Exploring service users’ and staff’s perspectives of outdoor clinical sessions
Intended for healthcare professionals
Evidence and practice    

Exploring service users’ and staff’s perspectives of outdoor clinical sessions

Anjali Dave Assistant psychologist, Leicestershire Partnership NHS Trust, Leicester, England
Kelly Fenton Clinical psychologist, Leicestershire Partnership NHS Trust, Leicester, England
Jansi Ganatra Assistant psychologist, Leicestershire Partnership NHS Trust, Leicester, England
Craig Griffiths Clinical psychologist, Leicestershire Partnership NHS Trust, Leicester, England

Why you should read this article:
  • To be aware of the wide-ranging benefits of outdoor clinical sessions for staff and service users

  • To read about service user and staff’s experiences of engaging in outdoor clinical sessions

  • To recognise that outdoor sessions can offer a way of engaging people with severe and enduring mental health issues in longer-term interventions

There is growing interest in outdoor therapy sessions, which appear to have physical and mental health benefits, but there is still a lack of research in this area. A service evaluation was undertaken in a community rehabilitation service to explore the perspectives of service users and staff on outdoor clinical sessions. The rehabilitation team members work with people with severe and enduring mental health issues towards community reintegration. All participants had positive views of outdoor sessions, which were described as supporting people to overcome anxiety, develop confidence and reconnect with the community. Suggestions on how to improve the sessions included staff training and allocating more time. Difficulties included the unpredictability of the environment, logistical barriers and maintaining confidentiality.

Mental Health Practice. doi: 10.7748/mhp.2024.e1701

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

anjali.dave1@nhs.net

Conflict of interest

None declared

Dave A, Fenton K, Ganatra J et al (2024) Exploring service users’ and staff’s perspectives of outdoor clinical sessions. Mental Health Practice. doi: 10.7748/mhp.2024.e1701

Published online: 04 June 2024

Background

The therapeutic value of contact with nature is of growing interest to researchers (Frumkin et al 2017). Outdoor, nature-based therapeutic interventions are considered to hold wide-ranging physical and mental health benefits and have significantly grown in number and type in recent years (Moeller et al 2018, Cooley et al 2021). Outdoor therapies are highly diverse in format and processes, but contact with nature is an essential component (Harper et al 2021).

Severe and enduring mental health issues can be described as a group of conditions that are often chronic and so debilitating that they severely impair people’s ability to engage in functional and occupational activities (Office for Health Improvement and Disparities 2023). People with severe and enduring mental health issues are at greater risk of physical health issues and tend to die 20 years earlier than the general population (Office for Health Improvement and Disparities 2023, Parker et al 2023). This is largely attributed to physical health conditions related to increased body weight, hypertension, dyslipidaemia and insulin resistance, which antipsychotics, often prescribed to people in this group, may exacerbate (Schnor et al 2019).

Exposure to or contact with nature has been shown to have physical and mental health benefits, including reduced blood pressure and heart rate, lower incidence of diabetes mellitus, reduced cardiovascular and all-cause mortality (Twohig-Bennett and Jones 2018), enhanced mental well-being (McMahan and Estes 2015, Yao et al 2021), reduced stress levels, improved sleep and reduced symptoms of depression and anxiety (Coventry et al 2021, Olcoń et al 2023). Therefore, outdoors therapies are relevant when working with people with severe and enduring mental health issues (Hartley et al 2013, Faulkner and Bee 2016).

Engaging in therapeutic work outdoors offers an alternative for patients who find indoor sessions too formal, intimidating and/or anxiety provoking (Jordan and Marshall 2010, Cooley and Robertson 2020). Outdoor clinical sessions enable people to process their thoughts and emotions non-verbally (Adevi et al 2018), give them a greater sense of ownership of the sessions and provide an escape from daily routines and environments (Cooley et al 2020). These factors are important when working with people with severe and enduring mental health issues, as research has shown that it can be challenging to engage them in longer-term interventions (Dixon et al 2016, Melamed et al 2019).

The British Psychological Society (Cooley and Robertson 2020) and Leicestershire Partnership NHS Trust (Crossley et al 2022) recommended evaluating the effects of outdoor therapeutic work to help address the lack of research in this area (Cooley et al 2020). James et al (2021) explored the perspectives of service users and clinical psychologists in inpatient rehabilitation units within Leicestershire Partnership NHS Trust on the feasibility of outdoor psychology sessions. The researchers found such sessions decreased distress, increased sense of freedom and made service users feel more comfortable talking to psychologists, and concluded that ‘outdoor sessions can be an effective and safe mode of therapy, and can offset the challenges of working indoors, providing certain risk factors are considered and managed’.

