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The Five Ways to Wellbeing model identifies the five activities most beneficial to feeling and functioning well. This article discusses the model and how nurses can use it for both patient care and self-care. This article comes with a handout for a journal club discussion
Five Ways to Wellbeing is a model that identifies the five activities that are most conducive to individual wellbeing. However, despite being beneficial, it has not yet had a significant influence on nurses’ understanding and practice. This article highlights good-practice examples in which the model has been used to improve patient care, and describes how the five activities can have a positive impact on
both patient and staff wellbeing.
Citation: Gilliver C (2021) The Five Ways to Wellbeing model: a framework for nurses and patients. Nursing Times [online]; 117: 5, 48-52.
Author: Catherine Gilliver is director, Trauma Informed Care Community Interest Company (TIT CIC), and staff nurse, Birmingham and Solihull Mental Health NHS Foundation Trust.
Health and wellbeing are important characteristics of human functioning for both the individual and society, as people with better wellbeing tend to have improved health and life expectancy (Mackay et al, 2019). These individuals also tend to be better equipped to cope with adversity, are more productive and have stronger social relationships than those with poor health and wellbeing (Park et al, 2016). Conversely, people who have reduced health and wellbeing often report poorer overall quality of life and, when they are ill or injured, they recover more slowly (Perry et al, 2010).
The World Health Organization’s (1946) constitution defined health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”. The New Economics Foundation (NEF) identified two main elements of wellbeing – “feeling good and functioning well” – in which the feelings of happiness, contentment, enjoyment, curiosity and engagement stem from “having some control over one’s life and having a sense of purpose” (Aked et al, 2008).
Five Ways to Wellbeing
Five Ways to Wellbeing is an evidence-based, cost-effective model that identifies the five activities most likely to promote individual wellbeing (Fig 1). Developed by the NEF on behalf of the UK government through Aked et al’s (2008) systematic review of evidence of how to successfully promote individual wellbeing, it has been described as a counterpoint to the NHS’s Five a Day public health message about the importance of eating fruit and vegetables to sustain physical health.
The Five Ways model has been adopted by NHS England and other national agencies, along with a wide range of NHS trusts, charities and local authorities – case studies are outlined in Box 1 – usually through a top-down health promotion message, such as that used by NHS Wales. However, it does not yet feature in National Institute for Health and Care Excellence guidance or mainstream healthcare provision through training and policy; as such, its direct use in UK healthcare settings and, more specifically by nurses, is intermittent at best.
Box 1. The Five Ways model in action: case studies
Bristol Homeless Health Service
This project was supported by the Queen’s Nursing Institute’s Fund for Innovation and Leadership programme, and developed and implemented by two primary care nurses, Claire O’Connell and Sheila Shatford. Both nurses were aware of the poor mental and psychological health of their homeless clients, as well as a lack of dedicated time and space to focus on this.
They, therefore, set up a programme of wellbeing workshops, which were attended by 22 clients. They evaluated the workshops using the Warwick-Edinburgh Mental Wellbeing Scale, which showed that 50% of attendees demonstrated a six-point increase in scores, with 38% having a clinically significant increase of more than seven points. Additional outcomes were that 100% of participants rated the sessions as helpful or extremely helpful, there was positive peer learning, and clients were involved in running the project and showcasing it at QNI events.
Sessions were based around each of the Five Ways of Wellbeing model’s activities (Fig 1). The session about connecting was particularly successful, as it enabled participants to form ongoing friendships around shared interests; for the session on taking notice, the group went for a mindful walk and visited a cafe. Clients commented that the programme had given back some hope to them, and got them out and about.
Source: Queen’s Nursing Institute (2019)
Birmingham and Solihull Mental Health NHS Foundation Trust – Recovery College for All
The Recovery College for All was set up in 2016 and is open to service users, staff, carers and volunteers from the trust, as well as members of the public. It is held in a non-clinical trust building and service user attendance is entirely on a voluntary, self-referral basis.
