The study, conducted at the Azienda USL–IRCCS of Reggio Emilia and published in Supportive Care in Cancer, evaluated the UNAMANO project, a social-healthcare pathway developed in 2018 to address the work-related difficulties of cancer survivors living in the Province of Reggio Emilia. Rather than testing effectiveness, the researchers set out to answer a more fundamental question: is such a complex, individualized intervention actually deliverable in a real-world healthcare setting? Feasibility was measured through a series of concrete metrics, including the percentage of eligible patients invited to participate, the proportion who accepted, dropout rates, adherence to the intervention, satisfaction with the support received, and ultimately the rate of return to work.

The clinical rationale for the work is sobering. In Italy, 436,000 new cancer diagnoses were recorded in 2022, and breast cancer accounted for 13.2 percent of incident cases, with nearly half occurring in people of working age. Cancer survivors are 1.4 times more likely to be unemployed than healthy individuals, and while 73 percent of long-term survivors employed at diagnosis eventually return to work, that figure falls to 65 percent six years after diagnosis. Among breast cancer survivors specifically, return-to-work rates range from 56 to 88 percent. The obstacles are both physical and organizational: upper limb disability and lymphedema can make physically demanding tasks impossible, cancer-related fatigue and cognitive problems often prolong absences, and strenuous postures or shift work have been linked to a higher risk of never returning to work within two years of diagnosis.

Compounding these biological challenges is a communication gap within healthcare itself. Patients frequently hesitate to raise employment concerns with their oncologists, and clinicians tend to address work issues only when patients bring them up first. Yet survivors often need concrete information about employment rights, practical workplace accommodations, and emotional support as they navigate the transition from patient back to worker. Previous research has shown that multidisciplinary interventions combining vocational counseling, patient education, and physical exercise can enhance return to work compared with standard care, but these approaches must be adapted to local contexts and individual needs to be effective, a principle that shaped the design of the UNAMANO pathway.

The intervention itself is deliberately flexible. Participants can receive one or more of three types of support: information, occupational therapy, and social support, all provided free of charge. Occupational therapy, the most frequently delivered module, encompasses the collection of work needs, goal setting, and the definition of coping strategies agreed upon with the participant. The pathway also integrates with the broader supportive care services of the Reggio Emilia hospital network, including psycho-oncology, physical therapy, and nutritional support, allowing healthcare professionals to discuss cases and coordinate care across disciplines. Work-related difficulties were systematically categorized using the Core Set-VR-Onco, a checklist based on the World Health Organization’s International Classification of Functioning, Disability and Health that was recently adapted and validated for cancer survivors in the region.

Recruitment proved to be the study’s most instructive challenge. Of 85 working-age individuals with breast cancer recruited from a concurrent observational study, 32, or 37.6 percent, met the eligibility criteria and were invited to participate; half of those accepted and signed informed consent. Notably, no eligible patient who was merely referred to the UNAMANO project during a post-surgical educational session, without the deeper engagement of the observational study, ever contacted the service. The researchers interpret this as evidence that discussing work-related difficulties with healthcare professionals is itself a facilitating factor, and that passive referral may not be enough to connect patients with the support they need. Recruitment peaked at four months after surgery, while most work difficulties and study proposals emerged between seven and thirteen months post-surgery, suggesting that patients may be more receptive to vocational support once the acute phase of clinical recovery has passed.

Once enrolled, participants largely stayed the course. The overall dropout rate was 25 percent, with the highest single loss, 12.5 percent, occurring at baseline: one participant withdrew because of high emotional distress, and another declined to commit to another year of appointments after completing the observational study’s follow-up. Adherence to the intervention remained above 90 percent at the one- and three-month assessments, dipped to 75 percent at six months, and returned to nearly 90 percent at twelve months. Assessment appointments, initially conducted in person and averaging roughly 53 minutes at baseline, shifted steadily toward remote delivery at participants’ request, with nine of the eleven final participants opting for telephone follow-up by the study’s end, a pattern the authors note mirrors findings from a Scottish feasibility study where telephone appointments dominated.