This article details a service evaluation undertaken in Leicestershire Partnership NHS Trust to expand the evidence base and to consider whether James et al’s (2021) findings apply to community rehabilitation settings. This service evaluation considered the perspectives of a wider range of professional disciplines and roles than James et al (2021) and expanded the definition of ‘outdoor session’ beyond nature settings and green spaces.

Aim

To explore the perspectives of service users and staff in an adult mental health community rehabilitation setting on outdoor clinical sessions.

Method

Setting

The Community Enhanced Rehabilitation Team (CERT) (Kidd and Fenton 2022), which forms part of Leicestershire Partnership NHS Trust’s enhanced rehabilitation and recovery pathway, supports people with severe and enduring mental health issues. The CERT aims to help service users develop independence and autonomy and focuses on delivering bespoke rehabilitation interventions in the community. One key goal is community reintegration. Outdoor clinical sessions are undertaken for a variety of purposes, such as supporting activities of daily living, facilitating community engagement and increasing physical activity.

Recruitment and data collection

Recruitment and data collection was undertaken in May-July 2023 by two assistant psychologists (the first and third authors of this article) who were not involved in clinical care.

Service users with an open referral to the CERT during the data collection period were approached and invited to participate. Service users were not approached if the multidisciplinary team (MDT) deemed it inappropriate to do so, if they were not discussed in MDT meetings during the data collection period or if they were inpatients. Service users could participate over the phone – which 95% chose to do – or face to face.

Service users who agreed to participate (n=19, 12 men, 7 women) completed a questionnaire comprising three yes/no questions with space for additional comments (Figure 1). An additional question following completion of the questionnaire asked participants to confirm if they had experience of outdoor sessions. Those who said they had experienced outdoor sessions were then asked to take part in a semi-structured interview containing seven questions and/or complete the Session Rating Scale (SRS) V3.0 (Miller et al 2000). The SRS is designed to measure three domains of the therapeutic alliance – ‘relationship’, ‘goals and topics’ and ‘approach/method’ – and is intended as a visual scale. There is a 10cm line between two statements for each domain; the person marks a point along the line, between 0 and 10, to rate their experience. As this part of the service evaluation was undertaken over the phone, the researcher read each statement to the participant and asked them to verbally rate it on a scale of 0-10; for example, for the relationship domain the statement on the left side of the scale was ‘I did not feel heard, understood and respected’ and the statement on the right side of the scale was ‘I felt heard, understood and respected’. James et al (2021) used the SRS with an additional domain, designed to ‘assess how comfortable/uncomfortable service users felt outdoors’ and this was included in the present service evaluation.

Figure 1.

Service users’ (n=19) responses to the questionnaire

mhp.2024.e1701_0001.jpg

Key points

  • Being outdoors can facilitate conversations and allow time away from the usual environment

  • Anxieties triggered by the idea of participating in outdoor sessions may resolve once the person is taking part in them

  • Being outdoors may be an intervention in itself, helping to reduce anxiety, increase confidence and reconnect with the community

  • Staff should ensure that outdoor sessions remain person centred

Of the 19 participants who completed the questionnaire, 12 took part in an interview (8 men, 4 women) and ten completed the SRS (5 men, 5 women). Participants’ ages ranged from 18-74 years.

The two assistant psychologists also invited CERT staff, who were not part of the team undertaking the evaluation (n=17), to take part in an interview. Ten CERT staff agreed to participate (1 clinical psychologist, 3 trainee psychologists, 1 assistant psychologist, 2 nurses who were also part of management, 2 occupational therapists, 1 healthcare support worker).

Interviews with staff were semi-structured and contained ten questions; nine of the interviews were conducted via a digital communication platform.

Before each interview, the definition of ‘outdoor session’ used in the evaluation – ‘anywhere outside of your typical therapy space, such as the service user’s home, a hospital or GP surgery. This might include sessions conducted outdoors, on public transport or in community buildings such as shops’ – was read to the participant.

Qualitative data analysis

The interviews were recorded, transcribed verbatim and analysed following Braun and Clarke’s (2006) steps of thematic analysis. All authors independently coded the transcripts and generated provisional themes, which were then re-worked by the authors as a team.

Ethical considerations

The service evaluation was approved by the trust’s quality improvement programme panel. Consent forms – which included consent for the findings to be published – were read to participants and their verbal agreement was sought and obtained before participation.

