shifting gears: engaging nurse practitioners in ... · and low-cost tool to health care providers...

Shifting Gears: Engaging NursePractitioners in PrescribingTime OutdoorsLois A. Wessel, MS, FNP-BC

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ABSTRACTChronic diseases are responsible for about 70% of deaths annually, and treatment ofthese diseases accounts for 86% of national health care expenditures. Individuals arespending more time indoors, leading to “nature-deficit disorder.” Nurse practitionersare looking for ways to address lifestyle changes to reduce chronic disease burden.“Park prescriptions” are gaining popularity and spending time outdoors can addresshealth problems, including obesity, depression, and behavioral problems. TheNational Park Prescription Initiative has been launched nationwide with support fromthe Surgeon General and the National Park Service. Nurse practitioners can play a rolein promoting such programs and tracking outcomes.

Keywords: active living, built environment, chronic disease, nature, obesity, Park Rx� 2016 Elsevier Inc. All rights reserved.

usy lifestyles and technology have contrib-uted to a shift in the United States to a
Bsedentary lifestyle, and an increase in chronic
diseases such as coronary artery disease, diabetes, anddepression. According to the United States Centersfor Disease Control and Prevention (CDC), chronicdiseases are responsible for 7 of every 10 deathsannually and these diseases account for 86% of na-tional health care expenditures. Richard Louv,author of Last Child in the Woods,1 describes anepidemic of “nature-deficit disorder,” due tochildren’s reduced time outdoors in exchange forelectronic media and academic demands that cancontribute to obesity, attention deficit-hyperactivitydisorder (ADHD), and vitamin D deficiency.

Smartphones and computers, the reduction ofschool recess time, and concerns over neighborhoodcrime have decreased the amount of time spentoutdoors, and less than half of all adults meet thephysical activity guidelines for exercise. The NoChild Left Behind Act of 2001 resulted in reducedtime for physical education, art, and recess, and forincreased time in the classroom. Currently, almostthree fourths of teens participate in < 1 hour of

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physical activity per day.2 A report by the WorldHealth Organization ranked lack of physical activityfourth on a list of risk factors for noncommunicablechronic diseases, behind high blood pressure,smoking, and high blood glucose.3 Lack of physicalactivity and limited exposure to nature are separateconcerns, but time outdoors is ideal to promotespontaneous physical activity.

Technology has brought entertainment, socialinteraction, and video gaming into the home, whiledecreasing the need to be outside to see friends, attenda movie, or meet peers for outdoor activities. Thegrowth in electronic devices has led to teens spending> 7 hours per day on all forms of e-media, includingcomputer games, social media, and the internet, and< 30 minutes of outdoor time daily.4 The physicalinactivity of screen time is often associated withincreased consumption of unhealthy foods andsubsequent overweight and obesity issues.5 Data fromthe National Health Interview Survey show that, ifobesity rates continue, 1 in 3 persons will developdiabetes in his or her lifetime.6 Over the last 20 years,use of personal electronics has increased, whereas timespent outdoors has decreased.7 According to the

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National Wildlife Federation, “our kids are out ofshape, tuned out and stressed out, because they aremissing something essential to their health anddevelopment: connection to the natural world.8

OUTDOORS AND HEALTHExposure to green environmental spaces is an essen-tial component to human health that has beencurtailed in modern society. Nature can promotehealthy social behavior and reduce stress.9 Time spentoutdoors offers a number of health and wellnessbenefits for children and adults alike. For children,green spaces have been associated with improved testscores, improved self-discipline and cognition, anddecreased behavioral issues that may be attributed toADHD.10 A study of 421 children with ADHD wasconducted using an internet-based survey of parents.The findings suggest that everyday play outdoorsreduces symptom severity.9

Obesity has numerous contributing factors andtherefore has a number of complex solutions.Decreased physical activity is a contributing factorthat needs to be addressed by clinicians and com-munity efforts. Data on 2,810 Head Start childrenwere reviewed and the results show that the childrenwho played outdoors for roughly 37 minutes per daywere less likely to be obese and those who playedoutdoors for 60 minutes a day showed improvementsin body mass index.11

Additional studies have shown that increasingtime spent outdoors may be a simple strategy toreduce the risk of developing myopia and its pro-gression in children and adolescents, given that theeye movement of looking at things close up and faraway in succession in a park can be protective againstmyopia.12 Studies indicate that the decline in vitaminD among older people is probably due to decreasedsun exposure from decreased outdoor time.13 Timespent outdoors increases exposure to ultravioletB light with improved synthesis of vitamin D.

