Abstract
Green Care is an international concept, where utilization of agricultural farms is a base for promoting human mental and physical health, as well as quality of life for a variety of client groups. The purpose of this study was to improve knowledge and understanding of opportunities and difficulties faced by providers of Green Care services, and to discuss the role of being a Green Care service provider. Data were collected by three qualitative multi-stage focus group interviews with seven providers of Green Care services (five women, two men). The findings indicated that running Green Care services means different kinds of challenges such as low predictability and complicated cooperation with authorities and stakeholders. Efforts toward increased quality assurance are regarded positive. Being a Green Care service provider means that the farmer’s function is extended, that is, by shaping a therapeutic environment and being a role model, which takes a genuine interest and belief in the idea of Green Care, and ability to think creatively and innovatively. To watch the users grow as persons and master new tasks is rewarding to the service provider. Providers of Green Care Services have to face different and sometimes incompatible social worlds. Their role is sometimes indistinct and they find themselves in a border position. Perhaps some of the potential in Green Care will get lost with a more professionalized provider role.
Introduction
Green Care is a well-known international concept, defined as “utilization of agricultural farms—the animals, the plants, the garden, the forest, and the landscape—as a base for promoting human mental and physical health, as well as quality of life for a variety of client groups” (de Vries, 2006, p. 1). It is an active and partaking process aiming at improving health (physical and mental) and well-being—it is not about experiencing nature in a passive manner. Green Care is a way for farmers to find new opportunities for their business and also to contribute to the development of rural areas. Despite substantial development and positive interest from various actors in many countries, including Norway, there are still many problems, of which some are addressed by Vik and Farstad (2009). They believe that the development of Green Care has stagnated: For Green Care to be a useful supplement to the existing health services there is a clear need to develop a proper understanding of the barriers to the development of Green Care. For the agricultural sector, which is in constant need of appropriate fields for farm diversification, improved knowledge of the limits and possibilities of Green Care services is vital. (p. 541)
Vik and Farstad (2009) see it as a problem that communication between the different “social worlds” that are involved in Green Care is inadequate. Users, providers, and government agencies on different levels are the most important of these “social worlds,” or stakeholders. A qualitative study of the interaction between farmers and local authorities, from an organizational psychological perspective, has found that the collaboration is characterized by a lack of common understanding of Green Care as a phenomenon, which hinders beneficial cooperation, and thus compromises further development of Green Care (Gjerstad, 2010). These obstacles may affect the users of Green Care as well. A person with mental health problems, for instance, is more than just his suffering; he needs to be supported by a coordinated system of actors that work together and “speak the same language,” so that his needs, desires, and ambitions that extend beyond just symptom relief can be taken care of (Anthony, 1993; Davidson, O’Connell, Tondora, Lawless, & Evans, 2005). Then, the key question is, “What combination of treatment and support is required for this person to fully participate in community life?” (Davidson et al., 2005, p. 486). Green Care can respond to this question by supporting the individuals’ different and personal needs, not focusing entirely on the symptoms and diagnoses (Granerud & Eriksson, 2014).
Green Care—A Developing Field
Green Care as a movement is increasing in several European countries (Hassink & Van Dijk, 2005) and includes various forms of therapeutic activities such as gardening therapy, animal-assisted therapy, or using nature or the farm and farm work to achieve benefits in health, learning, or social skills (Sempik, Hine, & Wilcox, 2010). Users of Green Care can work without feeling pressured, which offers an opportunity for development and coping with various tasks that are adjusted to their functional level and current condition. Users can participate in meaningful activities and productive work and activities that have a lot in common with a regular job, with structure, physical activity, and belonging to a social community (Granerud & Eriksson, 2014; Irvine & Warber, 2002; Sempik et al., 2010). The main focus of research in the area of Green Care services has been on their therapeutic importance and on the participants’ experiences. However, it has been difficult to measure the isolated effects of Green Care (Berget, 2006). Research shows general positive changes with regard to physical health, stress reduction, self-confidence, the ability to deal with problems, taking responsibility, experiencing meaningfulness, and the improvement of social skills (Hassink & van dijk, 2005; Haubenhofer, Elings, Hassink, & Hine, 2010; Irvine & Warber, 2002; Kaplan, 1995; O’Brian & Murray, 2007; Sempik et al., 2010). Being in nature has its own recreational effect, and experiences in nature seem closely linked to aesthetic factors that provide pleasurable experiences, which further stimulate a person’s functioning (Berget, Ekeberg, & Braastad, 2008). Among people with mental illness, or people with substance-abuse problems, participating in Green Care services, research shows that the participants got a better structure in everyday life, felt social belonging to a group, and appreciated the opportunity to participate in meaningful activities (Elings & Hassink, 2008; Granerud & Eriksson, 2014). Research on Green Care might be considered part of the research in the health and caring sector. Health and social care in Norway is run by the state and the municipalities. The services are free of charge, and people who are unable to work receive a pension through the social security system. The municipalities and the state can buy health and social services from private providers. The farms that are owned and operated by the farmers themselves can get time-limited contracts with municipalities to carry out rehabilitation activities, such as Green care, on their farms.