The outcomes were encouraging. By the twelve-month assessment, ten of the eleven remaining participants had achieved work reintegration, whether by returning to their previous workplace or joining a different employer, and the same near-universal rate was observed at six months. Every participant assessed at the final timepoint reported being satisfied with the intervention, a result the researchers attribute in part to the continuous twelve-month follow-up, which continued regardless of employment status even after participants had returned to work. Interestingly, four participants were offered the option of organizing part of the intervention directly at their workplace, but none accepted, and some participants completed their intervention modules before the study formally ended because their needs had already been met, prompting the authors to suggest that future programs could define clearer criteria for concluding support.

The study population itself offers a portrait of the modern working cancer patient: all participants were women with a mean age of 50.7 years, most were private-sector employees with permanent contracts, and roughly two-thirds described their jobs as psychologically demanding while half reported physically demanding work. The authors are candid about the limitations. Recruitment drew exclusively from a cohort of patients who had undergone lymph node surgery and attended an educational session, excluding those with different prognoses and raising concerns about equitable access, particularly since only about 60 percent of eligible patients attend such sessions. The target sample size was not reached, and social desirability bias cannot be excluded, since the occupational therapist who delivered the intervention also conducted the follow-up assessments.

Nevertheless, the findings carry significant weight for the design of future cancer rehabilitation programs. The researchers argue that assessing work-related difficulties and delivering supportive interventions may be more appropriate several months after surgery rather than in the immediate postoperative period, when patients are focused on clinical recovery and prognosis. They call for further investigation of the occupational therapist’s role, which emerged as the backbone of the UNAMANO pathway, and for rigorous effectiveness trials of integrated approaches combining vocational interventions, physical exercise, and psychological support, not only for breast cancer but across cancer types. As survival rates continue to climb, the question is shifting from whether patients will live to how well they will live, and for millions of survivors, a meaningful answer must include the dignity and financial security of a working life restored.

Subject of Research: Feasibility of a multidisciplinary intervention to support return to work in working-age breast cancer patients

Article Title: A multidisciplinary intervention to support return to work of individuals with breast cancer: a prospective feasibility study

Article References: Paltrinieri, S., Braglia, L., Bravi, F., Fugazzaro, S., & Costi, S. (2026). A multidisciplinary intervention to support return to work of individuals with breast cancer: a prospective feasibility study. Supportive Care in Cancer, 34(10), Article 979. https://doi.org/10.1007/s00520-026-11198-5

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11198-5

Keywords: breast cancer, cancer survivors, return to work, occupational therapy, vocational rehabilitation, feasibility study, cancer rehabilitation, UNAMANO project, multidisciplinary intervention, supportive care, work-related difficulties, ICF framework

The Assessment of Work Performance, or AWP, was originally developed in Sweden and has now been translated into ten languages, with Finnish being the most recent addition. Unlike interview-based instruments, the AWP relies on direct observation. An occupational therapist watches a client carry out a real or simulated work task and rates fourteen distinct observable skills on a four-point scale, from incompetent to competent performance. These skills fall into three domains: motor skills such as mobility, coordination, and strength; process skills such as time management, planning, and adaptation; and communication and interaction skills such as social contact and information exchange. Crucially, the instrument is not tied to any particular diagnosis. Because it measures the interaction between person and environment, it can be applied to clients with mental health conditions, musculoskeletal problems, or any other work-related challenge, in genuine workplaces or constructed assessment settings.

In the new study, a team led by Jennie Nyman of Metropolia University of Applied Sciences, together with colleagues at Linköping University in Sweden, put the Finnish translation, the AWP-FI, through a demanding statistical technique known as Rasch analysis. Seventeen occupational therapists across Finland, all trained in a one-day session and two follow-up meetings, collected ninety-four assessments as part of their routine clinical work. The clients ranged from 18 to 60 years of age, and a majority of those with reported diagnoses had mental or behavioural disorders. Most assessments were conducted through direct observation, and the overwhelming majority, 84 percent, took place in simulated settings, with tasks such as book binding, household chores, and arranging and indexing magazines standing in for real jobs.

Rasch analysis is a form of modern psychometrics that converts ordinal rating-scale data into interval-level measurements. The method estimates two quantities simultaneously: the ability of each person and the difficulty of each item, placing both on a common scale. If the data behave as the model expects, the instrument can be said to measure a single coherent underlying trait, in this case work performance, in a way that is fair and comparable across individuals. The researchers structured their evaluation around three questions drawn from established psychometric guidance: whether the scale’s difficulty range matched the abilities of the sample, whether a reliable measurement scale had been constructed, and whether the individuals in the sample were being measured reliably and meaningfully.

