Engaging with nature and the outdoors: A scoping review of therapeutic applications in contemporary occupational therapy

Abstract

Introduction:

Engagement with the natural outdoors is recommended for public health and wellbeing. Occupational therapists are well-placed to promote these therapeutic benefits, yet limited evidence exists of the scope of such applications.

Methods:

A scoping review was conducted informed by the Joanna Briggs Institute framework. A systematic search was undertaken across five databases, and 64 sources were included following screening. Data were extracted using deductive content analysis, and themes identified through thematic analysis.

Findings:

Three themes were identified: occupation-based applications; occupation-focused applications; and occupational therapy’s contribution. Whilst current applications were evident, most literature explored potential or emerging practice. Outdoor engagement was found to be a complex, therapeutic occupation with the potential to promote mental health and restoration; quality of life and wellbeing; and healthy lifestyles through connection to nature; others; and self.

Conclusion:

Occupational therapists enable outdoor engagement through occupation-focused and occupation-based interventions across a range of practice contexts. Occupational science may offer a valuable contribution to the evidence base, through considering being in nature as a meaningful occupation and outdoor accessibility as a matter of occupational justice. However, evidence of current practice is limited. Further research is recommended to strengthen the evidence-base and inform routine consideration within practice.

Introduction

The natural outdoors encompasses outdoor environments where human activity or materials are not intensive and nature dominates the environmental context (WHO, 2016). Increasing multidisciplinary evidence suggests numerous health benefits from engagement with the natural outdoors, including enhanced immune functioning, improvements in sleep quality and decreased health inequalities (Kuo, 2015; Mitchell and Popham, 2008; Twohig-Bennett and Jones, 2018; World Health Organisation, 2016). Mental health and wellbeing outcomes include reduced symptoms of anxiety and depression, stress reduction and increased self-reported happiness (Gagliardi and Piccinini, 2019; WHO, 2016). Outdoor engagement is recommended internationally as a preventative tool for a variety of lifestyle-affected diseases and conditions (WHO, 2016). The use of nature as a preventative intervention strongly aligns with the current emphasis on health promotion and prevention within healthcare, and the potential to improve public health through connecting people with nature has been emphasised (National Health Service, 2019; Public Health England, 2014; WHO, 2016). This has been further highlighted in light of the COVID-19 pandemic, with inequalities in accessibility to green spaces being exacerbated, alongside a heightened public and political awareness of the therapeutic importance of outdoor engagement (Geary et al., 2021; Natural England, 2020b; World Health Organisation, 2020).

Occupational therapy, with its emphasis on meaningful engagement for health and wellbeing, is well placed to explore and apply these therapeutic benefits. Genter et al. (2015) argue that occupational therapy originated from this preventative viewpoint on health, and that this current focus is an opportunity for the profession to fulfil its original potential. There is evidence of outdoor interventions being applied in occupational therapy including through gardening, environmental design and outdoor adventure (Jeffery and Wilson, 2017; Wagenfeld et al., 2018; York and Wiseman, 2012). However, evidence of current applications has been found to be limited in scope and quality, despite consistent emphasis that occupational therapy is well placed to promote therapeutic engagement with the natural outdoors (Raine, 2018; Stickley, 2015; Wagenfeld and Atchison, 2014).

A preliminary search indicated that much of the occupational science literature focuses on physical activity or the social benefits of outdoor groups, as opposed to any benefits specifically attributed to engagement with the natural environment (Genter et al., 2015; York and Wiseman, 2012). Yet there is evidence to suggest that simply being in and observing nature can be a pleasurable and meaningful occupation with therapeutic and physiological benefits (Brown et al., 2013; Gladwell et al., 2012; Leaver and Wiseman, 2016; Natural England, 2016). This could be an important area for occupational therapy to consider when working with people who may not be able to engage in the physical activities traditionally associated with the natural outdoors.

Defining engagement: Doing, being and belonging in nature

Occupational engagement, through both doing and being, is widely considered within occupational science as the process by which the environment is experienced as a meaningful, therapeutic occupation (Doroud et al., 2018). Wilcock (1993) first conceptualised occupational engagement as encompassing experiences at a spiritual and psychological level, as opposed to a purely physical level. Occupational engagement is frequently associated with finding value and meaning, developing identities, interacting with the environment and a sense of connection (Black et al., 2019; Roberts and Bannigan, 2019; Watters et al., 2013). The consideration of emotional or cognitive involvement as a form of occupational engagement, irrespective of physically doing, may be valuable when considering being in nature as a form of occupational engagement (Leaver and Wiseman, 2016). Thus, the term ‘engagement’ is used within this review to reflect the experience of interacting with the natural outdoors, irrespective of physical participation.

Establishing existing reviews

A search was conducted on the 14th January 2020 across CINAHL Plus, Cochrane database of Systematic Reviews, ethos, Joanna Briggs Institute (JBI) Systematic Review Register and Prospero to establish any existing scoping, systematic or literature reviews on this topic (Peters et al., 2020).

Relevant reviews were found within occupational science literature exploring the therapeutic benefits of gardening (Genter et al., 2015; York and Wiseman, 2012), the meaning of outdoor adventure (Raine, 2018) and the mental health benefits of green walking groups (Swinson et al., 2020). However, these reviews focused on specific outdoor occupations and outcomes of participation, as opposed to the scope of applications within occupational therapy. Furthermore, Raine (2018) identified a lack of high-quality evidence of occupational therapy’s role in this area, recommending a scoping review including grey literature to establish current practice. Gagliardi and Piccinini (2019) conducted an integrative literature review on applications of nature-based therapy, exploring a broader range of interventions. However, only the client group of older adults were considered and, whilst findings were discussed in relation to occupational therapy, this was not the primary focus.

