Navigating a Middle Ground

Abstract

Contemporary practice has started to rethink use of outdoor and community environments for advancing comprehensive rehabilitation outcomes. The aim is to examine health professionals’ experiences and perceptions of providing rehabilitation in outdoor community settings. The purpose is to use these experiences to generate practice-based knowledge in using the outdoors as a means to guide community-based rehabilitation. The Interpretive Description methodology was accompanied by social practice theory. Fieldwork was conducted utilizing participant observation, photovoice, and focus-group interviews. Included were 27 health professionals. The analysis revealed how “naturalistic learning opportunities” offered health professionals strategies to empower activity and participation levels and yet invoked “rehabilitation setting tensions.” A continuum was engaged in the theme “navigating a middle ground,” representing an integrated environment approach; rehabilitation in conventional indoor and outdoor community settings. Development of a sustainable concept for outdoor community-based rehabilitation involves strengthening health professionals’ competencies and skills for providing outdoor and community work.

Keywords

rehabilitation health professionals community-based rehabilitation outdoor settings photovoice interpretive description qualitative methods Denmark

Introduction

Contemporary practice has started to rethink use of outdoor and community environments for advancing comprehensive rehabilitation outcomes for people with disabilities (Dorsch et al., 2016; Jakubec et al., 2016). Health professionals are the lynchpin for these programs, with strong potential to endorse or dismiss such innovation (Kendall et al., 2009; McCluskey & Middleton, 2010). In the current article, we examined the development phase of a new concept, outdoor community-based rehabilitation (CBR), by drawing on health professionals’ experiences and perceptions, to understand the programs potential and practice and policy implications.

Background

Substantial evidence points toward rehabilitation as effective in supporting people with disabilities (arising from any cause) in obtaining optimal functioning (Wade, 2020; World Health Organization, 2011). In developed countries, conventional rehabilitation programs are typically delivered indoors, relying on health professionals who use state-of-the-art equipment and measurement tools to ensure effective rehabilitation (Lightfoot, 2004; Wade, 2020). However, ever growing complexities for treating acute and chronic conditions demand progressive approaches, and everyday outdoor environments have emerged as affording additional avenues to providing rehabilitation (Nunnerley et al., 2013; Sahlin et al., 2012). CBR can expand the frame of conventional rehabilitation by adding focus on community inclusion of people with disabilities and achieving broader social, environmental, and systemic changes (World Health Organization, 2010). Reported CBR outcomes include increased independence, improved mobility and enhanced social participation among people living with disabilities (World Health Organization, 2010). Concurrently, increasing awareness of the various health benefits for contact with outdoor environments has led to the growth of nature-based rehabilitation programs (Moeller et al., 2018; Sahlin et al., 2015). Documented health benefits include increased physical activity (Maas et al., 2008; Pretty et al., 2005), social connectedness (Hartig et al., 2014; Maas et al., 2009), enhanced mental well-being (Bowler et al., 2010; Jakubec et al., 2016), and reduced stress levels (Kondo et al., 2018; Sahlin et al., 2015).

In summary, outdoor-based rehabilitation and CBR has emerged as having much potential for advancing rehabilitation outcomes for people with disabilities (Madsen et al., 2020). That said, rehabilitation programs traditionally take place indoors (Wade, 2020) and shifting those practices to include outdoor community environments can challenge long-standing practices (Kendall et al., 2009; McCluskey & Middleton, 2010). The aim of this article is to examine health professionals’ experiences and perceptions of providing rehabilitation in outdoor community settings. The purpose is to use these experiences to generate practice-based knowledge in using the outdoors as a means to guide CBR.

Method

Setting

This study is embedded in the SPARK (Sound, Park, Activities, Rehabilitation & Climate) project; a 7.2 hectares green meeting place under development (2019–2021) in the center of the city, Aarhus, Denmark (Handberg et al., 2018). The SPARK project facilitates a basis for CBR with integrated outdoor experiences (Handberg et al., 2018). Besides providing an innovative context for rehabilitation related to everyday outdoor and community life, the SPARK project is a solution for climate adaptions and a health promotion program lobbying all people living in Aarhus to sustain physical and social activities. The SPARK project is being established in the outdoor surroundings of a cluster organization with approximately 20 rehabilitation affiliations who provide services tailored to people’s life situation regardless of the actual disability cause. These services are provided free of charge as part of the Danish welfare system legislation. The study was conducted in collaboration with three rehabilitation institutions among the key users of the evolving SPARK project: Orthopedic Rehabilitation Center, Neurological Rehabilitation Center, and Dementia Activity and Rehabilitation Center (Table 1).

Table 1.

Characteristics of the Included Rehabilitation Institutions.