The headline result was encouraging. The AWP-FI showed an overall fit to the Rasch model, with a non-significant chi-square test indicating that observed responses aligned well with model expectations. Individual items performed within acceptable statistical limits, and, importantly, no item behaved differently for different groups. Tests for differential item functioning, which detect whether an item is biased, for example by being harder for women than for men at the same underlying ability level, came back clean across gender, across direct versus participatory observation, and across simulated versus genuine work tasks. This stability suggests the Finnish instrument can be used confidently with men and women alike, in real workplaces or assessment laboratories, and whether the therapist watches from the side or joins the work activity as a participant.

The analysis was not without complications. Five of the fourteen items showed disordered thresholds, meaning that adjacent response categories were not being used in a consistent, ordered way. In practice, the middle rating of the four-point scale was rarely the most probable response for those items, likely because the observed clients clustered at similar performance levels and the full range of the scale was seldom used. The researchers collapsed the affected categories and reran the analysis, a standard corrective procedure, but they caution that any permanent change to the rating scale should wait for confirmation in larger and more varied samples.

Two deeper issues also emerged. First, targeting was suboptimal: the mean person location of 1.6 sat well above the item mean of zero, and the item difficulty range, spanning roughly from minus 1.3 to 0.9 on the logit scale, was narrow. In plain terms, the clients assessed were generally more capable than the hardest items could measure, leaving the scale without items at the demanding end of the work-performance continuum. The authors attribute this largely to the tasks chosen: most assessments used simulated, non-work-specific activities with relatively low demands. Their clinical recommendation is that assessors think carefully about task selection, since the nature and demands of the chosen task directly shape what the assessment can reveal. Adding harder items could widen the measure, but the authors urge caution, because new items must remain faithful to the instrument’s theoretical foundation in the Model of Human Occupation, and expanding item counts carries its own psychometric risks.

Second, the analysis flagged local dependency among items and indications of multidimensionality. Twenty-four of ninety-one residual correlations exceeded the statistical cut-off, and these correlations clustered neatly within the three AWP domains, suggesting that items within a domain share information beyond what the single underlying trait of work performance can explain. When the researchers compared person estimates derived from different domains, between 11 and 17 percent of respondents fell outside the range expected for a truly unidimensional scale, well above the 5 percent benchmark. Notably, this finding diverges from an earlier evaluation of the Swedish original, which found no multidimensionality. The authors suggest the clinical impact may be minimal, since the domain structure reflects the deliberate theoretical architecture of the Model of Human Occupation, but they recommend that future studies with larger samples apply multidimensional or testlet-based Rasch approaches to confirm the pattern.

On the reliability front, the news was solid. The person-separation index reached 0.83, comfortably above the 0.8 benchmark, indicating the scale can distinguish roughly three clinically meaningful groups of clients. Only four participants, about 4 percent, showed erratic response patterns outside acceptable fit limits, meaning nearly everyone was measured in a statistically coherent way. Taken together, the results provide an initial validation of the AWP-FI and support its use as a valid and reliable observational tool for assessing work performance in Finland, where the Finnish Institute for Health and Welfare has explicitly called for more reliable and valid vocational assessment practices. Used alongside the interview-based Worker Role Interview, whose Finnish version passed a similar evaluation in 2023, the AWP-FI can contribute to the kind of holistic, multi-source assessment that sickness insurance and vocational rehabilitation systems increasingly demand.

The study’s limitations are candidly acknowledged. The sample of ninety-four assessments is modest, the DIF analysis suffered from very unequal group sizes, with simulated tasks dominating at 84 percent, which raises the risk that genuine item bias could have gone undetected, and the narrow spread of client performance likely constrained several of the analyses. The authors therefore frame this as a first step rather than a final verdict, recommending further testing with larger and more diverse samples to resolve the local dependency and targeting issues. For clinicians, the practical message is immediate and actionable: the AWP-FI works, but its usefulness depends on choosing work tasks demanding enough to reveal the full range of a client’s capability, and on remembering that the fourteen observed skills are organised into three theoretically distinct domains that should inform, not obscure, the interpretation of results.