Internationally, concepts such as Shinrin-yoku,Japanese for “forest bathing,” have demonstrated thatexposure to nature improves physical and mentalhealth. One Japanese study noted that forest envi-ronments promote lower concentrations of cortisol,lower pulse rate, lower blood pressure, greater

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parasympathetic nerve activity, and lower sympa-thetic nerve activity than do city environments.14

There are numerous innovative approaches togetting children outdoors. An elementary schoolteacher in Quechee, Vermont, held “Forest Mon-days” class outdoors every Monday, rain or shine.Standardized test scores increased more in the yearthe students were outdoors than in other years in theteacher’s experience.15 The East Bay Regional ParkDistrict in California is working with the Universityof California, San Francisco Benioff Children’sHospital in Oakland to provide free transportation,healthy snacks, and outdoor activities for childrenwith chronic diseases and their families to teach aboutintegration of outdoor time.16 Furthermore, the parkhas installed visuals of the parks in the clinic as astarting point to talking about outdoor time, andexam rooms are named after regional parks. SafeRoutes to School, a national program providingtechnical assistance and funding to localmunicipalities, aims to making biking and walking toschool safer and fun. In Apex, North Carolina, awalk-to-school coalition began a walking school bus,whereby parents and children meet at a departurepoint and walk to school together.17

St. Luke’s Hospital in eastern Pennsylvaniapartnered with the Delaware and Lehigh HeritageCorridor to form “Get on Your Tail on the Trail” toencourage physical activity on the historic pathway.Under the Affordable Care Act, nonprofit hospitalsmust conduct community health assessment plans andaddress the findings. This shift from treating chronicdiseases to preventing them has resulted in residentslogging > 1.8 million miles of walking, running, andbiking on the trail.18

NATIONAL RECOMMENDATIONSThe 2008 Physical Guidelines for Americans and theNational Physical Activity Plan support physical ac-tivity for physical and mental health purposes andsuggest that adults get at least 150 minutes of mod-erate activity or 75 minutes of vigorous activity aweek, and children be active for at least 1 hour perday.19,20 In addition, political support from MichelleObama’s “Let’s Move!” campaign and SurgeonGeneral Vivek Murthy’s “Step it Up: The Surgeon

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General’s Campaign to Promote Walking andWalkable Communities,” focus on a national call toget people outdoors and moving. The goals of theSurgeon General’s campaign include making walkinga national priority; designing communities that makewalking safe for people of all ages and abilities;promoting programs and policies to support walkingwhere people live, learn, work, and play; providinginformation to encourage walking and walkability;and increasing the quality of data collected onwalkability.19 The current Surgeon General’scommitment to walking can be compared with theSurgeon General C. Everett Koop’s warning on thedangers of smoking as addressing a major publichealth issues (Figure 1).

This national campaign seeks to encouragetransportation planners to focus on safe roadways forwalking. It encourages organizations to supportwalking programs, increase exposure in the mediathrough campaigns to promote walking, and research

Figure 1.US Surgeon General Vivek Murthy prescribingtime outdoors on National Park Rx Day, April 22, 2016,at Meridian Hill Park, Washington, DC.

Photo by author, Lois A. Wessel.

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on the topic by public health professionals. Last, itpromotes the assessment by health care providers ofphysical activity and providing walking counseling toall patients, especially those at risk for chronic disease.

In 2012, the National Park Prescription Initiative(Park Rx), led by the National Park Service and theNational Recreation and Park Association, waslaunched. Park Rx is an innovative and valuablemodel that can easily be incorporated into anypractice setting, both out- and in-patient, and can betailored specifically to meet the individual lifestyle ofthe patient or family. It is part of a global publichealth movement that encourages people to utilizepublic lands for the public good. Park Rx programsfocus on the interprofessional collaboration amonghealth care providers, public land agencies, andcommunities to utilize existing outdoor space,including trails and parks, for the purpose ofimproving health. The idea of Park Rx offers a newand low-cost tool to health care providers to promotepatients’ steps to improve health care, expose patientsand families to nature, and foster the growth of ad-vocates for public lands.21

One of the founding members of Park Rx is acommunity-based pediatrician, Dr. Robert Zarr.With the support of the local Washington, DCAmerican Academy of Pediatrics Chapter, the Na-tional Park Service, and the George WashingtonSchool of Public Health, Dr. Zarr created a web-hosted database entitled DC Park Rx of over 350green spaces in the District of Columbia (seeResource Table). This database22 is considered the“gold standard” of Park Rx programs, as it is linkedwith the electronic health record of the clinic and canbe customized to meet the needs of patients.