Institution	Traditional Indoor Rehabilitation Services	Rehabilitation in Outdoor Community Settings	Professionals/Staff	Types of Disabilities Handled
Orthopedic Rehabilitation Center: A multidisciplinary service for people with musculoskeletal injuries.	- Individual consultations - Back training programs in teams (physical training and patient education) - Leg training programs in teams - Training of walking with a leg prosthesis - Heated basin training - Fitness self-training	Nature training program in teams being delivered outside all year round. Additionally, some individual consultations and team programs was performed outside during summer time.	Physiotherapists Occupational therapists Social workers Administrative staff n = 21	- Back pains - Back injury (operated) - Leg amputations - Knee injury - Achilles injuries - Hip fractures - Shoulder and neck injury - Hand and wrist injuries - Elbow injuries
Neurological Rehabilitation Center: A multidisciplinary service for people with brain injury or related neurological injuries.	- Individual consultations - Fitness training in teams - Balance training in teams - Stress relief in teams - Patient education about the brain in teams - Energy management training in teams - Home visits and family inclusion	Balance training in teams was often performed outside during summer time. Additionally, some individual consultations and home visits were performed outside; in the garden or in the local community.	Physiotherapists Occupational therapists Administrative staff Coordinator Trainees n = 24	- Apoplexy/Stroke - Dysphagia - Cerebral Palsy - Head and neck cancer - Meningitis
Dementia Activity Rehabilitation Center: A day and activity service for community-dwelling elderly with dementia or related issues.	- Socializing around the- dinner table - Cognitive stimulation - Playing games - Physical and balance training and gymnastics - Community singing	Strolls in the park when the weather allowed it. Weekly excursions to nearby communities and nature parks.	Occupational therapists Health assistants Volunteers n = 7	- Dementia - Alzheimer - Social marginalized populations

Methodology and Theory

To generate practice-based knowledge guiding future outdoor CBR, interpretive description was applied (Thorne, 2016), accompanied by social practice theory as the theoretical lens (Giddens, 1997). Interpretive description offered an organizing logic providing a practice-based focus to the study aim, use of methods and analytical interpretive processes (Thorne, 2016). Within the interpretive description framework, ethnographic field methods were used (Hammersley & Atkinson, 2007) to provide rich insights to why and how people engage with natural environments (O’Brien & Varley, 2012). Data were triangulated using participant observation (Hammersley & Atkinson, 2007), photovoice (Catalani & Minkler, 2010), and focus-group interviews (Krueger & Casey, 2014). In line with patient public involvement principles, four health professional representatives from the three included institutions were involved in the study planning phase (Brett et al., 2014).

With the purpose of establishing empirical and theoretically grounded knowledge (Thorne, 2016), Anthony Giddens’ (1997) social practice theory including “the duality of the structure” was used to interpret and elaborate on the analyses of observations, photovoice, development of interview questions, and interpretive processes throughout the analysis. Specifically, social practice theory provided a frame to focus on connections between health professionals and service provision within the complexities of conventional indoor rehabilitation structures and health professionals’ agency (ability to act autonomously) (Giddens, 1997).

Sample

In all, 27 health professionals were included in the study. A purposive sample strategy was utilized (Thorne, 2016). Inclusion criteria were as follows: health professionals working at Orthopedic Rehabilitation Center, Neuro-logical Rehabilitation Center, and Dementia Activity and Rehabilitation Center, representing broad variation of disciplinary and experiential background with rehabilitation. Sampling involved two steps, both utilizing a purposive strategy (Thorne, 2016). First step: 27 health professionals were recruited for focus-group interviews (Table 2). Second step: 10 of the already included 27 participants were recruited as key informants for the photovoice component and an additional focus-group interview. The key informants included health professionals with diverse disciplinary backgrounds—physiotherapists (n = 5), occupational therapists (n = 4), and a health assistant (n = 1)—varying experiences with rehabilitation in outdoor community settings, and working at Orthopedic Rehabilitation Center, Neurological Rehabilitation Center, and Dementia Activity and Rehabilitation Center. None of the health professionals were educated or guided to use the outdoor community setting in connection with this study, and hereby, the majority had limited experience.

Table 2.

Characteristics of Participants.

Participants	n = 27
Profession
Physiotherapist	n = 15
Occupational Therapist	n = 10
Health Assistant	n = 2
Gender
Female	n = 23
Male	n = 4
Age (years)
<40	n = 8
40–50	n = 8
>50	n = 11
Professional experience
<10 years	n = 6
10–20 years	n = 14
>20 years	n = 7
Affiliation
Orthopedic Rehabilitation Center	n = 15
Neurological Rehabilitation Center	n = 8
Dementia Activity and Rehabilitation Center	n = 4

Data Generation

Five months of fieldwork was conducted in the naturalistic settings of Orthopedic Rehabilitation Center, Neuro-logical Rehabilitation Center, and Dementia Activity and Rehabilitation Center (Hammersley & Atkinson, 2007). To obtain diverse insights (experiential, visual, and verbal; Hammersley & Atkinson, 2007) and address health professionals’ different levels of knowledgeability (discursive, practical, and unconscious; Giddens, 1997), data were generated holistically with triangulated methods (Thorne, 2016).