In Norway, work is underway to create quality systems, standards, and a unified organization of businesses in Green Care, partly by means of a special trademark—Into the Farmyard (in Norwegian: Inn På Tunet [IPT]). This is important for the providers, and they are in a special situation being outside the health and social care system.
The knowledge of the provider’s experience is still too narrow. This article presents an empirical study from the perspective of providers in eastern Norway that offer Green Care activities for people with mental health problems or substance-abuse problems. The aim is to contribute to improved knowledge and understanding of the opportunities and difficulties that come with being a Green Care provider, thereby overcoming some of the barriers that Vik and Farstad (2009) highlight. The intention is also to discuss the provider’s role, a position along borders in various respects. 1
Material and Method
In this explorative-descriptive qualitative study, the data were collected by means of three multi-stage focus group interviews (Hummelvoll, 2008) —characterized by explorative, knowledge-focused dialogues around themes that are close to the participants’ experiences, bringing up as many different points of view as possible (Kitzinger, 1994).
The providers were recruited through mailing lists of farms offering Green Care. Forty invitations were sent out by mail and email addresses that providers had entered as contact information. However, due to changed conditions in their services, long travel distances, and heavy workloads, as many as 33 of the invited service providers declined to participate. According to Hønsen (2005), the majority of service providers of Green Care services (63.4%) are women, which was demonstrated in this study as well: Five of seven informants were women. The informants, aged 32 to 50, all with 4 to 10 years of experience in running Green Care services, were representing a large geographical area in east Norway. The farms were ordinary operation farms. Some farms were of medium size, others were small farms. They were running a number of different Green Care activities, such as life skills training, offering foster care for children or adolescents, school-training, or self-produced packages on how to take care of animals, or actively being in nature. As the activity was multi-faceted, there were also large differences in the number of users who were present every day. It ranged between 5 and 20 per day on each farm. The informants had Green Care activities 4 days a week.
Multi-stage focus groups mean that more or less the same group meets on more than one occasion, which encourages deepened, common reflection on the issues discussed (Granerud & Severinsson, 2007; Hummelvoll, 2008). The participants become better acquainted and develop more confidence in each other, which makes it easier for them to share stories and experiences. New viewpoints develop over time, and the group’s internal life becomes richer (Granerud, 2008; Morgan, 1997; Thornton, 2002).
The themes for the interviews were focused on the role of being a service provider of Green Care services, its complications, possibilities, and needs for improvement. At the beginning of each interview—apart from the first one—a summary of the previous interview was presented by the moderator. Two researchers from the research group—a moderator (the first author) and a comoderator (one of the other authors) —led the interviews, which lasted from 60 to 90 min. The moderators were totally independent and do not participate in Green Care activities. The number of participants varied from 3 to 5 in each interview, with altogether 12 interview participations.
The data were analyzed by means of a qualitative content analysis (Denzin & Lincoln, 2011), adopting the following stages, inspired by Graneheim and Lundman (2004): (a) After being transcribed verbatim, all interviews were repeatedly read through. (b) Codes and analytical traces were identified. (c) Statements from the interviews were systematized by collecting those that seemed to belong to the respective code. (d) Categories and sub-categories were subsequently identified and labeled. (e) The contents within each category were made clear and again validated against the raw data. Significant statements were identified and contributed to this validation; some of them are used as quotations in the result presentation. The analysis was led by the first author, in cooperation with the third author. All authors read the material, reflected over, and suggested changes to the analysis to strengthen validity, contributing to a deeper review of the categories.