Whilst a range of relevant reviews were identified around this topic, no scoping or systematic review exploring the scope of applications of engaging with the natural outdoors in occupational therapy were found. Furthermore, the preliminary search indicated there was a sufficient range of literature to warrant a scoping review on this subject.

Research aims

This review proposed the following research question: How is therapeutic engagement with the natural outdoors being applied in relation to contemporary occupational therapy practice?

The research aim was thus to establish the extent and nature of therapeutic applications of engaging with the natural outdoors in relation to contemporary occupational therapy practice.

The secondary aim was to establish any experiences of personal meaning or benefits to health and wellbeing that people gain from these applications.

Method

A scoping review was identified as the most appropriate method to establish the extent and nature of evidence around this topic (Munn et al., 2018; Peters et al., 2020). Scoping reviews are valuable in mapping key concepts surrounding a research area and establishing the boundaries of a topic (Munn et al., 2018; Peters et al., 2020). Furthermore, a scoping review provides a rigorous and replicable approach, whilst not excluding grey or unpublished literature that may be relevant to the research question (Livoreil et al., 2017).

The JBI framework for scoping reviews was followed throughout the review to ensure a systematic, rigorous approach (Munn et al., 2018; Peters et al., 2020). The preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-scr) was used to inform and structure comprehensive reporting throughout the review (Khalil et al., 2020; Peters et al., 2020; Tricco et al., 2018).

Search strategy

Search terms were developed informed by the research aims. ‘Occupational therapy’ or ‘occupational therapist’ were established as key search terms, and the terms ‘outdoor*’, ‘natur*’, ‘green*’, ‘horticultur*’, ‘garden*’, ‘environment*’, ‘ecolog*’ and ‘wild*’ were identified as relevant search terms to establish literature relating to the natural outdoors. A pilot search was conducted through CINAHL Plus and SAGE Journals Online, individually combining each of these terms with AND ‘occupational therap*’ to test their relevance and identify any additional key terms (Peters et al., 2020). The final search terms are detailed below:

• Line 1: ‘occupational therap*’

• AND Line 2: Outdoor* OR natur* OR green* OR horticultur* OR garden* OR wild*

The final search was conducted on 9th March 2020 on the following electronic databases: CINAHL Plus, ethos, SAGE Journals Online, Scopus and Web of Science. This search was then repeated on 8th August 2021 to include literature published within this timeframe. These databases were identified as relevant to the research question and were chosen to provide a range of published, unpublished and grey literature sources (Peters et al., 2020).

Inclusion criteria

The inclusion criteria were developed in alignment with the research question and were considered in relation to population, concepts, context and sources, as presented in Table 1 (Peters et al., 2020).

Table 1.

Inclusion criteria.

Population	Participants of all ages, genders, sociocultural backgrounds and health conditions will be considered.
Concepts	Evidence of applications or potential applications of engaging with the natural outdoors in contemporary occupational therapy practice.
	These applications may be occupation based (actively using engagement with the natural outdoors as intervention) or occupation focused (interventions enabling people to engage with the natural outdoors; Fisher, 2013).
	Consideration of the therapeutic attributes or outcomes of these applications, in relation to health, wellbeing or personal meaning.
Context	The environmental context must be a natural and outdoor environment (e.g. outdoor urban environments will not be considered, but natural green spaces within a wider urban context will be considered).
	Any practice setting or occupation will be considered, provided there is evidence of engaging with the natural outdoors being applied therapeutically.
	Only contemporary practice will be considered, defined as between 2010 and 2021 or considerations of future practice.
	Engagement with the natural outdoors may be explored through any of the senses (e.g. a therapeutic application may involve observing the natural outdoors through a window because the person is unable to go outside. Whilst the person is not physically in the natural outdoor environment, they are directly engaged with the natural outdoors and thus such an application would meet the inclusion criteria).
Types of evidence sources	Any type of literature will be considered, provided they meet the inclusion criteria.
	Literature must be available in written English.
	Publication date of literature must be between 2010 and 2021 inclusive.
	No literature will be excluded through critical appraisal.

Selection process

Screening tools, informed by the inclusion criteria, were used to provide a comprehensive guide for reviewers to refer to throughout the selection process (Polanin et al., 2019). The first stage of the selection process involved screening the titles and abstracts of all literature using the title and abstract screening tool, which is presented in Table 2. The purpose of the title and abstract screening tool was to efficiently exclude irrelevant literature and establish all potentially relevant literature for a rigorous full text review (Polanin et al., 2019).

Table 2.

Literature screening tools.

Title and abstract screening tool	Yes	No	Unsure
Is date of publication between 2010 and 2021?	If yes to all, for review of full text.	Exclude	If insufficient information in abstract to determine eligibility, for review of full text.
Is literature available in written English?		Exclude
Does literature relate to engaging with nature or the natural outdoors?		Exclude
Does literature relate to occupational therapy?		Exclude
Full text screening tool	Yes		No
Does the literature explore engaging with a natural outdoor environment?	If yes to all, include		Exclude
Does the literature explore applications or potential applications of engaging with the natural outdoors in relation to occupational therapy practice?	If yes to all, include		Exclude
Do these applications relate to contemporary occupational therapy practice (defined as between 2010 and 2021)?	If yes to all, include		Exclude
Does the literature consider the therapeutic outcomes/attributes of engaging with the natural outdoors in relation to health, wellbeing or personal meaning?	If yes to all, include		Exclude

The full text screening tool was developed as a more rigorous tool to establish the relevance of all remaining literature to the precise research question and aims (Table 2). Evidence relating to all screening questions had to be found for literature to be included in the review. Any queries regarding eligibility were resolved through discussion and consensus with the second reviewer (Peters et al., 2020).

