Effectiveness Not Established

Natural Environment Intervention

for Anxiety

Natural environment intervention involves patient exposure to the natural environment through various activities.  This type of intervention was examined among patients with cancer for its effect on anxiety, cognitive impairment, and fatigue.

Research Evidence Summaries

Nakau, M., Imanishi, J., Imanishi, J., Watanabe, S., Imanishi, A., Baba, T., . . . Morimoto, Y. (2013). Spiritual care of cancer patients by integrated medicine in urban green space: A pilot study. Explore, 9, 87–90. 

Study Purpose

To examine the effects of an integrated medicine therapy involving forest therapy, horticultural therapy, yoga meditation, and group supportive therapy on spirituality and related symptoms

Intervention Characteristics/Basic Study Process

Participants walked in a forest in a park for about 40 minutes while conversing. Sixty-minute horticultural sessions were focused on vegetables that were easy to grow. Yoga sessions using postures, deep breathing, relaxation, and meditation were done for 90 minutes, and patients were encouraged to perform simple yoga exercises at home daily. Group support sessions were held for 60 minutes five times during the study.

Sample Characteristics

  • N = 22    
  • MEAN AGE = 55.5
  • MALES: 9.5%;  FEMALES: 90.5%
  • KEY DISEASE CHARACTERISTICS: All participants had completed initial treatment at least one month prior to participation. All were in essentially good physical condition.
  • OTHER KEY SAMPLE CHARACTERISTICS: All were city dwellers with no access to green environments in daily life.

Setting

  • SITE: Single site  
  • SETTING TYPE: Outpatient  
  • LOCATION:Japan

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment
  • APPLICATIONS: Palliative care 

Study Design

  • Quasiexperimental

Measurement Instruments/Methods

  • SF-36®
  • Profile of Mood States (POMS)
  • State-Trait Anxiety Inventory (STAI)
  • Cancer fatigue scale 
  • Natural killer (NK) cell activity

Results

There were improvements in functional and spiritual well being (p < .05). There were significant improvements in fatigue, with an average decline of 6.4 points (scale possible total score = 60; baseline average = 21) (p = .004).  Changes in fatigue were seen in physical and affective, but not cognitive components. Only the confusion subscale of POMS showed improvement (p = .002).  STAI scores declined (p = .001).  NK cell activity declined (p < .001)

Conclusions

Therapies involving green space, relaxation, yoga, and group supportive interventions may improve well-being, fatigue, and anxiety in patients with cancer.

Limitations

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)
  • Other limitations/explanation: It is not clear if baseline levels of symptoms were clinically significant. Authors compare results to a reference list of patients with cancer, but there is no comparison to other measures with known clinical significance levels.

Nursing Implications

Integrative therapies incorporating green space as well as other relaxation and supportive interventions may improve fatigue and anxiety and promote a sense of well-being in patients with cancer. This intervention included other components of relaxation, yoga, and group support, so it is not possible to tell how much the exposure to green space contributed to changes. Further research in this area would be useful. Exposure to the natural environment would be a relatively simple activity for patients to do on their own, and it may be helpful

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