Subject of Research: Psychometric validation of the Finnish version of the Assessment of Work Performance using Rasch analysis

Article Title: Psychometric evaluation of the Finnish version of the Assessment of Work Performance (AWP-FI)

Article References: Nyman, J., Sandqvist, J., Pihlava, J., Ekbladh, E., & Yngve, M. (2025). Psychometric evaluation of the Finnish version of the Assessment of Work Performance (AWP-FI). Scandinavian Journal of Occupational Therapy, 32(1), Article 2555182. https://doi.org/10.1080/11038128.2025.2555182

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2555182

Keywords: psychometrics, Rasch analysis, occupational therapy, work ability, vocational rehabilitation, AWP-FI, construct validity, differential item functioning, Model of Human Occupation, Finland, assessment tools, work performance

The study, led by Jessica Vollertsen of Linköping University together with Mathilda Björk, Anna-Karin Norlin, and Elin Ekbladh, recruited 48 working-age individuals in Sweden who had experienced a stroke within the previous five years and who reported fatigue. All had been gainfully employed at the time of their stroke. The participants, 37 of whom were women, were interviewed using the Swedish version of the Worker Role Interview, a semi-structured assessment grounded in the Model of Human Occupation that rates sixteen psychosocial and environmental factors on a four-point scale indicating whether each item interferes with or supports return to work. A questionnaire adding demographic data, the Mental Fatigue Scale, and the Hospital Anxiety and Depression Scale completed the picture. Data were analysed with a qualitative abductive content analysis complemented by descriptive statistics, and the study was approved by the Swedish Ethical Review Authority.

The technical profile of the sample underscores why post-stroke fatigue deserves attention as an obstacle to employment. On the Mental Fatigue Scale, 89 percent of participants reported mental fatigue, most at moderate to severe levels, even though the majority did not show clinically significant depression or anxiety. At interview, 96 percent were employed, but only 15 percent were working full-time; 58 percent worked reduced part-time schedules of 25 to 75 percent, and 23 percent remained on full-time sick leave. The Worker Role Interview ratings revealed a telling pattern: the items most often rated as supportive of returning to work were enjoying work, appraising work expectations, and commitment to work, while perceptions of the work environment, expectations of job success, and pursuing interests were most often rated as interfering. In other words, motivation was rarely the problem. Capacity and context were.

The qualitative analysis produced two overarching categories. The first, re-evaluating work ability while experiencing fatigue, captures how participants confronted an altered, fluctuating capacity that often manifested through memory difficulties, impaired concentration and multitasking, and heightened stress sensitivity. This altered capacity maps onto disruptions in what occupational scientists call personal causation, the appraisal of one’s abilities and the confidence to use them effectively. Participants described learning to recognise early warning signs of fatigue, because ignoring them could trigger headaches, migraines, or exhaustion lasting from a single day to a full week. Crucially, because the impairment was largely invisible, participants struggled not to express their needs but to have them understood and regarded as legitimate by supervisors, co-workers, and external contacts such as customers. Concrete needs, like sensitivity to noise or light, were easier for employers to accommodate than task-related needs, which were frequently dismissed.

The social architecture of the workplace emerged as decisive. Supervisors who actively sought to understand the nature of fatigue were described as crucial, yet frequent leadership changes repeatedly forced participants to re-explain their condition, eroding continuity and trust. One participant recounted how a supportive supervisor had arranged adapted work tasks, only for the next supervisor to remove that possibility. Close working relationships with colleagues were especially valuable because familiar co-workers could notice subtle signs of fatigue and informally adjust workloads. Gradual return-to-work programs and work training helped participants understand their changed abilities, but several experienced an abrupt withdrawal of vocational rehabilitation support the moment they reached full-time hours. Some also reported external pressure from employers or the Social Insurance Agency to increase working hours prematurely, leading to relapses and renewed sick leave, an experience one participant described as being forced to crash three or four times to prove the limitations were real.