According to The Washington Post, the DC ParkRx is the first such tool in the country that allowsproviders to type a patient’s zip code into their re-cords and retrieve specially tailored summaries andmaps. This allows park prescriptions to be integratedinto clinical workflows and enables researchers tocollect data regarding park prescriptions.23 Thecustomization can be sorted by location, facilities ateach site, and what types of recreational opportunitiesare present at each site, as well as publictransportation routes to get to each facility (seeResource Table).


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Resource Table. Background Resources and Patient Education Sources for Prescribing Time Outdoors

Organization Description Website

DC Park Rx Community health clinic initiative to tailor outdoortime based on interests and location of patients

http://www.dcparkrx.org/

Park Rx Tools for providers to inspire patients to take stepsto improve their health

http://www.parkrx.org/

Safe Routes toSchool

Programs are sustained efforts by parents; schools;community leaders; and local, state, and federalgovernments to enable walking and biking toschool

http://www.saferoutesinfo.org/

Let’s Move! First Lady Michelle Obama’s initiative to solve theproblem of obesity; worksheets for childrenavailable

http://www.letsmove.gov/

Step it Up! Surgeon General Vivek Murthy’s campaign toincrease walking and walkable communities

http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/

National WildlifeFederation

Tools on how to get children outside https://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Healthcare-Provider-Tips.aspx

National EnvironmentalEducation Foundation

Park Rx forms downloadable in English andSpanish

https://www.neefusa.org/resource/rx-outdoor-activity

National Park ServiceHealthy Parks HealthyPeople

Healthy Parks Healthy People is a global movementthat harnesses the power of parks and public landsin contributing to a healthy civil society

https://www.nps.gov/public_health/hp/hphp.htm

Prescription Trails in Albuquerque, New Mexico,is another initiative where a health care team has beenprescribing time outdoors via a field guide on safe andaccessible walking environments. In the pilot project,providers enjoyed prescribing time outdoors andcontinued after the initial evaluation periodconcluded.24 Partnerships developed among localpark and recreation departments, neighborhood civicgroups, and health care providers, indicating theimportance and value of health care workers reachingoutside of the medical team to address socialdeterminants of health.

All of these efforts recommend low- or no-costoptions for time outdoors and removing the financialbarriers to exercise that exist in private gyms. Themajority of local and state park facilities are free, withminimal costs involved in transportation and parking.

BUILT ENVIRONMENT AND SOCIOCULTURALCONSIDERATIONSAlthough the benefits of park prescriptions (Park Rx)are numerous, individuals need motivation and


opportunities to make lifestyle changes to benefittheir health. The social structure of the built envi-ronment and the areas where people play, work, andlive are directly related to how much time peoplespend outdoors. The layout of communities, trans-portation infrastructure, and access to parks and trailsallow individuals to have easy access or barriers tobeing outdoors. In this framework, nurse practi-tioners (NPs) can be advocates for sidewalks, lightingin parks, improved park maintenance, and neigh-borhood safety to strengthen local interest in beingoutside. “Salud America!,” part of the Robert WoodJohnson Foundation, notes that Latino children havefewer opportunities to engage in physical activitiesthan white children because there are fewer parks andrecreation sites in their communities.25 Theavailability of recreational facilities and parks variesacross the country. A study looking at the availabilityof recreational resources in low socioeconomic andminority areas in the US found access was lower inminority areas, and the authors suggested moreequitable access could be achieved by developing


http://www.dcparkrx.org/http://www.parkrx.org/http://www.saferoutesinfo.org/http://www.letsmove.gov/http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/https://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Healthcare-Provider-Tips.aspxhttps://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Healthcare-Provider-Tips.aspxhttps://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Healthcare-Provider-Tips.aspxhttps://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Healthcare-Provider-Tips.aspxhttps://www.neefusa.org/resource/rx-outdoor-activityhttps://www.neefusa.org/resource/rx-outdoor-activityhttps://www.nps.gov/public_health/hp/hphp.htmhttps://www.nps.gov/public_health/hp/hphp.htm

new parks or opening school facilities to thecommunity to allow for physical activity.26 Whereparks and recreational facilities do exist in low-income areas, they often need improvements to in-crease safety and neighborhood interest. The qualityof parks, as indicated by lighting, benches for rest,bathrooms, trail maintenance, cleanliness, and atten-tion to plants and playground infrastructure, mayinfluence usage. Improving the types and quality ofpark resources is important for increasing park us-age.27 “Salud America!” emphasizes the need forimprovements in the built environment so that thereis transportation to recreation sites and culturally andlinguistically appropriate messaging about healthyliving to engage families in the outdoors.25