A second reviewer screened all identified sources at each stage of the selection process, to reduce the risk of reviewer bias (Peters et al., 2020).

Lastly, the reference lists of all included literature were screened to identify any further relevant evidence (Peters et al., 2015). The above selection process was followed for all references.

Data extraction and analysis

The aim of this review was to establish both the extent and type of applications of engaging with the natural outdoors in occupational therapy. Qualitative content analysis was identified as a systematic method of analysis that can facilitate both quantifying and describing themes within the literature, recommended when analysing large quantities of textual data (Elo et al., 2014; Peters et al., 2020; Schreier, 2014). A data extraction table was developed including key data characteristics and categories relating to the research aims and objectives. Critical considerations of the literature, informed by Joanna Briggs Institute (2017a) critical appraisal tools, were also included. Whilst literature was not excluded through critical appraisal, as recommended within scoping review guidelines, this was deemed important for considering the strength of findings and quality of literature surrounding this topic (Pham et al., 2014). Critical considerations of all included literature are presented in Supplemental Appendix 1 and were used to inform critical interpretation of the findings throughout the thematic analysis and discussion.

Following data extraction, each category was analysed for common themes. Firstly, results relating to key literature details, methodologies and sources were categorised and summarised (Peters et al., 2020). Findings relating to each research aim were then analysed and categorised to establish common themes. Informed by the PRISMA-scr, findings were presented through descriptive thematic analysis to map key themes and concepts (Tricco et al., 2018).

Reflexive statement

It is recommended for high-quality literature to include a reflexive statement incorporating the researcher’s own background and orientation (Joanna Briggs Institute, 2017b). Many of the author’s own meaningful occupations involve being outdoors, and they feel passionately that connecting with the natural world is a fundamental and therapeutic human experience. It is thus acknowledged that the authors’ personal interest in this subject has the potential to influence the interpretation of findings.

Findings

A total of 2527 citations were identified, of which 52 sources were selected for inclusion within the review. The reference lists of all included literature were then screened, identifying 2238 additional citations of which 12 were selected for inclusion. This resulted in a total of 64 sources being included in the review, all of which are listed in Supplemental Appendix 1. Full details of identified and excluded literature are presented using the PRISMA flow diagram in Figure 1.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flow diagram.

Source: Moher et al. (2009).

Data characteristics and phenomena of interest

Data characteristics and concepts relating to the research aims were recorded throughout the data extraction process and are detailed in Tables 3 and 4.

Table 3.

Data characteristics.

Type of literature	n (%)
Journal article	42 (66)
Conference abstract	15 (23)
Book chapter	3 (5)
PhD thesis	2 (3)
Cochrane systematic review	1 (2)
Conference poster presentation	1 (2)
Research method
Qualitative	36 (56)
Literature review	9 (14)
Opinion	8 (13)
Systematic review	6 (9)
Quantitative	3 (5)
Mixed methods	2 (3)
Country of origin
United Kingdom	31 (46)
Sweden	6 (9)
Other European countries	8 (12)
United States of America	11 (16)
Asia	7 (10)
Oceania	3 (4)
Canada	1 (1)
Year
2010	3 (5)
2011	3 (5)
2012	5 (8)
2013	3 (5)
2014	7 (11)
2015	8 (13)
2016	7 (11)
2017	8 (13)
2018	7 (11)
2019	4 (6)
2020	5 (8)
2021	4 (6)

Table 4.

Phenomena of interest.

Phenomena of interest	n (%)
Occupation
Horticulture	34 (53)
Being in nature	13 (20)
Mixed nature-based occupations	5 (8)
Green walking	5 (8)
Environmental sustainability	4 (6)
Outdoor adventure	2 (3)
Outdoor play	1 (2)
Area of practice
Mental health	22 (34
Review of multiple areas of practice	6 (9)
Deprived communities	5 (8)
Older adults	5 (8)
Public health	6 (9)
Vocational rehabilitation	5 (8)
Leisure	4 (6)
Stroke rehabilitation	4 (6)
Dementia	3 (5)
Forensics	2 (3)
Learning disabilities	2 (3)
Cancer and chronic pain	1 (2)

The extent and nature of therapeutic applications of engaging with the natural outdoors in relation to contemporary occupational therapy practice

Three themes were identified in relation to the primary research aim: occupation-based applications; occupation-focused applications; and occupational therapy’s contribution. These are summarised in Table 5.

Table 5.

Summary of synthesised themes.