Outside the workplace, the study documented how everyday life shaped work ability in a continuous feedback loop. Fatigue left no buffer for unexpected events, so a child missing the school bus or misplaced keys could drain enough mental energy to derail an entire workday. Participants engineered elaborate routines, planning clothing the night before, using calendars and reminders, and keeping their homes meticulously organised, because, as one put it, a cluttered mind requires order and tidiness around it. All participants emphasised scheduling rest and recovery into their days, whether through sleeping, lying in a dark room, pausing during walks with a carried yoga mat, or retreating discreetly to restrooms at work. Remote work arrangements, accelerated by the COVID-19 pandemic, were welcomed because eliminating commutes and using home rest areas conserved scarce energy. Yet the researchers highlight a central paradox: structure and routine are the very strategies needed to manage fatigue, but fatigue itself makes those routines difficult to establish and maintain.

The second category, redefining identity in the context of everyday life, is arguably the study’s most striking contribution. Many participants had built careers around helping others and defined themselves through high performance, making it emotionally wrenching to reconcile current limitations with previous expectations. Family members, witnessing the toll of fatigue firsthand, often questioned whether participants should work full-time at all, fearing another stroke. Energy limits strained parental roles, with one mother describing how work overload left her without the energy to cook proper meals for her children, and reshaped spousal dynamics, sometimes producing closeness through emotional support and sometimes provoking worry about how long a partner would tolerate the changes. Deliberate occupational choices, such as moving closer to work or downsizing housing, conferred a sense of control, whereas giving up cherished social and physical activities was experienced as loss and grief. One participant captured the arc from mourning to acceptance with the phrase: this is the new me, Eva 2.0.

From a clinical standpoint, the authors argue that sustainable return to work cannot be achieved through rehabilitation that treats work in isolation. Because challenges at work and at home proved to be integral to the same adaptive process rather than parallel problems, they call for person-centred rehabilitation that integrates work and everyday life, supports the reconstruction of occupational identity, and enables engagement in meaningful activities despite fatigue. The findings align with the Action Plan for Stroke in Europe 2018 to 2030 and Sweden’s integrated care reform, both of which emphasise person-centred, preventive, and long-term support. The researchers also caution that previous studies have focused overwhelmingly on the binary outcome of whether people return to work, while the sustainability of that return over time has been comparatively neglected, leaving clinicians without evidence-based guidance for the long tail of recovery.

The study has limitations worth noting. Recruitment relied solely on Facebook groups for stroke survivors, which may have excluded marginalised populations and limits generalisability, and interviews were conducted by telephone without audio recordings, restricting verbatim analysis, a constraint the authors offset by conducting 48 interviews to ensure sufficient information power. The COVID-19 pandemic also overlapped with early data collection, although recruitment continued post-pandemic. Still, the scale and depth of the qualitative dataset make this one of the richest accounts to date of how fatigue reshapes working life after stroke. The message for employers is concrete: flexible task and schedule adjustments, consistent supervisory relationships, systematic information about post-stroke fatigue, and continued individualised follow-up beyond the return to full-time hours are not accommodations of convenience but prerequisites for keeping skilled people in the workforce. For clinicians, the message is equally clear: supporting someone back to work after stroke means treating the return not as an event to be achieved, but as an ongoing negotiation between a changed self and a demanding everyday life, one in which identity, not just capacity, must be given time to heal.

Subject of Research: How post-stroke fatigue affects sustainable return to work among working-age stroke survivors

Article Title: Return to work with fatigue after stroke: A complex occupational adaptation process

Article References: Vollertsen, J., Björk, M., Norlin, A.-K., & Ekbladh, E. (2025). Return to work with fatigue after stroke: A complex occupational adaptation process. Scandinavian Journal of Occupational Therapy, 32(1), 1-13. https://doi.org/10.1080/11038128.2026.2613621

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2613621

Keywords: post-stroke fatigue, return to work, stroke rehabilitation, occupational therapy, occupational identity, Worker Role Interview, Model of Human Occupation, vocational rehabilitation, mental fatigue, workplace accommodation, everyday life, person-centred care

The study was carried out by Harpa Lind Kristjánsdóttir of the Vocational Rehabilitation Center of the Westfjords, Sigrún Siguröardóttir of the University of Akureyri, and Anna María Pálsdóttir of the Swedish University of Agricultural Sciences in Alnarp. Their goal was practical: to find out which nature-assisted activities participants actually experienced as meaningful and psychologically rewarding, so that the rehabilitation centre could extend and improve the program it offers to clients working toward a return to work or education.