Social determinants of health, including language,culture, and socioeconomic factors, may inhibit parkuse for some individuals. Understanding the offeringsin each park will allow NPs to engage with patientson an individualized basis, explaining a park with aplayground to parents of small children or one with abasketball court for older children. Knowing if thereis signage in the language of the target population,clean bathroom facilities, and public transit routes isalso helpful. Local concerns by minorities andimmigrant populations in areas plagued by racial andethnic tensions are important to explore with pa-tients, community leaders, and advocacy groups.Partnering with a church or social service agency tohold a Park Rx launch in a local park can help buildcommunity partnerships. Local governmental parkauthorities should be encouraged to produce bro-chures with photos that reflect the ethnic diversity ofthe neighborhood.

In Prince George’s County, Maryland, outside ofWashington, DC, 69% of adults do not meet theCDC recommendations for physical activity and thecounty has higher rates of obesity compared withstate averages.28 The Maryland National Park andPlanning Commission, the governmental agency incharge of the parks, has a goal of decreasing obesityby 10% in 20 years. Numerous park-related activities,including expansion of bike trails, a senior walkingprogram, and yoga in the parks, are being promotedby local safety-net clinics to patients. To reach theobesity reduction goal, the parks department isworking alongside clinicians and information

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technology teams to integrate park databases intoelectronic health records. It is through these kinds ofpartnerships that the NP’s role in health promotioncan be effectively implemented and expanded.

Thinking broadly, as clinicians prescribe timeoutdoors, patients are being introduced to the beautyof American public spaces, which will hopefullycreate new stewards and advocates for parks and parklands, eventually impacting numerous environmentalbenefits for society as a whole. Human activities havecaused environmental changes of epidemic pro-portions, yet small steps in human activities can be astart to reducing and reversing the profound pastchanges to the environment. Health care pro-fessionals can appreciate how climate change isimpacting the health of the planet and its inhabitants,and, as trusted conveyers of information to patients,families, community members, and policymakers,NPs can be in the forefront of explaining the re-lationships between human health and environmentalhealth to patients and communities.29

NP IMPLICATIONSNPs are in a unique position to implement theSurgeon General’s walking campaign throughcounseling, prescribing time outdoors for patients,and setting examples. Health promotion and diseaseprevention are fundamental aspects of the NP’s role.Recommending time outdoors is not new to nursing.Florence Nightingale’s Notes on Nursing,30 based onher experience nursing the sick during the CrimeanWar, emphasized fresh air as a common-senseapproach to caring for patients. This family-friendlyhealthy activity aligns with the NP model of holisticand comprehensive care of prevention, wellness, andthe whole person—body and mind.

As a start, NPs can begin to ask about exercise andtime outdoors along with the more frequently askedprevention and risk assessment questions regardingtobacco and alcohol use, safety, and nutritionalhabits. Broadly suggesting that patients exercise issomething most patients already know and doesnot engage or support them in what they enjoydoing—playing basketball, dancing, or literallysmelling the flowers. Asking about what patientslike to do outdoors and following up with an indi-vidualized plan can make a deeper patient-provider



connection. A health care team from 11 KaiserPermanente medical centers in northern Californiaasked patients about exercise during vital sign docu-mentation. Adding exercise as a vital sign gave cli-nicians an opportunity to address lack of exercise andtalk about local exercise and weight-loss programs.The study showed that having clinicians address theneed for exercise was correlated with small but sig-nificant changes in exercise-related outcomes, avaluable first step in addressing lack of physicalactivity.31

Numerous resources exist to help NPs engagewith patients to recommend behaviors to improvechildren’s health by getting them outside and mov-ing. Providers faced with the high rates of obesity andother chronic diseases may often focus on what not todo or eat instead of what is positive and possible. TheNational Wildlife Federation has a simple guide forproviders (see Resource Table) to assess time spentoutdoors and how much screen time children areexposed to each day. As a way of institutionalizingquestions about exercise and playtime, NPs can workwith information technology colleagues to embedthese questions into an electronic health record. Inaddition, the National Environmental EducationFoundation has downloadable prescription forms inEnglish and Spanish to prescribe time outdoors(see Resource Table).