Synthesised theme	Subthemes
1. Occupation-based applications Engagement with the natural outdoors being used as a direct form of therapy.	1. Therapeutic groups Occupation-based groups with a focus on therapeutic or rehabilitative outcomes.
	2. Community projects Emerging roles included promoting social inclusion through horticultural communities and facilitating community health-promotion projects.
2. Occupation-focused applications Enabling and promoting engagement with the natural outdoors.	1. Education and advocacy Occupational therapy’s role in advocating for engagement with the natural outdoors at an individual, community and political level. Educational interventions were discussed in relation to health promotion, self-management and balanced lifestyles.
	2. Environmental design Occupational therapy’s emerging role in contributing to the design of outdoor spaces was discussed in relation to existing and potential practice
3. Occupational therapy’s contribution Occupational therapy’s valuable contribution to therapeutic engagement with the natural outdoors was emphasised in relation to existing and emerging practice.	1. Occupational therapy theory and philosophies Strong links between the philosophies underpinning occupational therapy and those of therapeutic engagement with the natural outdoors were found.
	2. The value of occupational therapy Occupational therapy’s core knowledge and skills were widely considered to add value and increase therapeutic outcomes of nature-based interventions.
	3. Promoting the profession The need to promote occupational therapy’s role in this area was emphasised.
	4. Collaboration Interprofessional collaboration was recommended to maximise outcomes.

Theme 1: Occupation-based applications

Occupation-based applications encompassed engagement with the natural outdoors being used as a direct form of therapy (Fisher, 2013). Two subthemes were identified: therapeutic groups and community projects.

Therapeutic groups

Occupation-based groups with a focus on therapeutic or rehabilitative outcomes were the most widely reported application in relation to existing practice, with horticultural groups comprising the majority of applications. Of these, the majority were within mental health in-patient units (Alty and Langfield, 2015; Cipriani et al., 2018; Joyce and Warren, 2016; Martin et al., 2018; Parkinson et al., 2011) or vocational rehabilitation programmes (Eriksson et al., 2010; Pálsdóttir et al., 2014a, 2014b). Evidence was also found of occupational therapy-led horticultural groups for adults recovering from traumatic brain injury and stroke (Patil et al., 2019; Vibholm et al., 2019), as part of a recollection therapy group for adults with Alzheimer’s disease (Kim and Belchior, 2020) and for women with cancer and chronic pain (Mori et al., 2021). The prevalence of gardening interventions within practice was explored through surveys of occupational therapists in the United States (Wagenfeld and Atchison, 2014) and Sweden (Müllersdorf and Ivarsson, 2012), with the implementation of gardening being evident across practice and most frequently within in-patient and psychiatric settings. Whilst both studies are subject to potential bias due to self-selecting respondents, they demonstrate evidence of current practice.

Therapeutic groups were also explored in relation to outdoor adventure, green walking and exploration. Jeffery and Wilson (2017) explored the use of outdoor adventure by occupational therapists practicing in mental health in New Zealand, with the limited number of participants being highlighted as reflecting the number of occupational therapists practicing outdoor therapy. Through a systematic review exploring outdoor adventure, Raine (2018) also found limited evidence of applications in occupational therapy. Diss and Niblock (2019) presented reflections on the incorporation of the natural outdoors within their practice with young adults, which included walking and exploring in the countryside. Whilst being single case studies, these reflective accounts offer insight into applications within current practice. Swinson et al. (2020) conducted a systematic literature review on green walking groups within mental health practice but, despite occupational therapy’s role being emphasised, evidence of existing occupational therapy input was not found.

Community projects

Community projects were associated with emerging practice, with limited evidence of existing occupational therapy input in this area. Emerging student placements were presented within horticultural communities, with one case report demonstrating the subsequent creation of an occupational therapy post (Carr and Cole, 2017; Carr and King, 2017; Diamant and Waterhouse, 2010). Algado and Townsend (2015) detailed a student-led community garden project working with deprived communities to promote wellbeing, social inclusion and ecological sustainability, highlighting potential applications for occupational therapy to expand its role to encompass both community resilience and global ecological issues.

Horticultural groups were recommended to combat occupational deprivation and promote wellbeing for deprived communities and refugees, with occupational therapy’s emerging role in this area being emphasised (Bishop and Purcell, 2013; Flicker, 2017; Mason and Conneeley, 2012). Green walking groups were explored in the context of community-centred health promotion, with occupational therapy’s valuable role in maximising sustained engagement in such groups being emphasised (Raine et al., 2016; Wensley and Slade, 2012). A recent pilot project by Greenway (2021) explored the facilitation of green walking through virtual groups and a graded support plan, with the aim of enabling community mental health service users to reengage in outdoor walking during COVID-19 restrictions. Whilst this application is limited to a single case example, it demonstrates innovative possibilities for Occupational therapists to enable engagement with the natural outdoors despite physical restrictions in practice.

Theme 2: Occupation-focused applications

Occupation-focused applications encompassed those whereby enabling outdoor engagement was the focus of practice (Fisher, 2013). Two key themes were identified: education and advocacy and environmental design.

Education and advocacy

Educating and supporting staff teams to facilitate outdoor engagement in care homes was explored by King (2018). Occupational therapy’s role in supporting staff to overcome barriers to engagement and advocating for increased outdoor engagement at an individual and organisational level was highlighted, proposing outdoor deprivation as a matter of occupational justice (King, 2018). However, limited evidence was found of existing occupational therapy practice in this area (King, 2018). Occupational therapy’s role in advocating for access to outdoor engagement was further emphasised at a community and political level in relation to outdoor play (Lynch et al., 2020) and access to outdoor spaces within healthcare settings (Wiseman and Sadlo, 2015). Advocacy was also discussed in relation to environmental sustainability, with outdoor engagement being proposed as a therapeutic intervention with the potential to promote eco-social change (Algado and Townsend, 2015; Aoyama, 2014; Dieterle, 2020; Hocking and Kroksmark, 2013).