The scientific rationale rests on a substantial body of research showing that nature acts as a salutogenic factor, meaning it actively contributes to health and well-being rather than merely avoiding disease. Both passive exposure to natural environments, such as simply being in a green space, and active engagement, such as gardening or hiking, have been linked to improved mental health. Nature-based interventions have shown particular promise for people with depression, anxiety, and stress-related conditions, and previous Swedish studies have found that longer nature-based rehabilitation may contribute to a faster return to work. Yet, despite this international evidence base, no studies had examined nature-assisted occupations specifically within the Icelandic vocational rehabilitation context, where the landscape, climate, and culture differ markedly from the settings of earlier research.

To fill that gap, the team used a mixed-method convergent longitudinal design over one year. Eleven participants, three men and eight women aged 29 to 53 with an average age of 42, were recruited from the rehabilitation centre and took part in voluntary two-hour nature sessions each week as an add-on to their ongoing rehabilitation. Participation periods ranged from four to eleven months, averaging seven months. The activities fell into five categories: outdoor play, foraging in nature, adventure activities, outdoor gardening, and indoor gardening. Crucially, the sessions were deliberately unstructured. No goals were set for completing work, participants were free to quit mid-task, and they were even encouraged to stop without finishing projects they had started, a design choice intended to relieve the performance pressure that many people with stress-related difficulties find debilitating.

The activity calendar tracked the rhythms of the Icelandic year. In winter, participants built snow sculptures and snowmen, made snow angels, and sledged down mountainsides, carrying their sledges back up repeatedly despite fatigue. In late June they picked herbs that were dried and brewed into tea; in August they gathered bilberries eaten with cream; in October they harvested Icelandic moss, later boiled in milk as a nourishing drink; and in November, timed carefully around low tide, they collected dulse seaweed that was rinsed, baked, and eaten as a snack. Cones, birch branches, heather, and moss gathered in early November became Christmas decorations in December. Spring brought a guided kayak trip from the local sailing club, and autumn a mountain hike along a gentle marked path to a viewpoint. Outdoor gardening ran from May to September in a 300-square-metre garden beside the centre, while indoor gardening, including sowing, repotting, and propagating plants under vegetation lights, continued year-round.

Quantitatively, the researchers used the Meaningful and Psychologically Rewarding Occupation Rating Scale, a validated instrument in which participants rate how well descriptors such as fun, boring, physically stimulating, mentally stimulating, connecting, and isolating apply to each activity on a scale from one to seven. A calculation method converts these ratings into scores for meaningfulness and psychological reward, each ranging from six to 42, with higher numbers indicating greater meaning or reward. The results were striking: every activity category scored above 30, and the two factors showed a strong positive correlation of 0.92, meaning that activities participants found meaningful were almost invariably the ones they found psychologically rewarding. Adventure activities, outdoor gardening, and outdoor play ranked highest, while foraging and indoor gardening, though still rated positively, came in lower.

The qualitative half of the study, based on a focus group interview with six of the eleven participants supported by photographs, videos, and field notes, explained why. Participants described outdoor play as something they had never considered or dared to do alone, with one remarking that it had not occurred to them to go sledging since childhood. The laughter and joy kept people going despite exhaustion, and for some the physical challenge stirred both sadness over their limitations and a sincere desire to improve. Others initially dismissed play as purposeless, only to conclude that perhaps doing something purely fun was exactly what they needed. Foraging, by contrast, produced a state of absorption and mindfulness, as participants learned to see what had been invisible to them, suddenly noticing cones or moss everywhere once they knew where to look.

The adventure activities generated the most dramatic emotional accounts. None of the participants had ever kayaked before, and one capsized after only fifteen to twenty minutes at sea, later describing the experience as passing through all the emotional realms: the excitement of trying the kayak, an indescribable feeling of freedom alone on the still sea, fear at falling into the water, relief at being rescued by the guide, and pleasure at having achieved it all. On the hike, one participant said he had overcome an invisible hurdle and now knew he could hike in the mountains again by himself. Outdoor gardening gave participants the satisfaction of real tasks that mattered and visible results, while indoor gardening offered the best opportunities for social connection and, for several, sparked a lasting interest in growing plants at home, with one participant reporting that she grew basil on her kitchen windowsill the following summer.

