Attitudes and declared practices of Polish psychiatrists toward nature-based interventions: a nationwide cross-sectional study

Introduction

Exposure to natural environments, particularly through structured nature-based interventions (NBIs), has been shown to exert beneficial effects on various aspects of mental health [1-3]. Systematic reviews indicate that such contact contributes to improvements in cognitive functioning, brain activity, blood pressure, mental well-being, physical activity, and sleep quality. Findings from experimental studies provide evidence for the protective role of natural environments in supporting mental health and cognitive performance [1].
A meta-analysis based on randomised controlled trials (RCTs) confirmed the efficacy of NBIs in alleviating depressive symptoms, reducing anxiety, enhancing positive affect, and decreasing negative affect. Interventions such as gardening, outdoor physical activity, and nature-based therapy have demonstrated particular effectiveness, including among individuals with previously diagnosed mental disorders [2].
Definition of key terms:
Nature-based approaches (NBAs) refer to a broad, umbrella term encompassing activities that promote contact with nature – both direct (e.g. spending time in urban green spaces, forests, or near bodies of water) and indirect (e.g. incorporating natural elements into indoor environments).
Nature-based interventions (NBIs) are specific actions undertaken with the aim of achieving defined health outcomes.
Nature connectedness, defined as an individual’s subjective sense of relationship with the natural world, has been shown to be a stronger predictor of well-being than the mere frequency or duration of exposure to natural environments [4].
Among the most frequently employed forms of NBIs are various types of forest therapies. A particularly popular practice is shinrin-yoku (forest bathing), which involves immersing oneself in nature through sensory engagement. A meta-analysis of studies from Asia and Europe, encompassing different forest bathing modalities (such as walking, breathing exercises, and yoga), suggests that shinrin-yoku can effectively alleviate short-term symptoms of mental disorders, especially anxiety [3].
Findings from research involving individuals with chronic illnesses indicate that NBIs may positively impact both psychological and physiological well-being in these patients. This suggests that NBIs can serve as valuable complements to standard supportive therapies [5]. A systematic literature review [6] demonstrated that a range of interventions based on contact with natural environments show efficacy across diverse age groups – including children and older adults. These interventions targeted various health issues such as cardiovascular diseases, musculoskeletal disorders, and mental health conditions. Meta-analytic results indicate benefits in normalising blood pressure, reducing symptoms of depression and anxiety, as well as increasing levels of physical activity. These findings are consistent with previous research on the influence of natural environments on cardiometabolic and mental health.
Subgroup analyses suggest that positive effects are more pronounced in studies where interventions were recommended or organised by health or social care professionals with prior contact with the patients. This underscores the importance of recommendations and paraclinical actions undertaken by mental health specialists and other healthcare workers in the implementation of such interventions.
In recent years, numerous efforts have been undertaken in Poland to raise awareness about the impact of contact with nature on mental health – both among the general public and among mental health professionals. Initiatives directed at the latter group, including psychiatrists and other mental health specialists, have primarily focused on forest therapy and therapeutic ornithology (also referred to in the literature as a mindfulness-based method – mindful birding [7]).
Although it is not possible to list all initiatives aimed at popularising knowledge about the importance of nature contact in the context of mental health, notable examples include book publications by Simonienko [8-10] as well as Tryjanowski and Murawiec [11]. The topic of nature contact and nature-based interventions has also been featured at numerous conferences, including sessions dedicated to ecopsychiatry held during the national meetings of Polish psychiatrists in 2021 and 2022:
Contact with nature and mental health, 46th Congress of Polish Psychiatrists “Psychiatry in the Face of Change”, Szczecin, 24-26 June 2021
Mental health and contact with the natural environment, 47th Congress of Polish Psychiatrists “When Science Meets Practice”, Łódź, 8-11 June 2022.
Several original and review articles concerning nature-based interventions have also been published in the Polish scientific literature [12-17]. A significant milestone was the publication of the monograph Ecopsychiatry, released in 2024 [18], which covers a broad spectrum of issues related to the impact of contact with nature on various aspects of mental health.
Efforts to enhance the knowledge of mental health professionals, particularly psychiatrists, are crucial for the effective implementation of NBIs in clinical practice. The knowledge, awareness, and resulting recommendations provided by psychiatrists can directly influence patient behaviours and their willingness to engage in specific activities. This is especially important because of the following:
Psychiatrists have direct contact with individuals experiencing mental disorders,
As experts in mental health, they hold authority that impacts patients’ decisions,
They can encourage or discourage certain activities, which directly affects therapeutic practice.
The information conveyed to psychiatrists should be grounded in contemporary scientific evidence and aligned with the principles of evidence-based medicine (EBM). Only such an approach fosters trust in the proposed interventions and protects against their dismissal as unscientific or alternative medicine. Mitchell et al. [4] emphasise the importance of these issues; although their analysis focuses on child and adolescent psychiatry, the concerns remain relevant to adult mental health care. The authors highlight apprehensions expressed by mental health professionals regarding the organisational culture within psychiatry, which may hinder the adoption of nature-based approaches (NBAs). Among the concerns voiced by specialists are the perceived lack of sufficient scientific evidence and uncertainties about the forms and role of NBAs within standard psychiatric practice. These concerns align with principles for implementing innovations in medicine, which underscore the importance of evidence availability and stakeholder awareness.
A practical manifestation of recommendations related to nature contact are so-called green prescriptions (green prescribing, GRx). This term refers to recommendations issued by physicians or other mental health professionals encouraging patients to spend time in natural environments and engage with nature for therapeutic, preventive, or rehabilitative purposes [18]. Green prescriptions may take the form of written recommendations, informational brochures, referrals to facilities offering such activities, or links to online platforms dedicated to ecotherapy. Some centres develop so-called ecotherapy calendars to help patients identify specific activities and locations in their vicinity. Green prescriptions are already in use in the United Kingdom, Norway, Finland, Austria, and some regions of Germany, with New Zealand being a pioneering country in their implementation [18].
The aim of the present nationwide study was to assess the current state of knowledge, awareness, and practices of psychiatrists regarding contact with nature and the use of nature-based interventions. Operating under the assumption that psychiatrists’ attitudes and beliefs influence clinical practice in this area, we sought to examine their knowledge, attitudes, and self-reported behaviours during the first half of 2025.