Participant observation

Engagement in the field included informal conversations, observing staff meetings, daily practices and routines, and participating in the different rehabilitation services at each of the three institutions (Table 1; Hammersley & Atkinson, 2007). Participant observations were conducted indoors and outdoors continuously throughout the 5 months, with at least 1 day weekly in each institution. Field notes were produced using the following: (a) sketch notes of people’s actions and interactions, places, and situations; (b) thick descriptions of “what is going on”; and (c) ongoing reflexive and analytical notes (Hammersley & Atkinson, 2007).

Photovoice

Photographs taken by the participants provided participatory approaches to the data generation (Catalani & Minkler, 2010). The 10 key health professionals were invited to document and share four photographs: two photographs to depict opportunities and two photographs describing the challenges of providing rehabilitation in outdoor community settings. The photographs were forwarded to the first author and printed for sharing at the focus-group interviews. The 10 key professionals were instructed to take turns sharing their images and accompanying narratives, including elaborating on what prompted them to take specific photographs (Catalani & Minkler, 2010; Creighton et al., 2018).

Focus-group interviews

A multiple-category design was applied conducting five focus-group interviews in total (Krueger & Casey, 2014). Data were generated in two phases by comparing and contrasting content within and across Orthopedic Rehabilitation Center, Neurological Rehabilitation Center, and Dementia Activity and Rehabilitation Center (Krueger & Casey, 2014). At the first phase, one focus-group interview at each of the three institutions was carried out (three in total). A semi-structured interview guide with open-ended questions assisted the photovoice approach to the group discussions (please see Supplemental File for interview guide; Krueger & Casey, 2014). The second phase utilized two mixed focus-group interviews with the key professionals across Orthopedic Rehabilitation Center, Neurological Rehabilitation Center, and Dementia Activity and Rehabilitation Center, comparing, contrasting, and challenging first interpretations and internal differences and similarities (please see Supplemental File for interview guide). The first author facilitated assisted by a co-moderator who also completed observations and a speaker’s log (Krueger & Casey, 2014).

Analysis

Guided by Interpretive Description principles, the analysis was conducted in four iterative steps (please see Figure 1; Thorne, 2016). To obtain a coherent analytic whole, all three methods were integrated at each analytic step, applying an iterative analytical approach, going back and forth to the raw data material (Thorne, 2016).

Initial coding in NVivo; organization and comparison of data. The first author read through and coded all data material, followed by shared discussion with the second and last authors.

Fractured coded data were subsumed under descriptive labels. First author mapped data by hand to enhance mobility and expanding on the associations in the data. The second and last authors were included for joint discussion based on illustrative quotes and photographs.

Initial themes and patterns were identified and tested through interpretive processes. Social practice theory guided the interpretive analytic processes (Giddens, 1997). The first author drafted memos of each theme, tested by the author team through written and verbal input.

Envisioning thematic findings; initial themes were subsumed into a coherent narrative. First author condensed and drafted the findings, qualified and co-authored by the author team through joint critical discussions of interpretations and relationships of the thematic findings (displayed in a figure in the “Results” section).

Figure 1.

Analytic steps illustrating how the codes and themes subsumed.

Ethical Considerations

The study was approved by the Danish Data Protection Agency Approval (no. 1-16-02-293-18). Participants were informed about the project with oral and written information and agreed for the first author to be present to conduct fieldwork. For focus-group interviews, verbal and written informed consent was provided. Regarding use of photovoice, specific verbal information and written consent forms were completed confirming the use of images for publication. To ensure anonymity and consent in all the photographs, participants were asked not to take photographs identifying people’s faces (Murray & Nash, 2017).

Results

Health professionals’ experiences and perceptions of providing rehabilitation in outdoor community settings were connected to three themes: “Naturalistic Learning Opportunities,” “Rehabilitation Setting Tensions,” and “Navigating a Middle Ground” (Figure 2). The naturalistic learning opportunities afforded by outdoor community settings offered health professionals strategies to empower activity and participation levels of people with disabilities. Yet, outdoor community settings invoked rehabilitation setting tensions wherein health professionals strived to reconcile and meet conventional indoor rehabilitation structures in less controlled environments. Therefore, providing rehabilitation in an outdoor community setting appeared to be a process of navigating a middle ground, which reinforced health professionals’ practice agency, involving an integrated environment approach: rehabilitation in conventional indoor and outdoor community settings.