Environmental design

Occupational therapy’s holistic, occupation-centred skill set was considered well placed to contribute to the design of outdoor spaces to maximise engagement, accessibility and therapeutic outcomes (Kendall, 2016; Lynch et al., 2020; Wagenfeld and Winterbottom, 2021). Occupational therapy’s involvement in the design of restorative natural spaces was found to prompt greater outdoor engagement, contributing to positive effects to health and wellbeing (Wagenfeld et al., 2018). Evidence of existing applications were found predominantly within in-patient settings, with occupational therapists involved in the design of therapeutic gardens being more likely to implement garden-based interventions (Brown et al., 2015; Wagenfeld and Atchison, 2014). Royeen (2016) detailed an occupational therapist specialising in creating therapeutic gardens within residential facilities, but only this case report was found as evidence of this specialism within current practice.

Theme 3: Occupational therapy’s contribution

Three subthemes were identified relating to occupational therapy’s contribution to this area: occupational therapy theory and philosophies; the value of occupational therapy; and collaboration.

Occupational therapy theory and philosophies

Occupational therapy’s underpinning values and theory, such as the influence of environmental factors on meaningful engagement, were considered closely linked to therapeutic outdoor engagement (Fieldhouse and Sempik, 2014; Jeffery and Wilson, 2017). Horticultural interventions were described as returning to occupational therapy roots, promoting the profession’s original focus on therapeutic occupation for health (Joyce and Warren, 2016).

Models of practice were applied to outdoor interventions in a number of settings, being considered valuable in providing a theoretical underpinning to practice and maintaining a holistic, occupation-centred approach (Jeffery and Wilson, 2017; Patil et al., 2019). The person–environment–occupation model (Baum et al., 2015) was found to be implemented by an occupational therapist working within environmental design (Royeen, 2016), and the Model of Human Occupation (MOHO; Taylor, 2017) was implemented within mental health, stroke rehabilitation and community programmes (Jeffery and Wilson, 2017; Kim et al., 2018; Patil et al., 2019). Kim et al. (2018) reported using MOHO to inform the creation of a horticultural programme led by volunteers, demonstrating the potential for occupational therapy theory to inform applications which are not ultimately run by occupational therapists. MOHO outcome measures were also found within horticultural programmes, highlighting occupational therapy input in this area through demonstrating occupation-focused outcomes (Coates, 2017; Martin et al., 2018; Parkinson et al., 2011).

The value of occupational therapy

Occupational therapists’ core skills in activity analysis, grading and overcoming barriers to engagement were emphasised as being well placed to maximise therapeutic outcomes of outdoor engagement (Greenway, 2021; Kendall, 2016; King, 2018; Wiseman and Sadlo, 2015). Occupational therapy was emphasised as taking a more holistic view of the person, occupation and environment than alternative outdoor therapies (Jeffery and Wilson, 2017; Wiseman and Sadlo, 2015). Furthermore, an occupational perspective was emphasised as enhancing understanding of the meaning and experience of outdoor engagement (Raine, 2018; Wensley and Slade, 2012). However, evidence demonstrating the added value of occupational therapy input was found to be limited, with a lack of comparative interventions making it difficult to ascertain outcomes were due to occupational therapy input (Alty and Langfield, 2015). The need for further, quality research to demonstrate the effectiveness of occupational therapy’s contribution was highlighted in relation to existing and emerging practice (Cipriani et al., 2017; Flicker, 2017; King, 2018; Mason and Conneeley, 2012; Wagenfeld and Achison, 2014). Furthermore, the need for occupational therapists to be proactive in promoting their contribution to this area was emphasised (Bishop and Purcell, 2013; Kendall, 2016).

Collaboration

Alongside the skills that occupational therapists can offer, outdoor interventions were emphasised as requiring specialist knowledge not provided through occupational therapy education, and collaboration with outdoor specialists was considered a valuable approach to practice (Jeffery and Wilson, 2017; Wiseman and Sadlo, 2015). Fieldhouse and Sempik (2014) argued that both occupational therapists and horticultural specialists have a range of specialist knowledge and skills which, when combined, can be greatly beneficial to both service users and professionals. This was reflected in relation to environmental design, where interprofessional collaboration was considered the optimum approach to maximise therapeutic outcomes (Wagenfeld et al., 2018; Wagenfeld and Winterbottom, 2021). The value of considering interdisciplinary research to enhance nature-based, occupational knowledge was also highlighted (Gagliardi and Piccinini, 2019; Raine, 2018).

Outcomes relating to health, wellbeing and personal meaning

Six themes were identified in relation to therapeutic outcomes and personal meaning, as summarised in Table 6.

Table 6.

Health, wellbeing and personal meaning: synthesised themes.

Theme	Subthemes
1. Health and wellbeing	1. Mental health and restoration Being in nature was associated with reduced symptoms of anxiety, depression and stress. The natural world facilitated the restoration of mental capacities through promoting feelings of calm, mental rest and enjoyment.
	2. Quality of life and wellbeing Engagement with nature was associated with increases in overall wellbeing and quality of life.
	3. Healthy lifestyles Increased outdoor engagement was associated with healthy lifestyle changes including increases in physical exercise, healthy eating and occupational balance. Physical health benefits included reductions in fatigue, improvements in sleep and cognitive functioning.
2. Personal meaning	1. Connection to nature The personal meaning of a connection to nature was widely reported. A sense of peace, wonder, and pleasure was reported from noticing and interacting with the beauty of nature, alongside a new-found appreciation for life, spiritual connections and shifts in perspectives.
	2. Connection to others Participants valued the social connections and sense of belonging associated with outdoor groups. The natural environment was considered to facilitate social interaction.
	3. Connection to self Time in nature was perceived as facilitating reflection, self-acceptance and healing. Outdoor occupations were also associated with long-standing or new-found positive self-identities.