Participation was voluntary and based on informed written consent. Service providers of Green Care services are not regarded as a vulnerable group, and the interviews did not have a sensitive character. Focus group interviews are regarded as a lenient form of data collection for the informants (Granerud & Severinsson, 2007). In Norway, it is not necessary to apply to an ethics committee when research participants are professionals. Approval for the study was granted by the managers of IPT. The Declaration of Helsinki guidelines were taken into account (World Medical Association, 2013).
Results
The analysis resulted in 5 categories and 15 sub-categories, disclosing both difficulties and opportunities in being a Green Care service provider, and also the providers’ motivations. “Challenging working conditions and an unpredictable economy” and “The need for quality control and follow-ups” describe difficulties and challenges, whereas “Creative thinking as a strength” shows both difficulties in the field and what the providers see as opportunities. “Genuine green driving force” and “The farmers extended function” highlight opportunities and potential for growth in Green Care services, according to the service providers.
The categories and sub-categories in Table 1 are described below and illustrated with quotations.
Categories and Sub-Categories Showing Opportunities and Difficulties in Norwegian Green Care, and Characterizing the Role of Service Providers.
Challenging Working Conditions and an Unpredictable Economy
The service providers had multiple challenges in their work. It was difficult to achieve a good flow in the cooperation with the different stakeholders in public health care systems, school systems, and in the municipalities. The work could be both physically and mentally demanding, with the added insecurity of unpredictable financing due to short-term funding agreements.
Low predictability and lack of flow
Because of uncertain funding in the yearly budgets, local authorities and schools would not enter into long-term contracts with the providers. Most of the providers had 1-year contracts; some only 3-month contracts, which created great uncertainty. Another downside was the distress when popular and well-functioning projects were closed because the funding from the local authorities was terminated. The provider’s workload therefore fluctuated widely: One year I had an income of one and a half million (NOK), and last year I had a personal income of approximately 104,000 (NOK).
Another grievance was the lack of long-term thinking. The providers felt that alongside with initiating a project, the responsibility for the users who participated persisted. The users’ processes of change took time, and this factor should have been considered when a project was at the stage of planning.
The project managers believe that a three-month offer will change life dramatically when people have struggled for years; that’s being naive. When you start a project where people participate, you should in advance have thought about how long such a project should be going on. But they don’t do that.
Complicated cooperation with stakeholders
In Norway, it was a requirement from NAV
2
that only providers and up-and-running farms can offer Green Care services. This meant that providers had to do the work that came with farming and having live animals, in addition to taking care of the users. Although they were passionate about helping users, they were frustrated when it came to cooperating with public health services, such as the NAV, the municipalities, and mediating agencies. Mediating agencies took 20% to 30% of the providers’ income. The providers felt that this system was straining their resources as well as being cumbersome. The providers claimed that having direct contacts with NAV would have been easier than directing users through these intermediaries. All the forms that had to be completed and submitted were perceived as pointless bureaucracy that took up too much time and could be simplified: I’m a little stubborn when it comes to this point. The person, patient, user, call him whatever you like, has completely disappeared! He’s just a little sentence at the bottom of the paper, and the rest is all organization and red-tape!
As each county and municipality implemented Green Care differently, it also varied how well the system worked. The providers felt that when the politicians understood the importance and impact of Green Care, they prioritized it in the budgets. In municipalities where local politicians in key positions were also farmers, Green Care was implemented to a far greater extent: I think it depends greatly on the executive officers and what municipality you live in, who you run into, and if IPT (Norwegian Green Care organization) is anchored all the way up to the councillor. In some places it is like that you know. You can see that in some places it really works.
A demanding job for the providers
In addition to the cumbersome bureaucracy and a lack of predictability, it could also be demanding to have users with different needs on the farm. The provider had to be very positive and attentive, “make it playful,” and make all users feel like they had been seen. The providers had great pleasure in taking part in the users’ progress, and they really cared about the users who came. In addition, it was up to the providers to market their own services to NAV and the municipalities, and they often struggled to enlist enough users. “We contacted them; it’s always like that . . . You have to sell your own products. That’s the way it is for everyone in this business!”