Figure 2.

Providing rehabilitation in outdoor community settings induced naturalistic learning opportunities and yet invoked rehabilitation setting tensions, involving navigating a middle ground.

Naturalistic Learning Opportunities

Providing rehabilitation in an outdoor community setting generated naturalistic learning opportunities for the health professionals in which they could uniquely support people with disabilities. The challenges to rehabilitation that were embedded in the less controlled outdoor community environments were framed as resources to advance rehabilitation as distinct from conceding the natural terrain as limiting rehabilitation outcomes or imposing barriers. The outdoors was observed to provide health professionals with a naturalistic community context comprising diverse physical and social inputs that resembled and reflected everyday life for the persons who were living with disabilities. The outdoor spaces were appreciated and strategically utilized by health professionals to empower people with disabilities. Participant observations revealed how most health professionals used the outdoors as a transition point affording unique opportunities for advanced activity and participation levels for people with disabilities. A physiotherapist with more than 15 years professional experience highlighted the connectedness afforded by the outdoors:

“Outside is a joint context. When I am inside in my training room, then all the participants are just standing there passively waiting to know if it is the training elastics or the yoga ball, or what I have planned for today. Because it is me, who is on known territory. When we are out in the forest or in the park, then it is a joint arena and we are all on stamping ground – and that also calls for a bigger initiative as I see it.” (see Illustration 1)

Illustration 1.

A joint arena.

Evident in this quote and photograph (Illustration 1) were partnerships, and the lure and power of the outdoors—both for people with disabilities and health professionals. The image reveals a collective engagement and work outdoors to the extent that it was routinely positioned as “more” interactive and generative compared to the artificial props used in the conventional indoor settings. The naturalistic learning opportunities flowed from outdoor community environments that represented a neutral context, familiar to both health professionals and the people with disabilities. Participant observations revealed how the outdoor community settings also facilitated change wherein the people with disabilities took on a more spontaneous active role in deciding what aspects of the environment they would engage. Conversely, the health professionals were less directive, with more attention to supporting the experiential and embodied aspects of rehabilitation. A physiotherapist with more than 15 years of professional experience affirmed the shifts to an advisory role that accompanied working in the outdoors:

“With this staircase, I would think: ‘What do we need to do, to go up? How can we remove the leaves? What would you do? Should we find some sticks to push away the leaves? Or can you reach down and get them? Or can you use your feet?’ Ehm, depending on what it is you need to practice [. . .] To me, it is also the changeability, that forms exactly the reality that they will meet.” (see Illustration 2)

Illustration 2.

Everyday life challenges and changes.

In this quote and Illustration 2, references were made to the everyday life challenges and changes that accompanied the outdoors—and how shifting environments might aptly afford opportunities to engage (albeit momentarily) season-specific therapeutic environments and activities (as distinct from conventional controlled indoor environments and simulated exercises). Utilizing this approach, health professionals’ evaluation of people with disabilities’ activity levels and capabilities transitioned to be environment specific with predictive qualities for how individuals might (or might not) cope in the community. Further-more, the health professionals underlined the social element naturally integrated in the outdoor settings. An occupational therapist with more than 20 years of professional experience highlighted opportunities for uniquely supporting people living with dementia to be socially connected:

“It gives some opportunities to jointly come out and do something together. Something meaningful. Something that is fun. Something that is challenging. Because it is challenging for a lady of her age standing here in her middle 90’s. And hardly wants to go outside anymore. But just the experience of ‘Wow, I am good at this’. She is our master shooter (laughs).” (see Illustration 3)

Illustration 3.

Social connections.

The benefits of social connection and friendly competition were evident in our observations and this photograph and narrative (Illustration 3). The opportunities for being a spectator and/or participant drove a unique milieu where joint interests were harnessed through the games being played. Naturalistic learning in outdoor community settings offered the health professionals unbridled opportunities to work with, and within familiar social environments to extend the worlds of people with disability. Nevertheless, in the theme, Rehabilitation Setting Tensions, working in the outdoors also came with significant challenges.

Rehabilitation Setting Tensions

Providing rehabilitation in the less controlled outdoor community environments also invoked rehabilitation setting tensions. Health professionals strived to reconcile and meet conventional indoor rehabilitation practice structures; however, the changeability inherent to outdoor settings often challenged service provision. A physiotherapist with more than 10 years of professional experience expressed self-doubts about being responsible for others in the less controlled outdoors:

“My thoughts here were to illustrate some uncertainty in me. That I feel insecure in the outdoor space because it’s unfamiliar to me [. . .] I usually say, ‘Like a bull in a china shop’. Mostly because it gives me that feeling. After all, it is a bit different from the way I’ve worked in the past [. . .] I feel that I cannot do any proper training, and wonder if they [people with disabilities] are in for it, and what do they think about it and such. I can feel that it is filling in on me. It is not because I do not think it is relevant, but much more an uncertainty in me.” (see Illustration 4)

Illustration 4.