A two-hour session on the Five Ways of Wellbeing model has been a core part of the college’s curriculum since 2017. Over the course of a year, the session had 113 attendees, of whom 61% were service users, 23% trust staff, and 10% family members and carers. The college evaluated the session over the year, gathering participants’ feedback:
- 99% reported finding the session useful
- 98% said they would recommend the session to others
- 98% agreed that having a range of participants helped them
- 97% reported learning something that will help them or someone else with recovery
- 95% said they found the session helpful because the facilitator had lived experience of mental illness
Comments from participants included:
“I’ve developed coping strategies for feeling well.”
“I made time for myself.
”It gave me a positive outlook.”
“It was a lifelong learning experience.”
“It taught me to appreciate the present.”
Despite the fact that the King’s Fund and the Mental Health Foundation have indicated the strong interconnections between mental and physical health, because Five Ways tends to be badged as a model that enhances mental health, it is likely to be seen as less relevant to physical healthcare settings.
Although the model’s five key activities are described separately, the behaviours most beneficial to wellbeing relate to more than one; for example, attending a weekly exercise group involves both being active and connecting, and may also provide opportunities for learning and giving. Hospital choirs are another good example of the combined effects of physical activity (through singing) and social interaction that provides connection and meaning; the Rhythm of Life choir at the Christie NHS Foundation Trust demonstrates this and includes patients and carers, as well as staff, among its members (Gilliver, 2018).
Mackay et al’s (2019) study of more than 10,000 adults in New Zealand showed participants’ levels of wellbeing increased with the adoption of each of the model’s five activities. However, it identified that the most important predictors of improved wellbeing were learning and taking notice.
Social prescribing – outlined by Buck (2017) – was developed in the UK in 2009 in response to the increasing number of patients presenting at GP practices whose main problem was social rather than medical. It uses an asset-based approach to connect primary care patients to community organisations and resources via a link worker; for example, patients can be referred to gardening projects, art classes or befriending schemes. The Five Ways model has been a central influence on the development of social prescribing, which acts as a key transmitter of the model.
Social prescribing is now becoming common practice due to the NHS’s (2019) commitment to employ a link worker in every GP practice by 2020. However, Henry (2018) highlighted that social prescribing does not need to be a formal activity that is confined to primary care alone: community nurses, in particular, are also well placed to recommend social activities, hobbies and exercise.
Barriers to nurses adopting the Five Ways model
The Five Ways model can support every nurse as:
- A framework that is actively adopted in its entirety in a particular healthcare setting;
- Background knowledge that is drawn on to inform specific interventions, and to improve physical and psychosocial aspects of the care environment;
- A way to support health professionals’ own wellbeing by identifying the most-effective actions to take.
However, despite its recognition among many nurses – particularly in mental health and community settings – there is still huge untapped potential for nurses to use the model in clinical settings to improve patients’ wellbeing and, by association, their own physical and mental health. Box 2 lists five tips for nurses, which will help them to start adopting the Five Ways model; Box 3 details five recommendations for nurse managers to help promote the model at a service level.
Box 2. Five tips to help nurses adopt the Five Ways of Wellbeing model
- Connect – welcome patients’ visitors as the connection to their life outside of the hospital or clinical setting
- Be active – encourage patients to make even the smallest movements, such as wrist and ankle rotation
- Take notice – change one aspect of the environment, for example, by bringing in a plant or picture
- Keep learning – talk to patients about their interests and hobbies
- Give – make a colleague a cup of tea and ask about their day
Box 3. How nurse managers can promote the Five Ways of Wellbeing model
- Ensure all staff use the ‘Hello, my name is’ approach to foster connection with patients
- Carry out a simple audit of your ward or unit to see how it promotes the model and identify any areas for improvement
- Consult with staff and patients about layout, decor and information displays
- Act as a role model who connects with people, learns and takes notice
- Appoint a champion for each of the model’s five activities
Stock (2017) explored an approach to human health that examines the factors contributing to the promotion and maintenance of physical and mental wellbeing (salutogenesis), rather than the factors that cause disease (pathogenesis). It places particular emphasis on the individual coping mechanisms that help preserve health in the face of stressful conditions.