A valuable lesson in Park Rx is that time in anatural environment has no prescribed amount oftime to achieve physical and mental health benefits.NPs can work with patients on goal-setting to maketime outdoors part of mutual goal-setting by askingpatients how they may integrate outdoor time intotheir commute, daily routines, and social life. AsSurgeon General Dr. Murthy noted, the refillsare unlimited.

The growing knowledge that our medical systemis not working to curb the obesity tide, combinedwith the environmental movement, has led to effortsto gain the support of health care providers to simplyprescribe time outdoors. “Walk With a Doc,”founded by Ohio cardiologist Dr. David Sabgir, isone effort that focuses on exercise and educationabout health while walking with a physician. Theseinteractions are intended to empower the participantto continue exercising and improving his or her


health. Although this framework is utilized across thecountry and internationally, the name implies thatthe physician is the only one that can provide thisempowerment. The basics of walking and healtheducation are such that nonclinical team membersmay also wish to be involved to have more patientinteractions. In many communities, communityhealth workers have the greatest ability to provideculturally and linguistically appropriate education topatients and could be the leaders of a walking group.Of course, nurses and NPs are other ideal leaders ofsuch programs where health education can be pro-vided during an active exercise session.

Starting a Park Rx program can be as basic asbecoming familiar with local parks and their resourcesand bus lines, getting park brochures in waiting rooms,and telling patients about the benefits of outdoor time.Furthermore, NPs and the health care team can hostoutdoor events in parks and lead park activities as partof community outreach efforts and health fairs.

In a world of evidenced-based medicine, trackingand documenting the benefits of time outdoors canbe challenging. NPs can track the number of parkprescriptions given to patients and continue to followbenchmarks of weight, body mass index, bloodpressure, vitamin D level, and glycated hemoglobinand cholesterol levels on those patients, as well asdepression screenings, such as the 9-item PatientHealth Questionnaire, to determine whether timeoutdoors has made an impact on overall health andwellness. Increased functionality of patient portalsmay be able to capture data about the user experi-ence, including how much time was spent outdoorsand what activities were conducted. Increased parkutilization around clinic settings may also be noted bypark and planning agencies when park prescriptionsare implemented. Technologies such as social mediamay be utilized to document where people arespending outdoor time, such as posting a picture ofthemselves in a park to the agency’s website. Futureresearch opportunities can also look at the specificfactors impeding physical activity, including socio-economic status, proximity to safe outdoor spaces,and culturally and linguistically appropriate park re-sources such as maps and signage.

Even without sophisticated electronic databases,NPs can advocate for increased access to local parks. In


particular, NPs in school-based health centers are theentry point for primary care for many school-agedstudents, and their families can start to engage withschool systems for local cost improvements, such asnight-time lighting and keeping school playgrounds

Figure 2. Illustration depicts 7 of the benefits of spending ti

(Reproduced with permission from artist Daniel Gallant for Environm

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open during evenings and weekends. As part ofongoing education about the built environment, thespaces where we live, play, and work, NPs can invitelocal park and recreation agencies to provide infor-mation on outdoor activities for clinic settings. Also,

me outdoors in parks.

ental Health Perspectives.)



because walking and time outdoors is a simple fix forcomplicated problems, NPs and the entire health careteam can start by prescribing time outdoors forthemselves and their team, includingwalking meetings.

The National Park Service turned 100 in 2015and the parks are among our nation’s greatest trea-sures. Numerous green spaces exist throughout ourcountry and NPs can be catalysts for interprofessionalteams of providers, support staff, park and recreationalfacilities staff, park rangers, public health officials,transportation planners, and community activists toshift gears toward engaging patients in being outside.Prevention starts outside the clinic walls, and thesolution to many prevalent diseases is looking beyondthose walls to the outdoors. This will provide benefitsfor patients, families, communities, and the providersthemselves (Figure 2).

References

1. Luov R. Last Child in the Woods: Saving Our Children From Nature-DeficitDisorder. Chapel Hill, NC: Algonquin Books; 2005:335.

2. US Centers for Disease Control and Prevention. Exercise or physical activity.Updated February 10, 2015. http://www.cdc.gov/nchs/fastats/exercise.htm/.Accessed April 22, 2016.

3. Kohl HW 3rd, Craig CL, Lambert EV, et al. The pandemic of physical inactivity:global action for public health. Lancet. 2012;380(9838):294-305; http://dx.doi.org/10.1016/S0140-6736(12)60898-8.

