitforthepurposeofcontactingyoutosharethereport.

Doyouwanttobeaddedtoourmailing listfor occasionalupdatesaboutourwork?

Ifyes,pleaseenteryouremailaddressbelow.

Thankyouverymuchforyourtimeandyourinput.

CDemographics

Demographicinformation:51participants

1-2-1interviews:25participants

Onlinesurvey:26responses