Nurses are largely trained in a framework that draws on a pathogenic, rather than salutogenic, model of health (Stock, 2017). The elements of wellbeing in the NEF’s definition – such as a sense of purpose, functioning well and happiness (Aked et al, 2008) – may, therefore, seem difficult to attain in healthcare settings in which patients are seriously ill and nurses work under extreme pressure (Bridges et al, 2019). As a result, combined with a lack of time and reflective space to consider complementary approaches, there is likely to be an almost exclusive focus on physical care.
The simplicity and adaptability of the the Five Ways model – both of which are potentially great strengths – may, paradoxically, have led to a lack of appeal to nurses and other health professionals, who are looking for something more technical and specific to their particular setting.
“There is huge untapped potential for nurses to use the model to improve patients’ physical and mental health”
This article illustrates the flexibility of the Five Ways model across different settings. However, as only a small number of services are both using the model and publicising it through reports and websites, this limits the range of examples that can be included.
Research studies relevant to each of the activities outlined in the Five Ways model are presented below, although none has been written by a nurse or specifically concerns nursing practice. This lack of published research relating to the model’s use in a healthcare context highlights a gap in nursing literature and reflects a missed opportunity to fully embed it through nurse education and management practice. More nurse-led research, along with research on a larger scale, is needed to raise awareness of the model and to promote its low-cost, high-impact outcomes.
Research over the past 10 years has consistently highlighted how loneliness and social isolation have a negative effect on health. For example, a link has been identified between loneliness and early death, with the associated higher levels of inactivity, smoking and risk-taking behaviours correlated to diseases such as coronary heart disease, stroke and depression, along with cognitive decline (Bolton, 2012). The Campaign to End Loneliness (2017) highlighted that a lack of social connection poses a major public health challenge as it:
- Creates a risk equivalent to smoking 15 cigarettes a day;
- Is worse for health than better-known risk factors, such as obesity and physical inactivity.
The UK government has published its first loneliness strategy, which includes a number of recommendations including an expansion of social prescribing. The strategy aims to highlight the importance of social relationships to health and wellbeing, defining social wellbeing as “our personal relationships and social support networks, and the way these can bring happiness, comfort and resilience, adding to our overall wellbeing” (Department for Digital, Culture, Media and Sport , 2018).
A range of NHS campaigns urge people to exercise more through walking, running or gardening. However, as these activities are not accessible to everyone, it is important to understand the concept of being active in its widest sense, which, for some people, may mean taking small actions towards becoming less sedentary and re-engaging with life. An excellent example of this approach is the #EndPJparalysis campaign (endpjparalysis.org), which was particularly aimed at acute hospital settings, where patients were often kept in bed longer than medically necessary, creating the risk of losing muscle strength and independence.
While the #EndPJparalysis initiative focuses mainly on the measurable physiological benefits experienced by patients who get up, get dressed and get moving, it also acknowledges the psychological impact of shifting patients’ self-perception from being unwell to recovering. The campaign resulted in significant improvements and shorter hospital stays for individuals, as well as having a positive impact on ward culture and environment; for example, wards have been redesigned to include day rooms, and communal tables have been provided to promote connection and interaction.
Sister Imogen O’Toole from Bristol Royal Infirmary, where the #EndPJparalysis initiative was launched in 2017, highlighted to me anecdotally the influence of patients’ feedback about regaining dignity and identity on staff attitudes. Dolan (2017) also noted that the physical and psychological aspects of the campaign are mutually reinforcing, as loss of physical fitness leads to lethargy and reduced wellbeing, whereas getting up and dressed creates a cognitive shift that has a positive effect on staff and families as well as on patients.
The charity Paintings in Hospitals was set up in 1959 with the aim of using art to promote health and wellbeing through organising exhibitions in healthcare settings. Its recent projects have included arranging an exhibition called Rooted in the Landscape, which toured hospitals in South West England, as well as working in partnership with the National Gallery and Pocklington Group Practice in York to loan a rare 17th-century painting to the practice. The charity highlights research showing that art in its widest sense can help reduce anxiety and depression, and improve memory, communication and recovery.
Through its partnership with Paintings in Hospitals, the Royal Trinity Hospice in London is able to include art in its service delivery. Since 2016, the hospice has also pioneered the use of virtual reality to enable patients to explore places and events that they can no longer experience physically. This project is currently being evaluated, but early signs suggest it is helping reduce patients’ pain and distress.