4. Rideout VJ, Foehr UG, Roberts DF. Generation M2: media in the lives of 8-18year-olds. Updated January 1, 2010. http://kff.org/other/poll-finding/report-generation-m2-media-in-the-lives/. Accessed April 14, 2016.

5. McCurdy LE, Winterbottom KE, Mehta SS, Roberts JR. Using nature andoutdoor activity to improve children’s health. Curr Probl Pediatr AdolescHealth Care. 2010;40(5):102-117.

6. US Centers for Disease Control and Prevention. 2014 National diabetesstatistics report. Updated May 15, 2015. http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html/. Accessed June 3, 2016.

7. Gray P. The decline of play and the rise of psychopathology in children andadolescents. Am J Play. 2011;3(4):443-463.

8. National Wildlife Federation. Health benefits. Updated 2016. http://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Health-Benefits.aspx/. Accessed May 10, 2016.

9. Faber Taylor A, Kuo FE. Could exposure to everyday green spaces helptreat ADHD? Evidence from children’s play settings. Appl Psychol HealthWell-Being. 2011;3(3):281-303. http://dx.doi.org/10.1111/j.1758-0854.2011.01052.x.

10. Seltenrich N. Just what the doctor ordered: using parks to improve children’shealth. Environ Health Perspect. 2015;123(10):A254-A259. http://dx.doi.org/10.1289/ehp.123-A254.

11. Ansari A, Pettit K, Gershoff E. Combating obesity in head start: outdoor playand change in children’s body mass index. J Dev Behav Pediatr.2015;36(8):605-612. http://dx.doi.org/10.1097/DBP.0000000000000215.

12. Sherwin JC, Reacher MH, Keogh RH, Khawaja AP, Mackey DA, Foster PJ. Theassociation between time spent outdoors and myopia in children andadolescents: a systematic review and meta-analysis. Ophthalmology.2012;119(10):2141-2151. http://dx.doi.org/10.1016/j.ophtha.2012.04.020.

13. Scragg R, Camargo CA Jr. Frequency of leisure-time physical activity andserum 25-hydroxyvitamin D levels in the US population: results from the thirdnational health and nutrition examination survey. Am J Epidemiol.2008;168(6):577-591. http://dx.doi.org/10.1093/aje/kwn163.

14. Tsunetsugu Y, Park BJ, Lee J, Kagawa T, Miyazaki Y. Psychological relaxationeffect of forest therapy: results of field experiments in 19 forests in Japaninvolving 228 participants. Nihon Eiseigaku Zasshi. 2011;66(4):670-676. http://dx.doi.org/JST.JSTAGE/jjh/66.670.


15. Hanford E. Out of the classroom and into the woods. Updated 2015. http://www.npr.org/sections/ed/2015/05/26/407762253/out-of-the-classroom-and-into-the-woods/. Accessed May 9, 2016.

16. Park Rx. Shine program. Updated 2016. http://www.parkrx.org/resources/case-studies/stay-healthy-nature-everyday-program-shine/. Accessed May 6, 2016.

17. Pedestrian andBicycle InformationCenter and theNational Safe Routes toSchool.Thewalking school bus: combining safety, fun and thewalk to school. http://guide.saferoutesinfo.org/walking_school_bus/. 2014. Accessed May 6, 2016.

18. Plunkett M. Hospital pushes trail runs to boost community’s fitness. TheWashington Post. June 7, 2016. https://www.washingtonpost.com/national/health-science/how-a-hospital-used-a-historic-trail-to-help-its-community/2016/06/06/1c9da024-dfe2-11e5-9c36-e1902f6b6571_story.html/. AccessedJune 7, 2016.

19. US Department of Health and Human Services. Step It Up! The SurgeonGeneral’s call to action to promote walking and walkable communities.2015. http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/exec-summary.html/. Accessed May 16, 2016.

20. Kraus WE, Bittner V, Appel L, et al. American Heart Association PhysicalActivity Committee of the Council on Lifestyle and Metabolic Health, Councilon Clinical Cardiology, Council on Hypertension, and Council onCardiovascular and Stroke Nursing. The national physical activity plan: acall to action from the American Heart Association: a science advisory fromthe American Heart Association. Circulation. 2015;131(21):1932-1940. http://dx.doi.org/10.1161/CIR.0000000000000203.