Self-doubts.

The image and narrative (Illustration 4) highlighted how the outdoor setting induced uncertainty wherein mastery outside of a controlled indoor environment challenged the practice competencies and authoritative expert stance so deeply aligned with professional service provision. Safety concerns were implied, and the shadows cast in the photograph symbolically reduced the visibility of what might be seen and operationalized in providing support in a controlled environment. This identity change (and perhaps threat) involved accepting a more explorative, creative, and playful approach to rehabilitation practice as the outdoor setting was not defined by specific equipment, programmed exercises, or objective tests. Moreover, the unruliness of the outdoors forced health professionals to “think outside the box,” and to set aside their need to be in control of the situation. For instance, on a rainy day, they had to improvise and use the mud as an active part of the activities instead of retreating and abandoning the outdoors and its inclement weather. This scenario, however, further evoked safety concerns. An occupational therapist with more than five years of professional experience narrated Illustration 5 in addressing these concerns:

“Sometimes, it is easier to be inside where you have the outlined areas, right? Where the safety is high level. In here I can make sure to create a space that is almost all white for this person, who are easily distracted [. . .] Because for those who are cognitive challenged we have to - limit the activities we set up. But, I do see the idea in doing it [rehabilitation outdoors], because we are not there all the time, but then it is not me as a therapist, who put them into a dangerous situation, right?” (see Illustration 5)

Illustration 5.

Safety concerns.

This quote and image (Illustration 5) depicted how the controlled conventional indoor setting could be argued as the safe place contrasting the inherent risks and uncertainties of the outdoors. The closed door and red mark signaled the room was in use, and the occupants were not to be disturbed, an environment deeply contrasting the public naturalistic outdoor environments (Illustration 5). In addition, the traditional values and obligations around duty of care, documentation, measurements, and efficiency structures and the less controlled outdoor community environments fueled tensions with regard to service provision (both in terms of consistency and therapeutic value). An occupational therapist with more than 25 years of professional experience problematized the stresses of diversifying from conventional indoor rehabilitation practice structures:

“We have a span of around 45 minutes to one hour. And, sometimes they are planned right after each other. And in that case, it [rehabilitation outdoors] is not possible, because it will change the whole schedule [. . .] So, if it gets too complicated, then maybe I will get more out of doing something inside. It just makes the time really compressed, because I have a sudden number of citizens that I have to cover. And that is just how the framework is. We cannot change that. We must work around it. But sometimes, it makes it difficult to be innovative, like using the outdoor space for example.” (see Illustration 6)

Illustration 6.

Professional dilemmas.

The image and narrative (Illustration 6) clearly represent the restrictive and orderly systems by which equitable services were scheduled and delivered. The temporal spaces were ever pressured whereby the transit times to the outdoors were factored in as potentially reducing the volume of people with disabilities directly seen each day. Afforded here were insights into the tensions between agency and structure wherein participants were rendered accountable and perhaps restrained by the structures within which their rehabilitation practices were provided. In the focus-group interviews, the health professionals enthusiastically shared ideas, discussed, and highlighted the benefits and challenges of providing rehabilitation in outdoor settings shared in the first two themes. However, overall, the relation between the conventional indoor rehabilitation structures and services and the health professionals practice agency informed the theme Navigating a Middle Ground.

Providing rehabilitation in outdoor community settings demanded balance navigating a middle ground to tackle practice concerns and ensure benefits of people with disabilities. The health professionals provided integrated rehabilitation by combining conventional indoor and naturalistic outdoor community settings to enhance customization of the kind of support provided. Specifically, navigating a middle ground entailed a changed mind-set among the health professionals. A physiotherapist with more than 10 years of professional experience explained how understandings of the quality standards differed depending on the setting:

“Some other values are brought into play. And that could be the exact reason for why we do it, right? I mean, if I want to work profound with the quality, then it might be true that it would be inside. But then it is other qualities that I emphasize when being outside. Outside it is about, for example in relation to walking, then maybe it is more about the pace and endurance than it is concerned with how to walk correctly so it looks good (laughs). Uh, so yes, it is quality in different ways.” (see Illustration 7)

Illustration 7.

A changed mind-set.