Quantitative findings

Questionnaire

Nineteen service users completed the questionnaire, 18 (95%) of whom said that working outdoors was something they would be interested in. Six (32%) had concerns about working outdoors, including that it ‘would be a bit much’ for them, fear that it could increase paranoia, concerns about physical health barriers and concerns about getting to the location on time. Four (21%) said that they needed adaptations to work outdoors, such as a walking aid. The adaptations were all needed because of physical health barriers. Figure 1 shows service users’ responses to the questionnaire.

Session Rating Scale

Ten service users completed the SRS. Most domains were rated highly, except ‘goals and topics’, which one service user rated as 0 but all others rated as ≥8. ‘Outdoors’ was the only other domain not rated >9 by all participants. ‘Approach/method’ was the highest-rated domain, rated <10 by only two (20%) service users. Table 1 shows the SRS results.

Table 1.

Session Rating Scale results (n=10)

DomainDescriptionMean (standard deviation)Range
RelationshipService user felt heard, understood and respected9.8 (0.4)9-10
Goals and topicsWorking on and talking about what is important to the service user8.7 (3.0)0-10
Approach/methodStaff member’s approach is a good fit9.9 (3.0)9-10
OutdoorsHow comfortable the service user felt outdoors9.7 (6.0)8-10
OverallHow the session felt overall9.8 (4.0)9-10

Qualitative findings

The following themes and subthemes emerged from analysis of the qualitative data:

  • The outside environment – being outdoors; beneficial for mental and physical health.

  • An intervention in itself – overcoming anxiety; reconnecting with the community.

  • Unpredictability – weather; managing confidentiality; logistical barriers.

  • Making improvements.

The outside environment

The outside environment was seen to have inherent benefits.

Being outdoors

Most participants had had positive experiences of being outdoors, for example from hearing ‘birds singing in the trees’ (Participant 1, service user) or experiencing ‘the fresh air’ (Participant 5, service user). Many service users noted that the environment and format of outdoor sessions met their needs and supported the sessions’ aims:

‘[The staff member] just walks alongside with me, chats with me the whole way so I don’t find it too intense, it’s just talking and stuff.’ (Participant 2, service user)

Being outdoors appeared to make communication easier, allowing people to ‘feel more open and free and normal’ (Participant 7, service user). One staff member commented:

‘When we’re outside, I don’t know why she’s more forthcoming to chat. I don’t know whether [it’s because] there’s no distractions. There’s nothing else to do, is there, while you’re out but talk, and of course you see things as you’re walking and you can comment on them.’ (Participant 17, staff)

Beneficial for mental and physical health

One service user (Participant 12) felt being outdoors helped them sleep better, while another (Participant 1) talked about getting ‘a bit of fresh air as well as good exercise’. There were also positive effects of visiting a place that was important to the person:

‘I love that place, I’ve been with my uncle a couple of times, I’ve been with my sister. I used to go there and draw, I used to walk up that road […] and draw the trees, oh I love that place, so going there was a real boost.’ Participant 8 (service user)

The mental health benefits of ‘getting out of four walls’ were described by staff, who also commented that this would ‘foster creativity’.

An intervention in itself

Being outdoors appeared to be an intervention in itself, supporting people to overcome anxiety and develop their confidence to go out into the community.

Overcoming anxiety

Several service users explained that outdoor sessions had initially provoked anxiety, but that they had been able to overcome that, with many using outdoor sessions to develop their confidence over time:

‘In the past I felt a bit nervous, but I’ve got a bit more enthusiasm over time really and I feel when I am out and about, I do feel quite happy now.’ (Participant 12, service user)

‘I kinda was nervous, but I did welcome [the idea of outdoor sessions] because I know in the end it’s gonna do me good […] It was helpful, it lessened my anxiety about being outdoors and being around crowds of people and going to places that I wouldn’t normally go into on my own, so yeah it was very helpful.’ (Participant 4, service user)

One staff member (Participant 22) explained that outdoor sessions can be helpful for people who are socially anxious or suspicious of others ‘as long as they’re okay with it, because it would be quite distressing for them initially, but I can see how that would ultimately be helpful for them’.