The authors interpret the findings through the lens of occupational science and the theory of occupational values, which distinguishes concrete value tied to results, symbolic value tied to personal and cultural meaning, and self-rewarding value found in the pleasure of performing an activity itself. The three highest-rated categories all took place entirely outdoors in natural settings, which the researchers believe acted as a supportive factor throughout the rehabilitation process, consistent with earlier findings that natural environments support clients across all phases of recovery. Equally important was the absence of performance pressure: participants could stop when they had had enough, and the outdoors even allowed them to step back from the group and work independently. The lower ratings for foraging and indoor gardening may reflect their result-oriented structure, since foraging sessions typically ended with a harvest or product, and indoor activities required cleanup and lacked fresh air, daylight, and the sense of freedom outside walls.

The study’s conclusion is that engagement in enjoyable, flexible, nature-based outdoor occupations supports psychological recovery and well-being in vocational rehabilitation settings, and that personally meaningful, low-pressure nature-assisted occupations deserve a permanent place in such programs. The findings also point to long-term effects: many participants continued nature-based activities on their own after the program ended, echoing earlier research showing that people find ways to incorporate nature into their lives and keep doing so after rehabilitation concludes. The authors caution that this was a feasibility study with a small sample, no specific target group, and a possible selection bias toward people already interested in nature, so the results reflect participants’ experiences of the activities rather than measured health outcomes. Even so, the work provides a concrete foundation for building nature-assisted rehabilitation programs in Iceland and for future studies targeting the needs of different user groups in vocational rehabilitation, suggesting that sometimes the most therapeutic prescription is permission to play, explore, and grow in the open air.

Subject of Research: Participants' experiences of meaningful and psychologically rewarding nature-assisted occupations within vocational rehabilitation in Iceland

Article Title: Meaningful and psychologically rewarding nature-assisted occupations – A feasibility study for improving alternatives in vocational rehabilitation in Iceland

Article References: Kristjánsdóttir, H. L., Siguröardóttir, S., & Pálsdóttir, A. M. (2025). Meaningful and psychologically rewarding nature-assisted occupations – A feasibility study for improving alternatives in vocational rehabilitation in Iceland. Scandinavian Journal of Occupational Therapy, 32(1), 1-14. https://doi.org/10.1080/11038128.2026.2633053

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2633053

Keywords: nature-assisted activities, vocational rehabilitation, occupational therapy, nature-based interventions, mental health, well-being, Iceland, adventure activities, gardening, stress recovery, meaningful occupation, feasibility study

The research, conducted by Amanda Susan Philip, Shalini Quadros, and Vinita A. Acharya of the Department of Occupational Therapy at Manipal College of Health Professions, Manipal Academy of Higher Education, was published in BMC Health Services Research. The team set out to explore the lived experiences of occupational therapists who conduct work skill assessments, often abbreviated WSAs, for individuals with mental illness. A WSA evaluates a person’s abilities, skills, values, and interests for employment using a range of tools and techniques, and for therapists working in mental health it serves a dual purpose: determining readiness for employment and guiding the design of intervention plans that can bridge the gap between clinical progress and workplace demands.

Methodologically, the study employed a qualitative phenomenological design, an approach that seeks to capture the essence of a lived experience as described by the people who live it. Twelve occupational therapists participated, and their accounts were analyzed using thematic analysis, a technique in which researchers systematically code interview data and distill it into recurring patterns of meaning. From this process, three major themes emerged: familiarity guided practice, unseen pitfalls, and moving towards awareness. Together, these themes sketch a portrait of a professional community that has learned to improvise in the face of structural gaps, and that is only now beginning to recognize and articulate the limits of its own methods.

The first theme, familiarity guided practice, describes how therapists lean heavily on the tools, frameworks, and routines they know best. Rather than drawing from a validated battery of vocation-specific instruments, clinicians reported adapting whatever was at hand, including measures designed for other purposes such as the Canadian Occupational Performance Measure, functional capacity evaluations, and assessments of activities of daily living. This adaptive, almost artisanal approach allows therapists to piece together a picture of a client’s work readiness, but it also means that the quality and comparability of assessments can vary dramatically from one clinician, clinic, or region to the next. Two clients with similar presentations may receive very different readiness judgments depending on which therapist evaluates them and which tools that therapist happens to favor.