The Need for Quality Control and Follow-Ups
As Green Care grew larger in Norway, the need for standardized operations and implementing systems for quality control arose. The service providers welcomed improvements in the quality control systems, but they also pointed out disadvantages that still needed improvement. Aftercare for the users was not standardized or even mandatory, and the providers wished for less bureaucracy.
A new standard in Norwegian Green Care
When Green Care in Norway came under a protected logo and the trademark Into the Farmyard (IPT in Norwegian) thus was introduced, stringent requirements for quality control were put on the providers. This generated a higher workload for the providers, as they now needed to cooperate with mediating agencies and meet the agencies’ standards for safety and quality control. However, the providers said that they had strong interests in improving Green Care, so that only those who run IPT in a serious manner would be included in the Norwegian Green Care network (IPT). They wanted to secure IPT a reputation as being a serious and well-functioning system, in the hope that the different stakeholders would come around and use the services more frequently and on a wider scale.
Those who are serious about this enlist in the network and take the required courses, and this way you weed out those who aren’t serious. It used to have a bad reputation.
Green Care providers as a new professional group
With the new requirements for quality control standards, the providers regarded themselves as a new professional group. They started to educate themselves to gain the necessary skills to work as a provider. All of the informants said they had taken various courses and training; that is, college education in Green Care; therapy riding as well as having participated in Innovation Norway’s School of Entrepreneurship. The providers wanted the effects of Green Care to be documented, because they saw that it was helpful to users, and they wanted to be able to show the different stakeholders the documented effects of Green Care. They emphasized the importance of getting guidance for their own development. The provider’s job could be tough, and guidance could help them to be able to stay in the job over time: I’ve had supervision once a week for the past 7-8 years. It’s very important to me, because it’s a lonely job. . . . I don’t know if I would have been able to keep up the job if I hadn’t had that opportunity.
Lack of aftercare—A large grievance
The providers called for a drastic change in aftercare, which they said was sometimes non-existing. Because the users all had different needs, it was impossible to standardize what aftercare should be. Some suggestions included a mentoring system where the most experienced users stayed on to take care of the newcomers. Another solution was to keep users living on the farm a while after they have found another job, to keep a more fluent transition and thus stabilizing into their new life. Their main goal was to create a safe environment for the user, so that positive change could happen.
Users who came from rehabilitation clinics often continued using drugs. The providers thought that this was due to poor (or complete lack of) aftercare. The providers were keen to spark an interest in outdoor life and nature, to give them inspiration to stay drug free and to live a more constructive life. The providers claimed that if the users had frequent contacts with providers or other key persons, it would help them staying sober. Because the users often had small networks, it was important that they had someone who cared about them, like the providers: We have to be flexible with these people. I don’t think we can just start a project and then just stop abruptly. They become a part of us!
Creative Thinking as a Strength
The service providers demonstrated a genuine ability to think creatively and find new ways of solving challenges. This could be seen in how they met challenges in running their services and in ideas on how to cooperate with different stakeholders. They also saw preventive work as an important part of Green Care’s potential.
A variety of activities creates dynamic farms
The providers ran their farms creatively in what activities they offered and in ideas about how to solve Green Care’s problems. They worked hard and were good at “think outside the box” and seeing various solutions related to problems in cooperation with stakeholders and economics. Although the short-term work contracts were problematic to the providers, they also saw it as a springboard for starting up new things: I think it opens up new opportunities, and you need to jump on board before the train leaves. You constantly have to keep track of and be active yourself; nothing will just fall into your lap.
The providers claimed that it was vital that they could offer various services or activities. The farm seemed more dynamic and lively when there were different things going on, and the users were constantly challenged in new arenas.
A need for different organization and collaboration
As the bureaucracy, red-tape, and cooperation with other agencies caused frustration, the providers called for a modernization of the Green Care organization to make it clearer and more straightforward for the case managers. They wished to make it easier to link the individual user to a suitable offer and suggested distribution of information pamphlets that included what the different providers’ offers entailed. This way the providers would not need to advertise their own business constantly. In Norway, the schools receive extra funding for children with special needs. The providers suggested that some of this funding should be used in Green Care, for instance, by sending these children into Green Care interventions with an assistant, instead of putting the assistant into the classroom: I think it’s a question of money, because they (the authorities) are well aware that Green Care exists! Many schools have experiences of it, but it depends on the funding. It’s up to the politicians. You need to establish it within the higher ranks in politics, so that they see that it’s possible to rearrange some of the money funding. . . . They should realize that it’s important, that it’s valuable!