Health and wellbeing

Health and wellbeing outcomes included mental health and restoration; quality of life and wellbeing; and healthy lifestyles.

Mental health and restoration

Engaging with nature was found to promote restoration of mental capacities and wellbeing, through facilitating feelings of calm, inner quietness and escapism (Eriksson et al., 2011; Heard et al., 2020). Stress reduction and relaxation were frequently reported outcomes, with the natural environment being perceived as integral to this through promoting the ability to just be (Mourão et al., 2021; Pálsdóttir et al., 2014b; Wagenfeld et al., 2018). Being in nature was found to promote feelings of hope, inner strength, resilience and self-worth, facilitating mental recovery (Fieldhouse and Sempik, 2014; Pálsdóttir et al., 2014a). Furthermore, feelings of happiness, enjoyment and contentment were widely associated with observing and experiencing nature (Mourão et al., 2021; Pálsdóttir et al., 2014b; York and Wiseman, 2012).

Quality of life and wellbeing

Positive outcomes relating to wellbeing and quality of life (QoL) were reported across a range of settings including mental health, stroke rehabilitation and community projects (Detweiler et al., 2015; Ho, Lin and Kuo, 2016; Kim et al., 2018; Vibholm et al., 2019). Participants reported increased life satisfaction, having a more positive outlook on life and using nature as a coping mechanism for managing everyday stresses (Cipriani et al., 2018; Eriksson et al., 2010). Outdoor engagement was associated with increased wellbeing for adults with dementia and care home residents, with negative impacts of limited outdoor access on QoL being highlighted (Derrett et al., 2015; Hewitt et al., 2013; King, 2018). Exploration of the experiences of people who regularly participate in outdoor occupations further highlighted negative impacts on wellbeing of a lack of outdoor engagement (Raine, 2018). This is valuable in considering how outdoor deprivation may impact on the wellbeing of those who value being in nature (King, 2018).

Healthy lifestyles

Outdoor engagement was found to promote healthy lifestyle choices including balanced routines, healthy eating and physical activity (Joyce and Warren, 2016; Sanders, 2017). Positive health outcomes were frequently reported, including improved sleep, reduced levels of fatigue and increased feelings of vitality (Cipriani et al., 2017; Mori et al., 2021; Raine et al., 2016; Wagenfeld et al., 2013). Negative impacts to physical health were found including injury and fatigue, but these were largely perceived to be short term and outweighed by positive impacts (Kam and Siu, 2010; Raine, 2018). Cognitive, motor and functional skills including balance, cognition, strength, co-ordination and sensory processing were found to improve following outdoor programmes, particularly those utilising gardening (Cipriani et al., 2017; Mori et al., 2021; Patil et al., 2019). However, the inseparability of the environment and physical activity make it difficult to assert influences of the natural environment (York and Wiseman, 2012).

Personal meaning

Experiences of personal meaning were associated with a connection to nature, others and self.

Connection to nature

A sense of connection to nature was frequently valued by participants (Heard et al., 2020; Raine, 2018), with the negative impacts of increasing human disconnection from nature being emphasised (Algado and Townsend, 2015; Aoyama, 2014). Noticing and experiencing the sensory elements of nature were associated with appreciation for and connection to life (Eriksson et al., 2011; Wiseman and Sadlo, 2015). Spiritual connections were noted in relation to reconnecting with the Earth and feeling part of a greater whole (Raine, 2018). Shifted perspectives, values and priorities were reported from such experiences, including setting a slower pace of life and feeling a greater sense of environmental responsibility (Pálsdóttir et al., 2014a; Raine, 2018). An increased sense of connection to nature was associated with greater motivation for environmental and sustainable change or activism (Algado and Townsend, 2015; Aoyama, 2014; Dieterle, 2020; Hocking and Kroksmark, 2013).

Connection to others

Social connections, a sense of community and sharing ideas were valued by participants of outdoor groups (Leaver and Wiseman, 2016; Raine, 2018; Wensley and Slade, 2012). Outdoor engagement was found to promote social interaction and facilitate easier discussion of difficult topics (Bishop and Purcell, 2013; Wensley and Slade, 2012). Social belonging and inclusivity were valued by participants of therapeutic groups, with this being associated with increased wellbeing, self-worth and social functioning (Diamant and Waterhouse, 2010; Kim et al., 2018; Swinson et al., 2020). However, it is possible that the prevalence of these findings correlates with the majority of included applications relating to groups, with evidence suggesting that social contact is rated less important by participants of solo outdoor occupations (Genter et al., 2015).

Connection to self

Solitude in nature was perceived as enabling self-reflection, contemplation and healing (Raine, 2018; York and Wiseman, 2012). Outdoor engagement was described by frequent participants as an important part of their self-identity (Raine, 2018). The value of reengagement with past identities and memories was also found through outdoor engagement, highlighting the importance of considering past identification with engagement with the natural outdoors (Kim and Belchior, 2020; Patil et al., 2019). Continued engagement in outdoor occupations was frequently reported following therapeutic groups, as well as participants taking up new outdoor hobbies (Birkby et al., 2012; Coates, 2017; Eriksson et al., 2011; Patil et al., 2019). New, positive identities were valued by participants, with these being perceived to transfer into life outside of the groups and to increase motivation, interest and self-efficacy (Cipriani et al., 2018; Mason and Conneeley, 2012; York and Wiseman, 2012).