Material and methods

Surveys

The survey developed for this study (Appendix 1) was distributed to participants at 3 psychiatry conferences held in Poland in an in-person format. This distribution method was chosen because an online survey could have attracted an overrepresentation of individuals already interested in nature-based interventions, potentially biasing the results and limiting their representativeness.
The selection of conferences with a general psychiatric focus – including a strong emphasis on pharmacotherapy of mental disorders – allowed us to reach a broad group of psychiatrists regardless of their personal interest in nature contact. Surveys were distributed through registration points at the following conferences (100 surveys at each event, totalling 300 copies):
Podlasie Psychiatric Workshops, Białowieża, 9-11 January 2025,
Psychiatry in Questions and Answers, Warsaw, 31 January – 1 February 2025,
Psychiatry – Case Studies, Wrocław, 28-29 March 2025.
The conferences were held in geographically distinct locations (Białowieża, Warsaw, Wrocław), enabling coverage of participants from various regions of Poland. Participants were instructed not to complete the survey more than once if they had already participated at an earlier conference.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics 30. Frequency analyses of responses to the author-designed survey questions were conducted, along with a series of c2 tests of independence to assess potential associations between specific responses. A significance level of a = 0.05 was adopted.

Results

Characteristics of the study sample

A total of 193 completed surveys were obtained out of 300 distributed, yielding a response rate of 64.3%. The majority of respondents were female (63.4%). Participants’ ages ranged from 25 to 70 years (mean: M = 40.18; standard deviation: SD = 11.61). The largest proportion of participants reported employment in hospital or day wards (63.7%), while the smallest proportion worked in outpatient clinics (35.8%). Nearly half of the respondents (47.9%) were employed in private practices, with a substantial portion (40.9%) indicating that they worked in more than one setting.
The respondents’ professional experience ranged from novices to highly experienced psychiatrists. Forty per cent of participants reported 0-5 years of professional experience, while 37.7% declared over 15 years of experience. Most respondents (55.4%) held a specialisation in psychiatry. The high proportion of psychiatry specialists in the sample suggests that the survey distribution method effectively reached the target professional group, i.e. psychiatrists.
Detailed percentage distributions of variables characterising the study sample are presented in Table 1.
In response to the question regarding whether respondents had encountered medical or scientific information (including publications, conference presentations, or other forms of professional communication) related to the impact of contact with natural environments on mental health or well-being, the most frequent answers were “rarely” (28.0%) and “occasionally” (26.9%). A total of 7.8% of respondents declared that they had never encountered such information, 10.4% reported encountering it often, and 8.8% very often. Overall, 62.7% of respondents indicated that their exposure to this type of information was rare, occasional, or non-existent (Figure 1).
Most respondents believed that contact with the natural environment can have a positive impact on the mental health of both individuals with and without mental disorders (60.1%) and simultaneously benefit mental health professionals (47.2%). Only 0.5% of respondents indicated that contact with nature does not positively affect mental health, and 1.6% stated that the positive impact applies exclusively to healthy individuals (Figure 2).
In the subsequent question, respondents were asked whether contact with nature could be considered an effective method for supporting mental health. A total of 72.4% of participants believed that it can support the treatment of mental disorders when present in an individual. Only 1% denied the existence of such an effect. Additionally, 7.8% of respondents regarded contact with nature as a standalone method for treating mental disorders (Figure 3).
Regarding clinical practice, the largest proportion of respondents reported that they recommend contact with the natural environment to their patients “quite often” (25.4%), while 20.7% stated they do so “very often”. Only 9.3% of respondents indicated that they never provide such recommendations. Overall, 63.2% of participants reported recommending contact with nature often, quite often, or very often (Figure 4).
Regarding specific recommendations, the most frequently suggested activities were walks in natural environments (88.5%) and trips aimed at spending time in such environments (60.7%). Forest bathing was recommended by 23% of respondents, other forms of forest therapy by 15.1%, and birdwatching by 14.3% (Figure 5).