A great need for preventive work
The providers were eager to use Green Care as a preventive measure in both psychiatric care and for adolescents in danger of dropping out of school. For young adolescents with learning disabilities in danger of dropping out, they asked for more cooperation between the stakeholders to come up with creative solutions to the problem: Then we could start doing some preventive work to help this person out of a difficult life now, instead of repairing the damage when he’s 20-30-40 years old.
The providers thought that Green Care could give meaningful experiences and help both groups learning new coping skills such as routines and structure. They felt that it could give meaningful additions to the institutional treatment for psychiatric patients but also prevent recidivism: Being able to do something meaningful, especially being with animals, it means so much to them. They become so attached to the animals. Just to have something to look forward to helps them to get up in the morning. That’s the first step: getting outdoors. And then you can start more long-term thinking about work and school.
Genuine Green Driving Force
A genuine engagement and belief in the concept of Green Care characterized the service providers. This engagement in combination with the users’ very evident changes, and all the proofs of the users’ appreciation, constituted a strong driving force for the providers.
Believing in the effects of Green Care
According to the providers, the right intentions were needed to be a Green Care service provider, because they work with vulnerable people. It would soon be discovered if the provider’s commitment was not genuine. It could seem as if it was necessary to have an honest genuine conviction and optimism about being a provider to be able to stand the rigors the job entailed. Even though users made great progress, the providers experienced that many fell back into substance abuse when their time in Green Care was over. The belief in the effect of Green Care was therefore paramount to the providers: You have to engage in these people, to be able to give them the services they need, in order for this to be successful . . . You can’t do that if you only think about money.
The providers did not set requirements for what the users should accomplish while on the farm. Their attitude was that all progress is good progress, and sometimes the difference is measurable: Even if they can’t do regular work, they can still get a higher quality of life. Some have almost completely stopped taking medication, some managed to take a driver’s license and have a small part-time job.
Green care provides unique opportunities for growth and recovery
The providers saw tremendous changes in the users. Obsessive compulsive behavior was often reduced or even totally disappeared. They stressed the importance of chasing away bad thoughts with physical labor. The providers also believed that it was meaningful for the users to feel a sense of belonging and being part of a social community. They stressed the fact that the users were not just stored on the farm; they had a real job to do there: There are real tasks that need to be done, it’s not like “we’ve set up something here to keep you occupied today.” The animals need feeding, it needs to be done in this manner, it’s important that you are present, you have a role here and you are important.
The providers thought it was important for the users to learn about responsibility, because it is an important coping skill and it builds confidence. The providers raised the users’ responsibility by delegating increasingly demanding work tasks or letting them care for live animals. To be in contact with animals also helped users move the focus away from themselves and their troubles. According to the providers, the animals were one of the truly healing powers of Green Care: We had a boy who was placed in foster care, who had his school day with us on the farm. It was in the middle of the lambing season, and the pupils get an assignment where they have to take the lamb away from its mother and place it in a different bin. This boy took the lamb in his lap and explained “You can’t stay with your mummy, you see.” He was telling this lamb his own story! I just stood there, tears flowing. It was so intense! It was pure therapy, how he was working through his own story with this lamb.
Valuable feedbacks
Being a provider in Green Care services was described as an intense job, where he or she needed to attend to each individual user and their very different needs. It was important to have the ability to be flexible and quickly adapt when things did not work out as planned. At the same time, the providers felt that the job was inspiring and rewarding: It’s the flexibility that lies within this system that makes us able to work this way, and there is a lot of positive feedback on that.
The providers said that they received great feedback when they had users on the farm who came from rehab institutions. The personnel in the institution had claimed that the users slept better when they had been at the farm. They also heard users saying that being on the farm was the highlight of their week and that they greatly appreciated going horseback riding and being out in nature: That’s the only thing they looked forward to all week, to come back to the farm. Well, if you don’t feel humbled by that, I don’t know . . . The gratitude they show. . . . Everyday someone takes you by the hand to say thanks, and they’re so happy to be part of this. This makes me grateful, too. People are so positive.