Symbolically, the person in the photograph (Illustration 7) was walking toward the institution but the foregrounded outside landscapes prevailed while literally inhabiting a middle ground between the health professional’s frame and the institution to which he was returning. Evident in the photograph and narrative were the shifts in perspectives as drivers of practice and made visible was the cognitive work by health professionals in rationalizing the need for a middle ground. An occupational therapist with more than 20 years of professional experience provided Illustration 8, elaborating her rational for navigating a middle ground:

“The outdoors means a lot. Because our physical surroundings indoors are very restricted. Of course, we have the fitness room where we can strengthen the body functions. However, that only fulfills a part of what those people [people with dementia] need. And some of them think that it is boring to do the exercises inside. More parameters are brought into play when you are outside [. . .] There is more stimulation of the senses—and more training of the balance—and training of the alertness as well. And the reminiscence, for sure. The conversation about the gardens and the lived lives back in the day. And sometimes we meet some people and they stop to say ‘hi’.” (see Illustration 8)

Illustration 8.

Rationalization of the outdoors.

This image (Illustration 8) and narrative beckons back to person centeredness as a lynchpin for sorting through one’s practice to find a middle ground. Provision of rehabilitation in an outdoor community setting seemed to be at the discretion of the health professionals, driven by genuine desires to harness all the potential benefits of the outdoors. Not all health professionals seemed to be ready to fully adopt the outdoors and community resources for rehabilitation and thus navigating a middle ground. The main barriers seemed to relate inertia and some participants’ uncertainty for how to effectively and safely include community members in outdoor rehabilitation. However, physical strength and balance to reduce the likelihood of falls, social connections outside of the institution and staff along with the appealing ascetics starkly contrasted but were positioned as augmenting—to promote comprehensive rehabilitation outcomes. Health professionals who navigated a middle ground explained how they perceived the indoor conventional and outdoor community settings as complementary. Utilizing outdoor community settings value added to their professional practice, making available empowering rehabilitation approaches imbued with health promoting and social benefits. A physiotherapist with more than 15 years of professional experience highlighted contextual benefits for blending the indoors and the outdoors:

“Well, most often it is the real life that is outside compared to the constructed one that the therapist set up, right? So, it may be that they [people with physical impairments] think, ‘well, my balance is fine’, and then they come out and experience a surface that is strange or meet a curb, and then get like, ‘Oh, there was actually something here that was difficult’.” (see Illustration 9)

Illustration 9.

Blended environments.

Evident here were the participants’ reflection of how blended environments could afford tailored support to challenge the status quo and enhance the adaptability and well-being of people with disabilities. Transitioning outside and away from red brick institutional walls, Illustration 9 revealed the diverse pathways made down the hilly terrain. Arguably, the people with disabilities were still within the boundaries of the institution but they are clearly free of its walls momentarily and in meaningful ways that compliment rather than contradict. Controlling what constituted therapeutic blended environments emerged in these ways as the middle ground for most health professionals: augmenting rather than competing, diverse rather than different, equally worthy rather than hierarchical. Evident as an endpoint was the reconciling of both environments as legitimate and value adding to rehabilitation outcomes of people with disabilities.

Discussion

The unruliness and variation of outdoor community environments stimulated playful, creative, improvised approaches to rehabilitation and shifted focus from body functions to empowering activity and participation levels. A different set of values were engaged and called in a comprehensive rehabilitation approach. The changes in practice drivers lobbied health professionals to reflect upon and re-evaluate underlying structures and presuppositions of their traditional professional disciplinary training. Although attractive, the outdoor community setting also appeared to conflict with conventional rehabilitation practice structures developed for indoor purposes (documentation, quantifiable tests, and time-effectiveness) (Wade, 2020). To that end, the readiness of the health professionals to learn, and/or re-learn practice skills and competencies related to integrating the outdoors, local community and its members into the rehabilitation work appeared to be a central component, and ongoing challenge.

The idea behind the SPARK project was to create an innovative and accessible outdoor arena as a means to guide CBR by attracting attention and inspiration for health professionals to encourage behavior change (Handberg et al., 2018). Furthermore, skills and competencies development were central to reinforcing health professionals’ practice and distilling the restorative and health promoting benefits from outdoor and community environments (Kendall et al., 2009; McCluskey & Middleton, 2010). In that connection, Kendall et al. (2009) highlight the importance of educational institutions to respond more effectively to the demands of changing health environments from the various stakeholders. For instance, in pandemic times, there are growing needs to rethink the use of the outdoors and its fit and function with conventional rehabilitation practice settings. Therefore, considering the potentials connected to outdoor settings within CBR is more important than ever. One avenue toward a practice of integrated environments and community capacities in rehabilitation is to insert training of health professionals at the undergraduate levels in outdoor and community practices (Kendall et al., 2009; Wolsko & Hoyt, 2012). We consider it a central component to address the readiness of the health professionals but also educational institutions as well to take responsibility and respond to the demands of integrating the outdoors, local community, and its members into the rehabilitation work.