Group differences analysis

Statistical analysis revealed no significant differences between women and men regarding exposure to scientific information about the impact of nature on mental health, beliefs about which groups may benefit from contact with nature, or opinions on the effectiveness of nature contact as a mental health support method. However, a statistically significant gender difference was found in the frequency of recommending contact with nature: women were significantly more likely to report recommending such contact very often, whereas men more frequently reported recommending it sporadically (c²(5) = 12.41; p = 0.030; V_c < 0.30 – weak effect).
No significant gender differences were found in terms of specific activities recommended to patients. Length of professional experience did not differentiate responses to the question of who might benefit from contact with nature. However, a significant difference was observed regarding the frequency of recommending nature contact: respondents with over 10 years of experience more often declared very frequent recommendations, while those with less than 5 years of experience more often reported never making such recommendations (weak effect, V_c < 0.30).
The work setting differentiated responses concerning exposure to scientific information: respondents working in private practices more frequently reported very frequent contact with such information, whereas those working in hospital wards, day wards, or outpatient care more often indicated rare contact (moderate effect, 0.30 < V_c < 0.50).
Length of experience also differentiated exposure to scientific information – individuals with over 15 years of experience significantly more often reported frequent or very frequent contact, whereas those with up to 5 years of experience more often reported never having encountered such information (weak effect, V_c < 0.30).
Regarding specific recommendations for nature-based activities, significant differences were found only for birdwatching – respondents with over 10 years of experience recommended it significantly more often; other activities were more frequently recommended by those with 10-15 years of experience. Other differences concerning forest bathing, walks, and trips to natural environments were not statistically significant.
A significant difference was also found in the frequency of recommending nature contact depending on whether the respondent held a psychiatry specialisation: those without specialisation more often reported never recommending such contact, whereas specialists significantly more often reported recommending it sporadically (p = 0.027; V_c = 0.28 – weak effect).