The Farmer’s Extended Function
Running a Green Care service meant making use of one’s knowledge and experience from farming but also developing strategies to help the users to solve their problems. The service providers were not professional therapists but rather alternative role models, wishing to offer the users a calm and therapeutic milieu.
A therapeutic environment with time for spontaneous conversations
The providers had their own ideas regarding what helped the users to make progress, and they claimed that the skills acquired at the farm were transferable to everyday life. According to the providers, many users had experiences of being looked down upon and not being accepted, but the farm represented a place of refuge where the users were accepted for who they are in the moment. On the farm stress levels decreased, users gained more confidence and became happier and more satisfied. The reason for this might be that the users were given a chance to show mastery, rather than focusing on what they could not do. The providers were patient and refrained from imposing strict demands, which, in turn, relaxed the users. The providers also pointed out the importance of “the farmers’ tranquility,” the ability not to become stressed whenever something unforeseen happened. Instead, the tone at the farm was quiet and unpretentious.
The providers understood that processes of change took time. By cooperating with municipalities and work agencies, the providers sometimes made it possible to keep the users for longer periods of time, but changes in positive directions could still be seen regardless of the user being at the farm for a longer or shorter period of time. While working together on practical tasks, or hiking in nature and sitting around a campfire, spontaneous conversations occurred which were healing to the users. The providers had time to listen and the conversation took place in a setting that felt natural to the user: When you work with animals, or work with practical things like cooking, you create a framework in which it feels natural to talk about things. And they really do share their innermost thoughts with you.
The provider as an inspirer and role model
The job as a provider entailed responsibility, which required consideration before entering the profession. Responsibility was also an important trait to teach the users. One of the provider’s roles is to be clear on rules and limits, but another important aspect is to inspire the users to exceed their own limits and the providers could tell when someone was ready to be pushed a little extra to make further progress. The provider could be a drug-free role model showing users that there were a lot of enjoyable things in life while being sober. However, the impact of the providers’ job was often limited: We are there to inspire them to want to do something, to broaden their horizons within different areas. And when the IPT program is finished, they go back to where they were, in 90% of the cases.
A safe and generous atmosphere
When users came to the farm, their history and any limitation they might have were of little importance to the providers. They found that it was better not to know too much and rather met the users with a clean slate. Winning the confidence of the users was important, and it felt great to be able to meet the user where he or she was, and it was rewarding to see the joy the users felt at being accepted. Generosity and open mindedness provided a fertile ground for the personal growth of the individual user: It’s not an assembly line what we do. Everybody’s very individualistic. And we have to be generous enough to meet everyone and see their needs and then just play it by ear as we go, because nothing’s settled in advance.
Discussion
Green Care at the Crossroads Between Different Social Worlds
One of the aims of the study was to increase knowledge of Green Care services and of the service providers’ working situation by acquainting themselves with their own experiences and reflections. The service providers’ frustration with the complicated cooperation with different stakeholders, the bureaucratic administrative system, and the lack of follow-up support for the clients was striking, but so was also their engagement and ambition to make a difference. Since the IPT trademark was introduced in 2001, there has been a demand for higher quality and certain standards of quality assurance by the service providers. However, there were still shortcomings on the part of the authorities, which caused problems to ensure the service providers’ stable and long-lasting contracts. It seemed that this issue of stability was a double-edged sword, where—on one hand—the service providers were forced to relate to time-limited contracts and income from the authorities, while—on the other hand—they experienced the users’ need for expanded time to recover.
The service providers felt desperate when well-functioning projects were closed because the scheduled time was over, or when the authorities reorganized, and the users were, again, left without help. While the service providers regarded it as a responsibility to follow the users throughout their recovery process, once it had been started, it could not be taken for granted that the authorities would prolong the project, even if it had been successful and the users felt well after participating.
In general, it was problematic to achieve long-term planning as long as the annual public budgets implied a natural limit for the length of the service providers’ contracts. As small, one-man/family enterprises, they were in a weak position with regard to the authorities, living in the insecure situation of maybe having to close down within a year. In addition, it was risky to invest in enlargement of the farm or improvements of the service, as there were no automatic prolongation, rather it was uncertain whether other service providers would get next year’s contract. It seemed that a different kind of motivation, such as engagement and idealism, was needed to build up a working situation containing so much adaptation and such insecurity. It seemed essential that the users in need of Green Care services got relevant information on this situation, and maybe the service providers would have felt safer with more stable conditions. When the study was conducted, they had to “oscillate” their offers with regard to the users they had.