Discussion

The findings highlighted a range of occupation-based and occupation-focused applications encompassing engagement with the natural outdoors being considered in relation to occupational therapy practice. However, the majority of applications related to potential and emerging roles as opposed to existing scopes of practice. Whilst the strong philosophical and historical links between occupational therapy and nature-based interventions were emphasised across the literature, this was considered by some to be an untapped, emerging area of practice (Fieldhouse and Sempik, 2014). Existing applications of engagement with the natural outdoors within occupational therapy practice were found within the review, but the quantity, quality and range of this evidence was limited. The majority of existing applications related to occupation-based therapeutic groups, most prominently incorporating gardening, with a high level of evidence supporting the therapeutic outcomes of such interventions. However, this did not reflect the range of potential applications for occupational therapy being highlighted within the findings such as environmental design, health promotion, community inclusion and advocating for outdoor occupational justice. The prominence of potential and emerging roles within the findings highlights the emerging nature of this area of practice and the opportunities for expanding occupational therapy’s remit both in practice and research.

Implications for practice

The findings of this review presented a range of therapeutic applications encompassing engagement with the natural outdoors within a range of specialist, routine and emerging practice contexts. The complex and therapeutic outcomes of such interventions were highlighted, with the incorporation of occupation-centred concepts such as occupational balance and overcoming barriers to sustained engagement being frequently identified as intrinsic to maximising such outcomes (Eriksson et al., 2011; Wiseman and Sadlo, 2015). This highlights the multi-faceted potential of therapeutic interventions incorporating outdoor engagement for occupational therapists. However, the limited quality of evidence relating to existing practice highlights the need for further research in this area to inform evidence-based practice.

This review did not seek to present a definitive overview of the therapeutic benefits of engagement with the natural outdoors, but to establish outcomes associated with the reviewed applications to consider implications for practice. Numerous therapeutic outcomes relating to physical, psychological, emotional, social, cognitive and functional health, wellbeing and personal meaning were evident from these applications, reflecting the wider evidence base (Natural England, 2017; Shanahan et al., 2019; WHO, 2016). Furthermore, these outcomes were found across a range of preventative, restorative and rehabilitative contexts. This highlights the opportunities for occupational therapists to encompass the therapeutic potential of outdoor engagement across numerous practice contexts.

Emerging evidence suggests that a greater personal connection to nature is associated with greater therapeutic outcomes from outdoor engagement (Natural England, 2016). Findings relating to experiences of personal meaning were prominent within the findings of this review, with participants frequently valuing connections to nature, self and others. However, it is acknowledged that much of the evidence base explored the experiences of people that choose to participate in outdoor occupations, and that the natural outdoors does not hold the same meaning for everyone. Furthermore, the findings of this review suggested a correlation between connection to nature and changes in priorities and environmental responsibility, reflecting the wider evidence base (Natural England, 2020a). Evidence of the potential for outdoor engagement to contribute to wider social and ecological change are significant in proposing an emerging role for occupational therapy (Algado and Townsend, 2015; Drolet et al., 2020; Natural England, 2020a). The role of occupational therapy in promoting sustainable change has been emphasised within contemporary literature, yet the majority of evidence around this subject has been theoretical (Smith et al., 2020; Ung et al., 2020; World Federation of Occupational Therapists, 2018). Thus, evidence within this review is significant in presenting practical interventions for change through encompassing occupational engagement with nature to promote increased environmental responsibility and motivation for sustainable change (Algado and Townsend, 2015; Drolet et al., 2020; Natural England, 2020a). Occupational therapy’s emerging role in addressing social and occupational injustices through community-based outdoor engagement was also highlighted, with horticultural and green walking groups being emphasised as emerging interventions to promote community wellbeing and social inclusion (Bishop and Purcell, 2013; Mason and Conneeley, 2012; Raine et al., 2016). These findings highlight the potential of outdoor engagement to contribute to contemporary, social issues and community-centred practice.

Findings supporting being in nature as a meaningful, restorative occupation also poses an important area of consideration for occupational therapists, particularly when working with those who may be at a time of personal crisis or experiencing barriers to doing (Grahn et al., 2010; King, 2018; Wagenfeld et al., 2018). Occupational therapy’s contribution to the design of accessible and therapeutic natural spaces demonstrates an occupation-focused intervention to enable therapeutic engagement with nature through facilitating being (Lynch et al., 2020; Wagenfeld et al., 2018). Evidence suggests that a large proportion of people with disabilities, alongside deprived and minority communities, experience significant barriers to engagement with the natural environment (Natural England, 2015; WHO, 2016). This has been highlighted by Public Health England (2017) and the National Institute for Health and Care Excellence (NICE, 2018), who recommend the need to enhance accessibility to natural outdoor spaces to promote healthy lifestyles and reduce health inequalities. The findings of this review highlight occupational therapy’s role in advocating for and contributing to outdoor accessibility to address such injustices. Furthermore, this supports consideration of outdoor engagement by occupational therapists as part of routine practice (King, 2018).

The consideration of outdoor engagement as a matter of occupational justice highlights the enablement of outdoor engagement as an important consideration for occupational therapy (King, 2018). Considering engagement with the natural outdoors as a complex, health-promoting and meaningful occupation, the findings of this review strongly support the concept of outdoor occupational deprivation as a matter of occupational justice. With occupational therapists frequently working with people who may be more at risk of experiencing significant barriers to outdoor engagement (Natural England, 2015), outdoor occupational justice is proposed as an important concept for consideration within practice. However, limited evidence of applications of this concept within practice were found.

