This follow-up study focused on 3 overarching questions: what keywords can be extracted from experts’ definitions of character?; what is the operational definition of character for medical students?; and what possible solutions can be suggested to address the issues of character education that were identified in the previous study?Sixty-three medical education experts recruited through expert sampling and 19 non-medical education experts recruited through snowball sampling answered a questionnaire that addressed the 3 major questions of the study. The responses were analyzed for descriptive statistics with supplementary keyword extraction tools, including the Cortical and Monkey keyword extractors.A total of 93 definitional statements were counted, and 138 keyword terms were extracted. The top 5 keyword terms mentioned by the medical education experts were “patient”, “empathy”, “qualities”, “attitude”, and “ability”. These keyword terms were quite different from those mentioned by the non-medical education experts. Based on the extracted keywords, an operational definition of character education by the medical education expert group was presented as follows: the basic qualities and ability to empathize with patients affected by illness based on respect for patients and others. Various methods were proposed to solve the issue of character education, and many of them pointed to curriculum development, such as improvements in teaching and learning methods and evaluation methods, including role modeling.A clear statement of the concept of character education is the start to resolve issues of character education. Character education improvements will be possible at the institutional level according to the above results. Issues regarding physicians’ medical students’ character and professionalism have been discussed in the media for decades -3 and arThe next step is to identify the education needed to educate our medical students to become “good doctors”. This process could involve many aspects and content of medical education, and medical professionalism emerged as an important keyword in medical education along with medical humanities ,7. RespoCharacter education is an essential foundation for the rest of medical education. Previous studies have focused on identifying the core elements of character education ,7. ThereThis is a follow-up study of Hur and Lee’s previous studies ,7. It adThis study focused on the following overarching research questions: What keywords can be extracted from the experts’ definitions of character?; What is the operational definition of character for medical students?; What possible solutions can be suggested to address the issues of character education that were identified in a previous study?This study was approved by the Institutional Review Board of Hallym University (HIRB-2018-049-2-CC). Informed consent was obtained from the subjects.This is a survey-based content analysis study conducted by extracting keywords and developing an operational definition of character education.A single questionnaire with 3 major questions on character was distributed to medical education experts in Korea via e-mail. The questions were: “How would you define the ‘character’ that is required from a good doctor in the era of the fourth industrial revolution?”, “What are the issues of character education in current medical education (if any?)”, and “If you agree that there are any issue(s) of character education in current medical education, what possible solutions do you suggest?” The survey was distributed twice.In the first round, 145 e-mails were sent, and the answers were collected from September to October 2018. The low response rate from the medical education experts was expected due to their busy schedules. The second round of distribution was done the next year for non-respondents, and 29 additional responses were gathered from September to October 2019. The questionnaire surveys were completed in paper and pencil offline or online according to the respondents’ preferences.Expert sampling was chosen for the medical education experts due to the nature of the question, and the results may not necessarily be generalizable to the entire population. It is known that combining expert sampling with an additional sample of non-medical education experts enhances the reliability of the data. For this purpose, snowball sampling was used to recruit non-medical education experts who were willing to answer the survey questions. This group consisted of 2 nursing education experts, 11 private practice physicians, and 6 medical students.The expert sampling method was used to gather experts’ definitions on character education for doctors. The list of medical education experts was drawn from the medical education departments of all 40 medical schools in Korea. The medical education experts were required to be the person in charge or affiliated with the medical education department of their respective medical school, or to have at least 5 years of experience in medical education. They were required to have an affiliation with a committee or institution that was representative in relation to medical education . For theIn the first round of the survey, 145 e-mails were sent, and the response rate was 23.4% (34 responses). In the second round of survey distribution, 29 additional responses were gathered. Thus, responses from 63 medical education experts from 30 medical schools or colleges and 19 non-medical education experts were used in the final analysis.Since the operational definition of “character” cannot be measured, the keyword extraction method was used. Keywords were extracted separately from the medical education experts’ definitions or statements on character education and the statements made by the non-medical education expert group and combined. As supplementary keyword extraction tools, the Cortical and Monkey keyword extractors played