The service providers felt severely frustrated at the lack of aftercare and follow-up offers for the users. They had numerous suggestions for solutions to this problem, but they saw very few real changes. What is the point of running Green Care services—the service providers asked—if there is no continuation and no functioning follow-up system? For them, it felt more than wrong to let the users “out into nothing” when they had finished their time on the farm. The service providers were in a position where they had been met with trust and in turn cared about the users. Yet, they have experienced having to let the users go, while they knew that the “chain of care” did not work, and that the users would probably go back to where they were before, despite their progress when attending the Green Care project. In addition, it was noticeable that the service providers were not surrounded by a professional social network, which was the case for professionals working at an institution, allowing them to get supervision and professional support to handle frustration and disappointments.
Problems in interaction and common action between different “social worlds”/stakeholders, highlighted by Vik and Farstad (2009), are concretely visualized in this empirical study, from the position of a central stakeholder group. However, despite all indicators of things that did not work well in Green Care, some words should also be said about what motivated the service providers. There was a lot of enthusiasm and will to make a useful effort behind their work. In addition, they posed some existential questions on what they wanted to achieve in their lives. Running Green Care services felt right and in accordance with their own value bases.
Green Care Service Provider—A Position Along Borders
A second purpose of this article was to examine the providers’ border position in various respects. Although the providers did not offer therapy and did not work as therapists, the farm could certainly be called a therapeutic environment. The users gained health benefits from being there; their days became more structured, and sleep patterns improved. In addition, they did physical work which helped make dark thoughts give way. Spontaneous conversations took place naturally on the farm, and the conversations also included some of the more difficult themes in life. The providers claimed they knew things that the therapist did not, and they said it felt as if the users were “peeling off layers like an onion” when talking about more and more personal issues. The providers had the time to talk when the users needed it, and they laid the foundation by gaining the users’ trust and getting the users’ confidence as a caregiver, resource person, role model, and mentor. Other studies have shown that it is important for the individual recipient of Green Care (Berget et al., 2008; Granerud & Eriksson, 2014).
The study emphasizes the importance of the providers meeting the users with understanding and respect; he or she should be seen as an active, problem-solving individual rather than someone who has a disease (Eriksson & Hummelvoll, 2008; Kogstad, Ekeland, & Hummelvoll, 2011; Sempik et al., 2010). The providers met users with an acceptance of what they were, and they were not interested in their diagnoses, or how the user was doing years earlier. On the farm, the users could come with a clean slate and work from there. Mastery was an important focus.
The providers felt that the users should get the time they needed to work through their process of recovery, but this was highly individual and room for differences had to be taken into consideration. The results of Berget’s (2006) study can also be interpreted this way; the positive effects of animal-assisted therapy were clearly visible after 6 months, which can be interpreted as that people who have been mentally ill for a long time need time to recover. Recovery is as much about being on the road to change as it is about reaching a final destination. This process is highly individual, and to adapt to that, Green Care has to be very flexible (Slade, 2009).
While some users feel that today’s institutional psychiatry is too regulated by rules and restrictions, where they hear the word “no” too often (Bøe & Thomassen, 2000), the farm represented an experience of being part of a community where everyone was an active and equal participant. In time, they could become a resource person with certain responsibilities on the farm, like being responsible for showing others around, and helping to train new users.
Green Care is an additional source of income of farming, but the providers’ personal engagement went beyond the benefit of having users on the farm. Certain parallels can be drawn to social entrepreneurship, where the contractors address important social needs even if it does not provide direct financial benefits for their business. Their motivation may be multi-faceted and resting on, for instance, altruism or social responsibility (Mair & Martí, 2006).