Reconnecting with the community

Service users described outdoor sessions as helping them reconnect with their community by developing their confidence in going out in it. One service user (Participant 4) described how outdoor sessions ‘boosts your confidence, makes you realise that it’s not that bad out there as well […] it’s just good to get out and not worry about people’. Another depicted their journey towards being more independent in the community:

‘Before I wouldn’t walk much, now I’m walking about, go down to the shop instead of using the care.’ (Participant 1, service user)

Staff described seeing service users develop their confidence through regular outdoor sessions and many expressed the hope that these sessions would support them to feel more confident in going out independently:

‘I think a lot of it comes from us to push to go outdoors or change environment, so I guess we could kind of work to improve to kind of support service users feel empowered to make those decisions themselves, and hopefully the more we do those sessions in different environments, they’ll feel more comfortable and confident to do so.’ (Participant 21, staff)

Unpredictability

A salient difficulty of working outdoors was the unpredictable and uncontrollable nature of the environment.

Weather

The weather was mentioned by most staff as a barrier to outdoor sessions:

‘During the winter months you definitely see people wanting to go out less and it’s difficult, it’s even, it’s more difficult to persuade people or encourage people to come outside on your visits if it’s cold. Compared to if it’s like lovely sunshine, and I suppose in the summer as well, when it’s really, really, really hot, you’re not gonna be wanting to do sessions outdoors because you wouldn’t want to put your service user at risk.’ (Participant 16, staff)

Another staff member (Participant 14) felt it was important to ‘get [service users] comfortable with being indoors, as well as outdoors’, as those who relied solely on outdoor sessions would have their sessions cancelled more frequently because of poor weather.

Managing confidentiality

Although all participants felt that confidentiality was managed well overall during outdoors sessions, many staff participants considered that confidentiality issues could be a barrier and that one had to be cautious:

‘I don’t know how you’d improve it, but there’s like a bit of a barrier in terms of confidentiality so if you’re outdoors say in a park somewhere, and it’s a busy park you can’t always have all the conversations that you might want to cover on the visit.’ (Participant 16, staff)

Staff mentioned not knowing what conversations may come up during sessions and that this could be difficult to manage outdoors. Some also commented that there could be issues arising from encountering people that the service user knew. Many staff wanted additional training on managing confidentiality when working outdoors.

When service users discussed confidentiality, they stated that being cautious about it was normal and explained that staff had helped them feel comfortable about it:

‘They don’t push for me to talk about anything that wouldn’t be normal to talk about if I was overheard.’ (Participant 2, service user)

Logistical barriers

Location, access and availability were all cited by staff as potential difficulties when working outdoors. One staff member (Participant 19) talked about the ‘availability of good outdoor space to do it in […] Some of our service users will live close to a nice area where you can go, and other service users won’t’. Issues with travelling to an outdoor space, such as a lack of money, were also discussed by staff.

The difficulty of knowing where to go for an outdoor session was mentioned several times, particularly when staff were unfamiliar with an area. Staff discussed the importance of sharing knowledge between team members to help others plan outdoor sessions:

‘Even something like having some ideas laid out as to maybe where you can go and what you can do, because it can again take up a lot of time, especially if you don’t know the area, in terms of where might be suitable. Maybe routes that you can go, um and there might be some differences in terms of […] where [service user’s home] is situated in terms of town or rural environment.’ (Participant 13, staff)

Making improvements

All participants considered outdoor sessions positively and many suggested how they could be improved with additional resources.

Staff suggested that service users could be given information about the benefits of working outdoors, for example in the form of ‘education sessions on the evaluation of why it’s good for them […] so that they understand why we’re suggesting it’ (Participant 16, staff). Staff also suggested that training for themselves would help them ‘feel more comfortable doing those sorts of sessions’ (Participant 13, staff). Suggested topics for staff training included ‘what are the advantages versus risks […] and to go over some basic principles of privacy and, kind of what the differences are between outdoor sessions and indoor sessions’ (Participant 14, staff).

Staff and service users suggested encouraging and providing more outdoor sessions. One staff member (Participant 17) suggested that, to meet service users’ goals of community reintegration, ‘90% [of sessions] I would say should be about, um, being outside the home’. More diversity was another suggestion, notably a greater ‘variety of places’ (Participant 7, service user).

The most frequently suggested improvement was allowing more time for sessions, with one service user (Participant 1) calling for ‘more time to go for a longer walk and chill out’. This was also expected to improve staff’s experiences of outdoor sessions:

‘The sessions can be a bit longer and […] you know, when you’re kind of nearing that end of the visit time, it feels quite challenging to say, “Oh we’re coming to the end now, we need to go back […]”. It can be rushed sometimes.’ (Participant 21, staff)

Discussion

Similarly to previous research, such as Cooley et al (2020) and Harper et al (2021), this service evaluation identified wide-ranging benefits of outdoor clinical sessions. The SRS responses showed that most service users were interested in working outdoors, with outdoor sessions rated highly across SRS domains.