an auxiliary role in decision-making ,10. The As the extraction results of the Cortical and Monkey programs were not perfect, the relevance of the keywords obtained from the 2 keyword extraction programs were analyzed one by one and the keywords were added and subtracted from the existing terms ,10. The From the concepts described by a total of 82 respondents, 93 statements were counted. When very similar expressions were grouped, a total of 138 keyword terms were extracted. These 138 words were mentioned at least once and at most 39 times, as shown in Thirty-one keyword terms, such as “commit”, were mentioned twice, and 68 terms, such as “collaborate”, were mentioned once. Including the top 10 keyword terms  mentioned by the medical education experts, the following operational definition of character for medical students was developed:The basic qualities and ability to empathize with patients affected by illness based on respect for patients and others, to have basic ethical awareness and responsibility for human life, and to cooperate and communicate with colleagues.The top 10 keyword terms mentioned by non-experts were “patient”, “empathy”, “qualities”, “understanding”, “attitude”, “human being”, “ability”, “ethics”, “others”, and “life”. With these terms, the following operational definition of character for medical students was developed:The basic qualities, attitude, and ability to understand and empathize with patients and others, to have basic ethical awareness.In the previous study , the resForty-six medical experts, 2 physicians, and 1 nursing school professor responded to the question, where duplicate responses were possible. Eighty-four statements or ideas were suggested as the solutions to the issues of character education (Supplement 1). The responses were categorized, and numerous answers were on the subject of teaching and learning methods of character education . Some id“For character education, field education, including clinical practice, is a more effective method than lectures, but I think that the field of character education practice in Korean medical schools is not educational at all.”“If flipped learning is actively introduced so that students can help each other in class and create results, that in itself would be very helpful for character education.”“Reinforcing team-based activity and reflecting peer evaluation, and writing essays on a variety of topics.”“It is necessary to organize the content and format of the medical humanities curriculum in such a way that experience is possible. It is necessary to have a program that exposes students to real situations rather than lectures. Programs should provide opportunities to experience empathy, consideration, and dedication, as well as a system to reflect on them. For example, after pre-medical years, a one-to-one relationship with an elderly patient can be established. In addition to regular visits, a program can be operated to participate in medical care together during hospital visits until graduation. Debriefing opportunities should be provided to reflect on the results.”The responses were followed by some ideas on evaluation methods, role modeling issues, and curriculum development.[Responses on the evaluation method]“A portfolio including self-reflection for each item of personality element and feedback on it .”“Reinforcing team-based activity and reflecting peer evaluation, and writing essays on a variety of topics.”[Responses on role modeling]“It is necessary to change the character quality of the self-proclaimed medical education executives (those who are assigned in such positions). We need people with the humility to know that what they know is not everything and respect other fields of study. Doctors don’t know how ignorant they are. The crux of the matter is that they want to spend their whole lives with the triumph of their teenage years. You reap what you sow.”“In the end, the appearance of senior doctors/professors who see and hear what happens in the clinical field determines the success or failure of character education as a whole.”[Responses on curriculum development in general]“Recently, unlike in the past, students’ character qualities show individual, selfish, and hypocritical behaviors, so it is urgent to develop a curriculum and professors specializing in character education.”“If possible, we should apply interprofessional education to teaching/training not only within the medical school context/curriculum, but also with students in related fields such as nursing, clinical psychology, pharmacy, and social work. I am sure that this will be a good opportunity for dialogue between occupations, exploration, self-discovery, and understanding other occupations. It is hoped that this IPE model will be introduced and expanded in many medical schools in Korea.”There were some notable suggestions in the student selection category as well.“It seems necessary to find a way to choose well when selecting incoming students. The 4–6 years of education after admission may help, but the basic tendencies also seem to be necessary.”