Discussion

Previous research, reviews, and meta-analyses on the impact of nature contact on mental health have primarily focused on the efficacy of specific interventions and their application across various patient groups [1-5, 19, 20]. Far less frequently analysed is the perception of these findings by practitioners – psychiatrists included – and the extent to which such interventions are implemented in everyday clinical practice [21, 22]. Yet, it is precisely the beliefs and knowledge of specialists that constitute a crucial factor influencing the implementation of innovative therapeutic approaches such as NBIs.
In our study, most psychiatrists (62.7%) reported encountering scientific information about the effects of nature contact sporadically, rarely, or not at all. Simultaneously, as many as 63.2% declared that they recommend contact with natural environments to their patients fairly often, often, or very often. The most frequently recommended activities were walks and trips to natural settings, while forest bathing and birdwatching were recommended less frequently. The convergence between the use of such recommendations and personal beliefs or experiences indicates a significant role of clinical intuition and personal contact with nature in therapeutic decision-making. This phenomenon was previously described by Mitchell et al. [4], who noted that many professionals perceive NBIs as interventions with insufficient evidence base, despite personally practicing or recommending them to patients.
Moreover, our results revealed significant differences in reported behaviours and beliefs depending on gender, length of professional experience, and workplace. Women and psychiatrists with over 10 years of experience more frequently recommended nature contact, while younger psychiatrists less often reported such recommendations. This may be explained by a focus on acquiring fundamental clinical and pharmacological knowledge at early career stages. Respondents working in private practice significantly more often reported frequent exposure to information regarding the mental health benefits of nature, whereas those employed in hospital wards or outpatient care more often indicated rare contact with such information.
These findings align with the quantitative study conducted by Drolí et al. [21], which demonstrated that women and those working in diverse settings (both public and private) are more likely to recognise the health-promoting potential of nature contact. The authors also emphasised the role of natural environments within the context of ecosystem services and highlighted the importance of such knowledge for clinical practice. Interestingly, their study found that younger individuals showed greater interest in NBIs, contrasting with our results which suggest that younger psychiatrists may be less inclined to recommend these interventions. This discrepancy may reflect differences between professional groups or career stages.
For instance, an Australian qualitative study [22] highlights the critical role of clinicians’ personal experiences with nature in their willingness to implement NBIs. Respondents in that study viewed nature as a source of restoration, mindfulness, and social support. Many already recommended nature-based activities to patients, and some integrated them into their therapeutic practice. However, several barriers were noted: patient lack of motivation, cultural resistance to moving away from the biomedical model, low awareness of benefits, and organisational challenges in implementing NBIs within institutional healthcare settings. These barriers were further elaborated in a systematic review by Burrell et al. [23], who identified 3 main categories of obstacles: psychological, psychosocial, and physical. These included low mood, social anxiety, scepticism about NBI efficacy, reluctance to participate in groups, and physical limitations. The review also noted that most prior studies focused on participants who continued NBI participation, limiting insights into reasons for dropout or non-engagement.
In this context, a noteworthy finding of our study is that despite limited exposure to scientific literature, a considerable proportion of psychiatrists implement actions aligned with NBI principles. This may suggest that personal attitudes and experiences play a key role in recommending nature contact. Such an interpretation is consistent with qualitative research indicating that clinicians’ engagement with nature-based interventions often stems from their own lifestyle and belief in the therapeutic effects of nature [22]. In this sense, psychiatrists may not only be recipients of scientific evidence but, based on their own observations, informal co-creators of this evidence.
The method adopted in our study – distributing surveys during psychiatric conferences – allowed us to avoid a situation in which an online questionnaire on the mental health benefits of contact with nature would be answered primarily by individuals already interested in the topic. Nevertheless, our study has certain limitations. Although it was conducted among psychiatrists whose participation was not influenced by the authors, only 193 out of 300 distributed surveys were completed and returned (64.3%). This suggests that the topic may not have generated interest among 35.7% of conference participants. Furthermore, it should be noted that individuals attending scientific conferences constitute a pre-selected population in terms of pursuing professional development. As such, they may possess a broader perspective on psychiatric treatment methods and may be more frequently exposed to innovative therapeutic approaches. Despite these limitations, our study may serve as a valuable baseline for future comparisons aimed at monitoring changes over time in psychiatrists’ awareness of nature-based approaches to mental health support, as well as in the recommendations they offer to their patients.

Conclusions

While most of the psychiatrists surveyed acknowledged the potential benefits of contact with nature for mental health, nearly two-thirds reported sporadic or rare exposure to scientific information on this topic.
A significant proportion of psychiatrists reported recommending contact with nature to their patients, primarily in the form of walks and trips to natural environments, despite having limited access to formal scientific literature on the subject.
Female psychiatrists and those with over 10 years’ experience were significantly more likely to frequently recommend nature contact, suggesting that both gender and clinical maturity play a role in shaping therapeutic choices.
Psychiatrists working in private practice reported greater exposure to scientific information about nature-based interventions than those working in hospitals or outpatient settings.
The findings highlight the necessity of integrating evidence-based information on nature-based interventions into psychiatric training and continuing education, with the aim of enhancing clinical confidence and reducing variability in practice.
This study may serve as a baseline for future research tracking changes in psychiatrists’ awareness of, attitudes towards, and clinical use of nature-based approaches to mental health over time.

Acknowledgements

The authors would like to express their sincere gratitude to the chairs of the scientific committees of the conferences at which the survey was conducted: Dr Piotr Wierzbinski, Chair of the Scientific Committee of the conference Psychiatry in Questions and Answers, and
Prof. Błażej Misiak, Chair of the Scientific Committee of the conference Psychiatry – A Case-Based Approach, for their kind support in facilitating the distribution of the questionnaires. Prof. Agata Szulc, Chair of the Scientific Committee of the Podlasie Psychiatric Workshops, is a co-author of the present study.

Disclosures

Financial support and sponsorship: none.
Institutional review board statement: none.
Conflicts of interest: none.

References