In 2013, University Hospitals of Leicester NHS Trust introduced a meaningful activity service to support people living with dementia who were admitted to an acute care ward (NHS Providers, 2015). The service aims to improve patients’ wellbeing and is delivered by meaningful activity facilitators, who work alongside the nursing, medical and therapy teams. The facilitators use interventions – including music, games, puzzles, reminiscence activities and social activities – that are all informed by compassionate, person-centred care and carer involvement. In 2017, the trust opened one of the first frailty-friendly emergency departments and, in 2018, it opened a frailty assessment unit based on the same meaningful activity principles.
As a result of these initiatives, outcomes have included:
- An increase in patient wellbeing;
- Better nutrition;
- A reduction in challenging behaviour;
- Improved carer engagement and communication.
In addition, a learning culture has been created for staff, carers and patients, and senior nurses noted the service had greatly improved patient care because the facilitators have time to learn patients’ and relatives’ personal information and integrate it into care plans (NHS Providers, 2015).
A case study by Henry (2018) described Being There, a community-based service in Greater Manchester that provides emotional support and home-based practical help to people with cancer and other life-limiting illnesses, as well as to their family and carers. The service works closely with the Maguire Communication Skills Training Unit at the Christie NHS Foundation Trust and promotes social connection to combat the overwhelming sense of isolation that follows a cancer diagnosis or bereavement. It encourages clients to move from an internal preoccupation with illness and loss to a more external focus, resulting in clients taking more notice, not only of nature and their physical environment, but of other people’s feelings and coping mechanisms, so they can learn how to listen to, and support, others. Henry (2018) described this interplay between taking notice and giving, as well as the other three activities that comprise the Five Ways model, as the virtuous circle of wellbeing (Fig 2).
As a result of their involvement with Being There, some clients and carers become volunteers for the service – for example, by providing peer support; this experience of giving boosts both their sense of wellbeing and their skillset.
- The Five Ways to Wellbeing model identifies the five activities that are most beneficial to wellbeing
- The activities are: connecting, being active, taking notice, learning and giving
- Despite evidence of a link between physical and mental health, the model is often seen as less relevant to physical health settings
- The model is not widely used in nursing, but nurses can use it both for patient care and for self-care
- Where health services use the Five Ways model, patient outcomes and feedback are positive
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Bolton M (2012) Loneliness: The State We’re In – A Report of Evidence Compiled for the Campaign to End Loneliness. Age UK Oxfordshire.
Bridges J et al (2019) Hospital nurse staffing and staff-patient interactions: an observational study. BMJ Quality & Safety; 28: 9, 706-713.
Buck D (2017) What is Social Prescribing? kingsfund.org.uk
Campaign to End Loneliness (2017) Loneliness ‘As Bad for Health as Chronic Long-term Condition’. London: Campaign to End Loneliness.
Dolan B (2017) Mindset shift on PJ paralysis. Nursing Standard. 31, 47, 32-32.
Department for Digital, Culture, Media and Sport (2018) A Connected Society: A Strategy for Tackling Loneliness – Laying the Foundations for Change. DDCMS.
Gilliver C (2018) Your Hospital Choir has a Song for You. nursingtimes.net, 4 December.
Henry H (2018) Five Ways to Wellbeing. qni.org.uk, 7 December.
Mackay L et al (2019) New Zealand’s engagement with the Five Ways to Wellbeing: evidence from a large cross-sectional survey. Kōtuitui: New Zealand Journal of Social Sciences Online; 14: 2, 230-244.
NHS (2019) The NHS Long Term Plan. NHS.
NHS Providers (2015) Case Study: Introducing a Meaningful Activity Service – University Hospitals of Leicester NHS Trust. NHS Providers.
Park N et al (2016) Positive psychology and physical health: research and applications. American Journal of Lifestyle Medicine; 10: 3, 200-206.
Perry GS et al (2010) Addressing mental health promotion in chronic disease prevention and health promotion. American Journal of Public Health; 100: 12, 2337-2339.
Queen’s Nursing Institute (2019) Nurse-led Projects in the Community: For People Experiencing Homelessness. QNI.
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