“Within the current system, I think the most specific alternative is to develop a method for selecting students with outstanding character at the time of admission.”Some responses dealt with the hidden curriculum and the need for faculty development, including some negative responses saying that character building is home education, not medical education. There were also doubts about whether character education can be taught and evaluated properly .This study was a follow-up of the previous studies, which established the necessity and core elements of character education and the problems of current character education. In this study, the keywords were extracted from respondents’ definitions of character education, and an operational definition of character education was developed.This study gave some suggestions on how to solve those issues of character education brought up in the previous study. From the above results, it is notable that some terms highly mentioned by the medical education experts, such as “empathy”, “qualities”, and “attitude” were not frequently mentioned by other respondents. Conversely, terms such as “understand”, “heart”, and “point of view” had a higher count for other respondents than for the medical education experts.The top 5 keyword terms mentioned by the non-medical education experts were “patient” (78.9%), “understand” (47.4%), “attitude” (26.3%), “heart” (21.1%), “life” (21.1%), and “point of view” (21.1%), which were quite different from the medical experts’ choices. This means that the definition or concept of character education may differ to some extent between medical education experts and other health personnel.Different groups can have different perceptions on the subject of character education; therefore, the results should be considered when developing new curricula or setting goals in medical education ,12. The “The character that a doctor requires is the basic attitude, values, and mindset that must be present to perform his or her duties. These include respect for human beings, empathy and consideration for patients, a sense of calling, honesty, ethics, and responsibility.”This definition of a doctor’s character was drawn from the core elements identified by the Delphi survey in the research. The keywords in this statement were “respect for human beings”, “empathy”, “consideration”, “patients”, “calling”, “honesty”, “ethics”, and “responsibility”. If readers look at the keywords of the concepts stated above and the keywords of the concepts stated in the operational definition of character in this study, it can be seen that many words are identical or similar, as shown below.empathize with patients affected by illness based on respect for patients and others, to have basic ethical awareness and responsibility for human life, and to cooperate and communicate with colleagues.Education that fosters the basic qualities and ability to Respondents gave diverse ideas for solutions, but many thought that instructional methods should be reformed or need improvement along with changes in the evaluation method of character education, which go side by side in any curriculum development initiative. Some answered in broad terms that there needs to be some kind of curriculum improvement. Others specifically pointed out that character education should be started in pre-medical education, not only in teaching and learning methods and evaluations in medical schools. Therefore, the majority of the responses dealt with the wide-ranging theme of curriculum improvement. Nonetheless, the experts did not overlook the importance of faculty development, which is an essential part of any curriculum development . Role moSolving these issues is very important to bring about real change. In this study, experts’ solutions to the character education issues were presented, and some concrete ideas were also included. One of them was that character education or evaluation should start from the admission stage and pre-medical education. Most medical schools and colleges in Korea have adopted aptitude and personality interviews as part of the medical school admission interview process  to evaluate the qualifications, character, and aptitude required to major in medicine. Opinions were also presented by the medical education experts and National Assembly Health and Welfare Committee audit. It may also be worth considering whether to evaluate personality or character during medical license examinations as these examinations are the last phase before becoming a medical professional ,16. HoweMedical education experts comprised the majority of the population (75%), whereas relatively few responses were obtained from the non-expert group  and the responses from the non-expert group are subject to the basic limitations of the snowball sampling method. Therefore, the results from the non-expert group may have limitations in terms of generalizability.Based on the concept and core elements of character education revealed in the results of this study and prior research, institutions can provide a framework of character education. The definition of character and some character education instructional ideas suggested by the experts from this study, along with the 8 core elements of character education from the previous study, can be used to provide a framework for character education in medical schools and colleges. A longitudinal framework of character education could be formed with specific examples of embedding the elements of character education in the curriculum by showing appropriate teaching and learning activities and assessment methods for each domain. Furthermore, apart from the medical education expert group’s or medical students’ point of view, a survey on the patient and families’ opinion of character education is valuable as it brings the medical consumer’s perspective.The definition of character education was derived from the keywords extracted from the medical experts. Starting with the statement of the concept of character education, some solutions could be found to the issues of character education. In particular, it is necessary to strengthen character education starting from the entrance exam and pre-medical education, which are the beginning stages of medical education. In addition, character education should be improved through consistent inclusion throughout the entire process of medical education. Methods for effectively learning and evaluating attitudes, such as field trips, practice-based cases, journals and logs, role model learning, and peer evaluation, rather than current lecture-style education should be incorporated. Based on the results of this study, it is expected that institutions will be able to find ways to improve character education.