The providers had an important societal role, and the political agenda in Norway states that Green Care is to be prioritized, for example, through the Norwegian National Strategy for Green Care from 2012 (Landbruks-og matdepartementet & Kommunal-og regionaldepartementet, 2012). According to the government report Openness and Wholeness (Åpenhet og Helhet; Sosial-og helsedepartementet, 1996), many people with mental illnesses live in isolation and have difficulty in obtaining work and friends. The report proposes providing financial support for increasing services in job training for this group as a way to remedy the problem. Green Care offers this type of service. The Norwegian Psychiatric Reform (Sosial-og helsedepartementet, 1996) calls for a warmer society with an emphasis on human values, such as responsibility for each other and caring for the weakest. People with mental disorders should participate in meaningful activities, even if they are not able to return to work, and they should be given the opportunity to experience personal development on their own terms, within a meaningful community. These are also values upon which Green Care is built, and the providers can play an important part in the work to achieve the goals of the Psychiatric Reform (Sosial-og helsedepartementet, 1996, 1999).
Despite the fact that users showed progress during their time on the farm, the farmers stated that they did not engage in any form of therapy. But does it need to be therapy, anything that helps? Does it take a professional to make genuine progress take place? And what makes a person professional? Professionals are educated and have gained expertise through their work (Topor, 2001). The opposite of a professional is an amateur, a word that can also be associated with a novice. An amateur, by definition, means someone who loves what he or she is doing, with an extended meaning that he or she retains the ability to get emotionally involved in it (Topor, 2001).
The providers were not concerned with defining their position, but it is still interesting to reflect upon what to call them as a professional group. In their field they are professionals, although they are not professionals in mental health care. Are the providers a group of semi-health-care workers? Are they professional amateurs? Or perhaps anti-professionals, representing a counterbalance to traditional health care? Several authors (Borg, 2007; Topor, 2001; Walsh, 2011) write about the increasing demands of professionalism among health care workers. Also, many health professionals feel that by showing genuine care and personal engagement, they might be perceived as unprofessional or too devoted, whereas the providers of Green Care are still free to get involved in the users to the degree they wish. In the interviews, some providers claimed that they had private SMS contact with their users to follow them up after they were done at the farm, because the official health care service failed to set up an aftercare that worked. For mental health care workers, it may feel as if the old-fashioned, traditional way of care has to give way to work approved by guidelines and scientific research or evidence-based knowledge. The effects of giving care beyond these restrictions are difficult to document because the care workers cannot admit that they work outside this professional frame (Topor, 2001). Yet, the patients and users tell stories about reaching important turning points in their illness when a professional did care a little extra, and that this has meant a lot to them (Kogstad et al., 2011; Topor, 2001). If the difference between a professional and an amateur is not about knowledge, but more about the way one relates to the job, whether one has maintained spontaneity and allows oneself to be personally involved, the question can be posed whether this is something the providers are in danger of losing if they become an organized, professional group.
Comments on the Research Method
Multi-stage focus groups appeared to be useful for data collection in this study, and made it possible to get a dynamic discussion of the service providers’ situation and everyday working conditions (Hummelvoll, 2008). The limited number of informants might be regarded as a weakening factor; however, it reflects the busy situation of this group and long travel distances. With only seven informants, the results cannot be statistically generalized, but validation through member check and face validity indicated that the study conveys knowledge that might also be recognized as relevant for other service providers. At the end of the interview series, there was not very much new information, which might indicate saturation. The interviewed service providers were idealistic and highly motivated to help others in the same situation to manage their stressful work. However, they might have had an interest in putting forward the idea of Green Care in a positive way.
Conclusion
Providers, who find themselves in a position where the expectations of users and society of Green Care services are at a crossroads, have to relate to different and sometimes incompatible “social worlds.” The providers who participated in this study are very critical and have many suggestions for changes in the contacts with societal institutions, while their solidarity lies with the users. Greater clarity of the stakeholders who are involved, improved communication, and increased understanding of the providers’ situation can contribute to social and personal gains. The role of the provider is sometimes indistinct and lies in a border position in various respects, which can be both weakness and strength. Perhaps some of the potential of Green Care will be lost with a more professionalized providers’ role. Further research on the role of the provider of Green Care services is needed, as Green Care services are an increasing societal concern of growing importance.
Footnotes
Acknowledgements
We would especially like to thank the participants who were interviewed in this study and the project staff in the research project: Recovery Oriented Green Care Services at Hedmark University College.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: The study was financed through the Research Council of Norway.