Whilst the majority of evidence included in this review was conducted prior to COVID-19, the significant impacts of the pandemic are essential to consider when discussing implications for practice and research. COVID-19 and the associated lockdown measures have highlighted the importance of access to natural outdoor spaces for health and wellbeing, with a recent survey suggesting that 40% of United Kingdom (UK) adults were spending more time in nature than before COVID-19 (Natural England, 2020a). This increased awareness of the importance of contact with nature has the potential to provide a platform for the increased implementation of nature-based practice, with examples already emerging within practice (Natural England, 2020b). For example, following the prevalence of the benefits of being in nature throughout the pandemic, alongside the forecasted increases in mental health needs as society begins its recovery, the UK government has announced a pilot scheme of green social prescribing for areas most impacted by Covid-19 (Natural England, 2020b). This reflects the long-standing body of evidence around the need to consider green interventions within social prescribing services, yet this implementation appears to have been directly accelerated by the COVID-19 pandemic (Natural England, 2017, 2020b). This demonstrates a positive shift in the importance of engagement with nature at a policy and political level. Included in this review, Greenway (2021) presented a community intervention conducted during COVID-19 which aimed to support reengagement in green walking in the community through a graded re-enablement programme. Whilst a single case report, this demonstrates possibilities for occupational therapists to adapt their practice to enable outdoor engagement in light of the COVID-19 pandemic.

Implications for research

Despite the breadth of therapeutic applications discussed within the findings, the scope of evidence relating to existing practice was found to be significantly narrower, highlighting a limited evidence base of current applications within practice. Further research implementing the potential applications highlighted in this review within practice would be beneficial to expand the evidence base and applicability to contemporary occupational therapy. Further research into the contribution of occupational therapy in enabling and maximising outdoor engagement is also recommended to strengthen the evidence base for occupational therapy’s role within traditional and emerging scopes of practice.

This review highlighted outdoor engagement as a matter of occupational justice, yet this concept was not found to be widely considered in relation to practice (King, 2018). In light of the meaningful and health-promoting outcomes associated with outdoor engagement presented within this review, outdoor occupational justice, and in particular outdoor deprivation, is proposed as a valuable and under-researched area of interest for occupational science and therapy. Research into the incorporation of this into existing and emerging practice is recommended, to inform practice guidelines, education and routine consideration within practice.

Strengths and limitations

The scoping review methodology facilitated the presentation of a broad range of evidence to map the scope of applications around this topic (Munn et al., 2018). Furthermore, the use of the JBI framework and PRISMA-scr was beneficial in maintaining a transparent, rigorous and comprehensive approach (Peters et al., 2020; Tricco et al., 2018). However, several limitations are acknowledged. Whilst this review aimed to include grey literature, the included databases predominantly focused on published and peer-reviewed research. Furthermore, the inclusion of PhD theses alongside published literature included within the thesis (King, 2018; Raine, 2018) may have placed greater emphasis on certain themes included within such literature.

A high proportion of findings were from UK sources, with no sources being included from African or South American countries. This potentially reflects the under-representation of these countries within the chosen databases and highlights the Western bias of this review. Furthermore, only literature available in written English was included. Finally, it is acknowledged that the author has a personal interest in the research subject and personal bias is possible.

Conclusion

This scoping review sought to answer the following research question:

How is therapeutic engagement with the natural outdoors being applied in relation to contemporary occupational therapy practice?

Whilst existing applications were evident, engagement with the natural outdoors was found to be a predominantly emerging area of practice. Occupational therapy’s current scope of practice was found to be predominantly focused on therapeutic gardening groups within mental health settings. However, the emerging nature of occupation-based interventions was emphasised, with applications in physical health, health promotion and community-centred practice being highlighted. Emerging occupation-focused applications included environmental design, educational lifestyle interventions and advocating for outdoor accessibility. Furthermore, applying occupational science concepts highlighted occupational therapy’s role in promoting being in nature, which is particularly significant when working with people who may be at a time of mental crisis or experiencing significant barriers to doing. The core skills and knowledge that occupational therapy can offer were emphasised, proposing that occupational therapists need to be proactive in advocating for their role in enabling outdoor engagement within existing and emerging scopes of practice.

Numerous therapeutic and health-promoting benefits were found of engagement with nature, reflecting the wider evidence base. The complex nature of outdoor engagement was highlighted, encompassing the facilitation of changes in perspectives, identities and healthy lifestyles, with the potential to contribute to wider social change. This proposes emerging roles for occupational therapy beyond traditional therapeutic interventions. Furthermore, the concept of outdoor deprivation as a matter of occupational justice poses an important and emerging area of practice and research for occupational therapy.

The findings of this review highlight occupational therapy’s broad and fundamental role in the consideration of engagement with the natural outdoors as a meaningful, restorative and health-promoting occupation. Occupational therapy is well placed to embed and promote the complex, therapeutic attributes of outdoor engagement within existing and emerging practice. However, conclusions should be considered with caution and further research is recommended to strengthen the evidence base and inform routine consideration within practice.

Key findings

• Engagement with the natural outdoors is a complex, therapeutic occupation.

• Evidence of existing practice centres around gardening and green walking, yet this does not reflect the breadth of emerging applications for occupational therapy such as outdoor accessibility, health promotion and advocacy.

• Further research is needed to strengthen the evidence base for practice.

What this study has added

This review presents a comprehensive overview of the scope of existing, emerging and potential applications incorporating engagement with the natural outdoors within contemporary occupational therapy practice.