Besides addressing the work-related performance of health professionals, their person-related practice behaviors and personal characteristics have considerable implications for integration of outdoor and community environments into rehabilitation. Although change in role identity and power relations is a central aspect in developing CBR (World Health Organization, 2010) and utilizing outdoor contexts (McCluskey & Middleton, 2010), it cause ambiguities among the health professionals. On one hand, health professionals take on a gatekeeper role to protect people with disabilities from the risks inherent in outdoor community contexts (Burns et al., 2013; McCluskey & Middleton, 2010). On the other hand, this gatekeeper strategy may deprive people with disabilities from learning how to manage and cope in outdoor physical and social challenging environments, resulting in adverse consequences (Hernandez-Saca & Cannon, 2016; Nunnerley et al., 2013). Therefore, the unruliness and risks inherent in outdoor experiences pose complex circumstances for the health professionals to navigate (Burns et al., 2013; McCluskey & Middleton, 2010). Thus, we argue that navigating a middle ground offers health professionals a way to address these practice tensions and personal dilemmas attached. Hereby, we suggest that health professionals occupy a continuum rather than a for and against binary. By utilizing the diversities between controlled specialized contexts (Moeller et al., 2018; Wade, 2020), and naturalistic challenging environments (Barnsley et al., 2012; Jakubec et al., 2016), the health professionals obtain unique opportunities for supporting people with disabilities and advancing comprehensive rehabilitation outcomes related to the whole life situation of the individual.

Based on the findings, the lessons learned to move forward the work of the SPARK project and further exploration of outdoor CBR services lay within the unique support opportunities provided by engaging integrated environments in rehabilitation. Navigating a middle ground seems the most likely catalyst for changing social practices. The integrated rehabilitation approach established as outdoor CBR seems to enable health professionals to mediate the dualistic relations between structures and agencies, and instead encourage constructive connections (Giddens, 1997). To that end, the findings indicate that integrated rehabilitation in conventional indoor and outdoor community settings extends the frame of conventional rehabilitation in more ways. Nevertheless, to utilize the benefits of the outdoors within CBR and develop sustainable programs, barriers persists (Madsen et al., 2020). Tensions exist with conventional rehabilitation practices such as physiotherapy and occupational therapy using equipment indoors rather than utilizing community resources (McCluskey & Middleton, 2010; Nunnerley et al., 2013). Thus, there are potential encumbrances for family and community member involvement—a core function of CBR (World Health Organization, 2010). To fully integrate outdoor rehabilitation practice, skilling health professionals to confidently provide support outdoors will assist with navigating a middle ground and sustainable program development. By utilizing the strengths of already well-established, conventional indoor evidence-based services and integrating health benefits of outdoor settings and community members, the capacities of integrated environments offer potentials to advance comprehensive rehabilitation for people with disabilities. In short, to further develop and implement outdoor CBR, higher levels of community inclusion are sought for to obtain broader social and systemic changes (Madsen et al., 2020; World Health Organization, 2010).

The current study also offers methodological insights. Credibility of the findings was enhanced through data triangulation, which strengthened analytical interpretations through diverse insights attained over time (Thorne, 2016). For example, participant produced photographs afforded novel insights (and triangulation) to see and interpret the structure agency tensions in delivering rehabilitation in outdoor community settings. While previous photo-elicitation and photo voice work has documented patient perspectives (Dassah et al., 2017), the current study photographs offer relatively rare insights into the work of health professionals. As Oliffe and Bottorff (2007) have indicated previously, the power of photographs includes its reach and persuasion to drawing viewers into their own as well as the participant and researcher’s perspectives. In this regard, the image-based data generated in the current study can authentically talk to multiple audiences including health professionals and researchers, as well as people with disabilities and various stakeholders. However, engaging health professionals induced limitations to the photovoice approach as participants’ professional practice obligations meant that only 10 key informants could be involved in this component (Catalani & Minkler, 2010). This may have induced less variation to the photographs provided (Catalani & Minkler, 2010). Nevertheless, we consider that the field-observations and focus-group interviews contributed to rich and in-depth understandings and interpretations of the photographs.

Diversity in the data generation sites through the inclusion of three rehabilitation centers providing specialized services for people with musculoskeletal injuries, brain injury or related neurological injuries and elderly with dementia, was a study strength aligned CBR (World Health Organization, 2010). However, the diverse groups and rehabilitation services, while affording patterns and themes, are limited in terms of transferability of the findings, and tailored interventions for advancing outdoor practices in specific institutions (World Health Organization, 2010). Based on a literature review (Ravn et al., 2019) and current practice in the Danish welfare context, we argue that occupational therapists and physiotherapists play a significant role providing rehabilitation for people living with dementia. Although dementia is a progressive disease causing gradual loss in functioning rehabilitation provided by occupational therapists and physiotherapists among others, is a relevant approach to support optimal functioning and an independent and meaningful life in one’s own home as long as possible despite dementia (Johansen et al., 2004; Ravn et al., 2019).