21. DC Park Rx. http://www.parkrx.org/about-parkrx/. Updated 2016. AccessedMay 2, 2016.

22. DC Park Rx. http://www.dcparkrx.org/. Updated 2016. Accessed May 8, 2016.23. Sellers F. D.C. Doctor’s Rx: a stroll in the park instead of a trip to the

pharmacy. The Washington Post. May 28, 2015. https://www.washingtonpost.com/national/health-science/why-one-dc-doctor-is-prescribing-walks-in-the-park-instead-of-pills/2015/05/28/03a54004-fb45-11e4-9ef4-1bb7ce3b3fb7_story.html/. Accessed May 7, 2016.

24. US Centers for Disease Control and Prevention. Physicians write aprescription to get up and get moving in New Mexico prescription trailsprogram. Updated November 9, 2015. http://www.cdc.gov/stltpublichealth/phpracticestories/stories/PHPSFF_NMexico-prescription_v2.html/. AccessedMay 3, 2016.

25. Swanson J, Ramirez A, Gallion K. Increasing out-of-school and out-of-classphysical activity among Latino children. Salud America! The Robert WoodJohnson Foundation Research Network to Prevent Obesity Among LatinoChildren. Updated 2013. http://www.communitycommons.org/wp-content/uploads/2013/08/Active-Play-Research-Review.pdf/. Accessed June 3, 2016.

26. Jones SA, Moore LV, Moore K, et al. Disparities in physical activity resourceavailability in six US regions. Prev Med. 2015;78:17-22. http://dx.doi.org/10.1016/j.ypmed.2015.05.028.

27. Moore LV, Diez Roux AV, Evenson KR, McGinn AP, Brines SJ. Availability ofrecreational resources in minority and low socioeconomic status areas. Am JPrev Med. 2008;34(1):16-22; doi: S0749-3797(07)00615-0.

28. Creekmur P. Prince George’s County Health Department: health report. 2014.http://www.princegeorgescountymd.gov/sites/Health/ContactUs/Publications/Documents/2014%20health%20report%20v4-08-14%20no%20blank%20pages.pdf/. Accessed May 15, 2016.

29. Huffling K. Alliance of nurses for healthy environments. 2014. http://envirn.org/pg/groups/4104/alliance-of-nurses-for-healthy-environments/. AccessedMay 11, 2016.

30. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. New York: D.Appleton & Co; 1946.

31. Grant RW, Schmittdiel JA, Neugebauer RS, Uratsu CS, Sternfeld B. Exerciseas a vital sign: a quasi-experimental analysis of a health system interventionto collect patient-reported exercise levels. J Gen Intern Med. 2014;29(2):341-348. http://dx.doi.org/10.1007/s11606-013-2693-9.

Lois Wessel, MS, FNP-BC, is a instructor in the School ofNursing and Health Studies at Georgetown University inWashington, DC, and a family nurse practitioner at CommunityClinic, Inc., in Silver Spring, MD. She can be reached [email protected]. In compliance with national ethicalguidelines, the author reports no relationships with business orindustry that would pose a conflict of interest.

1555-4155/16/$ see front matter© 2016 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.nurpra.2016.06.013