Harper et al (2021) discussed contact with nature as an essential component of outdoor therapy. In the present evaluation, the definition of ‘outdoors’ was expanded to include anywhere outside typical therapy spaces, since service users’ goal of community reintegration may not always include being in nature. Benefits of outdoor sessions for mental and physical health were shown, which confirms previous research such as Cooley et al (2021), who suggested that both nature and urban walks produced various health benefits. This extends the scope for community services to provide outdoor sessions for people who live far from natural green spaces.

Common findings between the present evaluation and James et al (2021) included that being outdoors facilitated conversations and allowed time away from the usual environment, the challenges of managing confidentiality and the benefits of outdoor sessions for physical health. Some findings were specific to this evaluation, which may reflect the community setting but also suggests that there are unique benefits of outdoor sessions for service users living in the community.

The outside environment appeared to have several advantages, including facilitating conversations and benefiting mental and physical health. The idea of communication being easier outdoors is supported by research showing that outdoor sessions are a useful alternative for service users who find indoor appointments too formal and clinical (Jordan and Marshall 2010, Cooley et al 2020). However, the lowest-rated SRS domain in the present evaluation was ‘goals and topics’, which suggests that staff should ensure that outdoor sessions remain person-centred; this could also mitigate confidentiality issues by giving service users more control over the conversation.

Many service users had had their first outdoor sessions more than one year before the service evaluation and had continued to engage in these sessions and described them positively. Outdoor sessions may therefore offer a way of engaging people with severe and enduring mental health issues in longer-term interventions, which can often be difficult (Dixon et al 2016). The positive effects on mental well-being and physical health found in the present evaluation confirm previous research, such as McMahan and Estes (2015), Twohig-Bennett and Jones (2018) and Yao et al (2021).

Concerns mentioned by service users in the questionnaire were rarely discussed in the interviews, which could suggest that the anxieties triggered by the idea of participating in outdoor sessions resolve once the person is taking part in them. However, on the SRS the ‘outdoors’ domain was the second lowest rated. This may be because the environment in outdoor sessions is new to service users, which demonstrates the importance of discussing with service users what they can expect from such sessions.

Being outdoors appeared to be an intervention in itself, helping to reduce anxiety, increase confidence and reconnect with the community. This confirms findings by Olcoń et al (2023), who noted that outdoor interventions decreased anxiety and increased confidence in interacting with others, and by Coventry et al (2021), who found ‘large and significant effects’ of outdoor interventions on reducing anxiety. The fact that outdoor sessions appear to enable community reintegration is important, as this is a key goal of the CERT service.

Most comments on the difficulties of outdoor working came from staff. Information about the outdoor spaces and activities available should be shared among staff to reduce preparation time. Staff should be offered training, particularly on how to manage confidentiality issues when outdoors. However, there are benefits of working outdoors for staff, such as not being between ‘four walls’. Cooley et al (2020) suggested that working outdoors can help combat the high levels of staff burnout seen in the NHS.

Recommendations in the ‘unpredictability’ and ‘making improvements’ themes included developing a hybrid model combining indoor and outdoor working, given the issues with weather, access and confidentiality. This would ensure that fewer appointments are cancelled, all necessary conversations can take place and sessions better suited to indoor working, for example, paperwork or family therapy, remain possible. In addition, outdoor sessions should be diverse, offered to service users early in their contact with community teams and allocated enough time so that neither staff nor service users feel rushed.

Limitations

The SRS is intended as a visual scale on which respondents mark their ratings, therefore adapting it for use over the phone may have affected its validity and reliability. Some participants had their outdoor sessions over a year before the evaluation, so their memory of these sessions may not be accurate.

Service users who did not have experience of outdoor sessions were not asked to take part in an interview and/or to complete the SRS. Future evaluations could explore the perspectives of this group to understand their reasons for not wanting to take part in outdoor sessions.

Conclusion

This service evaluation in a mental health community rehabilitation setting explored service user and staff perspectives on outdoor clinical sessions. It adds to the nascent evidence on outdoor therapy interventions and confirms their wide-ranging physical and mental health benefits for service users and staff.

The findings suggest that outdoor sessions support service users on their journey towards community reintegration and offer a way of engaging people with severe and enduring mental health issues in longer-term interventions. The findings encourage continuation of outdoor sessions with service users supported by CERT staff, but also indicate that sessions should be given further thought and resources.

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