The second theme, unseen pitfalls, captures the hazards embedded in this improvisational system. Without standardized assessments, therapists risk overlooking critical dimensions of work performance, such as the cognitive and social stamina required to sustain a full shift, the ability to respond to supervisor feedback, or the tolerance for the sensory and interpersonal demands of specific workplaces. The study also points to a deeper structural problem: many assessments are conducted in clinical settings that bear little resemblance to actual work environments. A clinic-based simulation can measure task accuracy, but it cannot reproduce the unpredictability of a busy workplace, the pressure of deadlines, or the subtle social negotiations that determine whether a person with mental illness can maintain a job over time. The absence of institutional support, including dedicated time, funding, and vocational infrastructure, compounds these blind spots.

The third theme, moving towards awareness, suggests that the profession is not standing still. Therapists in the study described a growing consciousness of the possibilities and limitations of current WSA practices, an emerging recognition that creative tool modification, however valuable, is not a substitute for validated, context-appropriate assessment methods. This awareness, the authors suggest, is a necessary first step toward reform. It opens the door to developing standardized protocols suited to the Indian context, building partnerships with employers to create authentic evaluation settings, and advocating for the institutional support that would allow therapists to conduct thorough, ecologically valid assessments rather than hurried clinical approximations.

The technical significance of these findings extends beyond occupational therapy. Vocational rehabilitation for people with severe mental illness is a cornerstone of community-based mental health care, and the accuracy of work readiness assessments directly shapes whether clients are placed in jobs they can sustain, referred to further skills training, or prematurely labeled as unable to work. When assessment practices rest on unstandardized, individually modified tools, the entire chain of vocational decision-making inherits that uncertainty. The Manipal study provides qualitative evidence for what many clinicians have long suspected: the field’s assessment infrastructure has not kept pace with its clinical ambitions, particularly in low- and middle-income countries where formal supported-employment systems are still maturing.

The study also carries practical implications for health service planners. If therapists lack access to real-world settings for evaluation, health systems could invest in vocational simulation spaces, workplace partnerships, and supported employment programs such as individual placement and support models, which emphasize placing clients in competitive jobs and providing on-site assessment and coaching. Standardized WSA protocols, developed and validated for local labor markets and cultural contexts, would allow therapists to benchmark client performance against meaningful criteria and to communicate findings to employers, families, and interdisciplinary teams in a shared professional language. Training curricula could likewise incorporate explicit instruction in vocational assessment, ensuring that new graduates enter practice with a repertoire that goes beyond improvised adaptation.

For the therapists themselves, the study validates a difficult professional reality. These are clinicians who, in the absence of perfect instruments, have become expert modifiers, stitching together assessments from fragments of standardized measures, observation, and clinical rapport. Their creativity is a strength, but the research makes clear that it should not be the system’s permanent foundation. The findings emphasize both the possibilities and limitations of current work skill assessment practices: therapists use and modify tools creatively, but the lack of standardized assessments, institutional support, and access to real-world settings hinders accurate evaluation of clients’ work abilities. Closing that gap, the authors argue, is essential if occupational therapy is to fulfill its promise of helping people with mental illness not just imagine employment, but achieve and sustain it.

As mental health systems worldwide increasingly recognize work as a health outcome in its own right, studies like this one offer a grounded, clinician-centered view of where practice stands today. The voices of twelve occupational therapists in India reveal a field in transition, aware of its constraints and beginning to chart a path toward more rigorous, more authentic, and ultimately more equitable vocational assessment for one of the most underserved populations in health care.

Subject of Research: Occupational therapists' lived experiences in assessing work skills of people with mental illness in India

Article Title: The lived experiences of occupational therapists in assessing work skills of people with mental illness

Article References: Susan Philip, A., Quadros, S., & Acharya, V. A. (2026). The lived experiences of occupational therapists in assessing work skills of people with mental illness. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15584-x

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15584-x

Keywords: occupational therapy, work skill assessment, mental illness, mental health, vocational rehabilitation, qualitative research, phenomenology, thematic analysis, employment, psychological assessment, health services research, India