http://refhub.elsevier.com/S1555-4155(16)30325-7/sref1http://refhub.elsevier.com/S1555-4155(16)30325-7/sref1http://www.cdc.gov/nchs/fastats/exercise.htm/http://dx.doi.org/10.1016/S0140-6736(12)60898-8http://dx.doi.org/10.1016/S0140-6736(12)60898-8http://kff.org/other/poll-finding/report-generation-m2-media-in-the-lives/http://kff.org/other/poll-finding/report-generation-m2-media-in-the-lives/http://refhub.elsevier.com/S1555-4155(16)30325-7/sref5http://refhub.elsevier.com/S1555-4155(16)30325-7/sref5http://refhub.elsevier.com/S1555-4155(16)30325-7/sref5http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html/http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html/http://refhub.elsevier.com/S1555-4155(16)30325-7/sref7http://refhub.elsevier.com/S1555-4155(16)30325-7/sref7http://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Health-Benefits.aspx/http://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Health-Benefits.aspx/http://www.nwf.org/What-We-Do/Kids-and-Nature/Why-Get-Kids-Outside/Health-Benefits.aspx/http://dx.doi.org/10.1111/j.1758-0854.2011.01052.xhttp://dx.doi.org/10.1111/j.1758-0854.2011.01052.xhttp://dx.doi.org/10.1289/ehp.123-A254http://dx.doi.org/10.1289/ehp.123-A254http://dx.doi.org/10.1097/DBP.0000000000000215http://dx.doi.org/10.1016/j.ophtha.2012.04.020http://dx.doi.org/10.1093/aje/kwn163http://dx.doi.org/JST.JSTAGE/jjh/66.670http://dx.doi.org/JST.JSTAGE/jjh/66.670http://www.npr.org/sections/ed/2015/05/26/407762253/out-of-the-classroom-and-into-the-woods/http://www.npr.org/sections/ed/2015/05/26/407762253/out-of-the-classroom-and-into-the-woods/http://www.npr.org/sections/ed/2015/05/26/407762253/out-of-the-classroom-and-into-the-woods/http://www.parkrx.org/resources/case-studies/stay-healthy-nature-everyday-program-shine/http://www.parkrx.org/resources/case-studies/stay-healthy-nature-everyday-program-shine/http://guide.saferoutesinfo.org/walking_school_bus/http://guide.saferoutesinfo.org/walking_school_bus/https://www.washingtonpost.com/national/health-science/how-a-hospital-used-a-historic-trail-to-help-its-community/2016/06/06/1c9da024-dfe2-11e5-9c36-e1902f6b6571_story.html/https://www.washingtonpost.com/national/health-science/how-a-hospital-used-a-historic-trail-to-help-its-community/2016/06/06/1c9da024-dfe2-11e5-9c36-e1902f6b6571_story.html/https://www.washingtonpost.com/national/health-science/how-a-hospital-used-a-historic-trail-to-help-its-community/2016/06/06/1c9da024-dfe2-11e5-9c36-e1902f6b6571_story.html/http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/exec-summary.html/http://www.surgeongeneral.gov/library/calls/walking-and-walkable-communities/exec-summary.html/http://dx.doi.org/10.1161/CIR.0000000000000203http://dx.doi.org/10.1161/CIR.0000000000000203http://www.parkrx.org/about-parkrx/http://www.dcparkrx.org/https://www.washingtonpost.com/national/health-science/why-one-dc-doctor-is-prescribing-walks-in-the-park-instead-of-pills/2015/05/28/03a54004-fb45-11e4-9ef4-1bb7ce3b3fb7_story.html/https://www.washingtonpost.com/national/health-science/why-one-dc-doctor-is-prescribing-walks-in-the-park-instead-of-pills/2015/05/28/03a54004-fb45-11e4-9ef4-1bb7ce3b3fb7_story.html/https://www.washingtonpost.com/national/health-science/why-one-dc-doctor-is-prescribing-walks-in-the-park-instead-of-pills/2015/05/28/03a54004-fb45-11e4-9ef4-1bb7ce3b3fb7_story.html/https://www.washingtonpost.com/national/health-science/why-one-dc-doctor-is-prescribing-walks-in-the-park-instead-of-pills/2015/05/28/03a54004-fb45-11e4-9ef4-1bb7ce3b3fb7_story.html/http://www.cdc.gov/stltpublichealth/phpracticestories/stories/PHPSFF_NMexico-prescription_v2.html/http://www.cdc.gov/stltpublichealth/phpracticestories/stories/PHPSFF_NMexico-prescription_v2.html/http://www.communitycommons.org/wp-content/uploads/2013/08/Active-Play-Research-Review.pdf/http://www.communitycommons.org/wp-content/uploads/2013/08/Active-Play-Research-Review.pdf/http://dx.doi.org/10.1016/j.ypmed.2015.05.028http://dx.doi.org/10.1016/j.ypmed.2015.05.028http://refhub.elsevier.com/S1555-4155(16)30325-7/sref27http://refhub.elsevier.com/S1555-4155(16)30325-7/sref27http://refhub.elsevier.com/S1555-4155(16)30325-7/sref27http://www.princegeorgescountymd.gov/sites/Health/ContactUs/Publications/Documents/2014%20health%20report%20v4-08-14%20no%20blank%20pages.pdf/http://www.princegeorgescountymd.gov/sites/Health/ContactUs/Publications/Documents/2014%20health%20report%20v4-08-14%20no%20blank%20pages.pdf/http://www.princegeorgescountymd.gov/sites/Health/ContactUs/Publications/Documents/2014%20health%20report%20v4-08-14%20no%20blank%20pages.pdf/http://envirn.org/pg/groups/4104/alliance-of-nurses-for-healthy-environments/http://envirn.org/pg/groups/4104/alliance-of-nurses-for-healthy-environments/http://refhub.elsevier.com/S1555-4155(16)30325-7/sref30http://refhub.elsevier.com/S1555-4155(16)30325-7/sref30http://dx.doi.org/10.1007/s11606-013-2693-9mailto:[email protected]://dx.doi.org/10.1016/j.nurpra.2016.06.013

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