Examining the setting of the SPARK project during the developmental phase impacted the results. The full potential of the finished SPARK project established as outdoor CBR could not be examined and thus involvement and dissemination of skills to family and community members appear as unutilized potential for further program development and practice and policy implications. Although a limitation, the current developmental phase has advanced insights and strengthened opportunities for developing collaborations to extend and sustain outdoor CBR programs.

Ethnography has long debated the emic and etic binary (Hammersley & Atkinson, 2007; O’Byrne, 2007). The first author occupied an outsider researcher position, as an anthropologist observing and participating in rehabilitation practice fields (Hammersley & Atkinson, 2007). This outsider position might have impacted the results (Gair, 2012). However, ethnography is a process and product wherein “being there” is a key component of culture work—and by extension the findings drawn from the fieldwork experiences (Hammersley & Atkinson, 2007). During the initial stage of the fieldwork, the first author experienced to be assigned a role as an objective evaluator by the health professionals, with expectations of receiving constructive feedback, which challenged establishment of trustful relationships. But, over time a moveable position on the continuum evolved, by adopting a dynamic responsiveness to the field, occupying shifts in roles and statuses at various stages in the research (Ritchie et al., 2009). Furthermore, we consider the author team to complement insider perspectives, representing multidisciplinary backgrounds including anthropological, public health, nursing, and medical sciences, which enhanced practice understandings. Representation of different methodologies and traditions within the research team also led to critical methodological discussion and consideration.

Conclusion

Providing rehabilitation in outdoor community settings demanded health professionals to navigate a middle ground to mediate practice concerns and ensure benefits of people living with disabilities. The findings indicate that rehabilitation in integrated conventional indoor and outdoor community settings established as outdoor CBR afforded unique opportunities for supporting people with disabilities. Advanced activity and participation levels were engaged and called in comprehensive assessment and customization of services. Nevertheless, the changes in practice drivers lobbied health professionals to reflect upon and re-evaluate underlying structures and presuppositions of their traditional professional disciplinary training. A first step for development of a sustainable concept for outdoor CBR is to strengthen the health professionals’ competencies and skills for providing outdoor and community work. To that end, the starting point is to create the room for discussions and supports to challenge the inertia that has driven the exclusivity of rehabilitation being provided indoors. In conclusion, this study highlights the tensions and pathways toward including outdoor experiences within CBR and adds valuable knowledge on changes that can shift agency structure interactions to leverage positive rehabilitation outcomes for people with disabilities. Future research should illuminate the perspective of people with disabilities to further understand the implications and potentials for advancing comprehensive rehabilitation outcomes through development of outdoor CBR.

Supplemental Material

sj-pdf-1-qhr-10.1177_1049732320951771 – Supplemental material for Navigating a Middle Ground: Exploring Health Professionals’ Experiences and Perceptions of Providing Rehabilitation in Outdoor Community Settings

Supplemental material, sj-pdf-1-qhr-10.1177_1049732320951771 for Navigating a Middle Ground: Exploring Health Professionals’ Experiences and Perceptions of Providing Rehabilitation in Outdoor Community Settings by Louise S. Madsen, Claus V. Nielsen, John L. Oliffe and Charlotte Handberg in Qualitative Health Research

Footnotes

Acknowledgements

The authors would like to thank all the health professionals who generously contributed to this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Aarhus University Faculty of Health (Denmark) under Grant 81264 and the Foundation of Central Denmark Region (Denmark) under Grant A1369. The involvement of John Oliffe was made possible with the support of a Tier 1 Canadian Research Chair in Men’s Health Promotion.

ORCID iD

Louise S. Madsen

Supplemental Material

Supplemental material for this article is available online at journals-sagepub-com.web.bisu.edu.cn/home/qhr.

Author Biographies

Louise S. Madsen is a PhD candidate in Public Health at Aarhus University, Denmark and DEFACTUM, Central Denmark Region, Denmark.

Claus V. Nielsen is a professor and Chief Physician Social Medicine and Rehabilitation at Department of Public Health, Aarhus University, Denmark and DEFACTUM, Central Denmark Region, Denmark.

John L. Oliffe is a professor and Associate Director research at the School of Nursing at the University of British Columbia.

Charlotte Handberg is a senior researcher at the National Rehabilitation Center for Neuromuscular Diseases and associate professor at Aarhus University, Denmark.

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