Glioma patients have poor prognosis. The amount of detail of disease-related information patients wish to receive is not known. The aim of this study was to explore glioma patients’ experiences and preferences regarding receiving information on diagnosis and prognosis.Semi-structured interviews were performed with patients diagnosed with glioma. The interviews were analysed by qualitative content analysis without predefined categories by two independent coders.indirect, meaning they found out their diagnosis unintentionally, e.g., from their electronic health record (EHR) instead of from their doctor, this causing anxiety and feelings of abandonment, insufficiently tailored: lacking in many aspects or individualised and compassionate. Participants generally wanted to know “the truth” about diagnosis and prognosis, but what they meant varied; some desired full honest information to allow for autonomous choices, others preferred general information without details, and some wanted no bad news at all, only positive information. Participants disclosed vulnerability after receiving their diagnosis, being cast into the unknown. They expressed a need for better everyday practical information to help create some control. Supportive staff could reduce participants’ distress.Ten women and 15 men, with newly diagnosed grade II–IV glioma, age 25–76 years, were interviewed. Participants’ experience on diagnosis communication was either There is a need to further develop and implement individually tailored information to glioma patients, both in consultations and patient-accessed EHR systems, which should have safe guards for sensitive information. Not all patients want to know it all, one size does not fit all.The online version contains supplementary material available at 10.1007/s00520-020-05846-7. Malignant gliomas will decrease life expectancy, although glioblastomas (GBM) and low-grade gliomas (LGG) differ regarding prognosis and treatment and affect different age groups –6. They In Sweden, patients are according to law to be informed honestly and fully about their disease and treatment options . In contHow health practitioners should provide information to glioma patients requires further investigations. A better understanding of the patient’s perspective is expected to improve their care.This study was designed to explore how glioma patients wish to be informed about diagnosis and prognosis, also if, for example, no therapy that could influence the disease was available. We also investigated their experiences and reflections regarding recently received information on diagnosis and prognosis.Data was collected through interviews with newly diagnosed glioma patients, recruited in the postoperative period after primary surgery at the Neurosurgery, Oncology or Neurology Department before start of oncological treatment. Participants were selected through maximum variation sampling according to gender, age and tumor type (both GBM and LGG), in order to explore rich data on preferences and experiences from a diverse patient group . ExclusiBefore the interview started, we screened for factors that could influence the interview, such as symptom burden or cognitive decline. Therefore, the participants filled out the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 quality of life (QoL) questionnaire with Brain Cancer Module BN20 –14, asseAll 25 interviews were audio-recorded and conducted between April 2016 and October 2017 by two authors, MK or AM. They varied in length from 16 to 75 min. The participants were interviewed unaccompanied, apart from two having their spouse with them. The interviews were semi-structured, following an interview guide  had prepared them for receiving news of having a serious illness. The experience of receiving information about the brain tumor could be divided into three categories:I just wanted to check out my medications. But then it just stood there! I would rather have liked to talk about it with the doctor first. What does this mean? You can´t take in that it says “malignant”! Who has written this? My whole body started to ache. Woman, age 36, LGG(On accessing the EHR) I accessed the EHR and looked at the result - it’s called the preliminary result - and then I saw it. I felt… I felt it was a bit frightening // No, it wasn’t good. It’s destructive, self-destructive. You cannot handle it. You feel deserted with the information. Man, age 70, GBMSome participants found out they had a malignant brain tumour indirectly in unplanned ways, by reading the patient-accessed electronic health record (EHR) or when overhearing staff talking outside their room at the ward. In these situations, participants described feelings of fear, anxiety, abandonment and of being left alone with their questions, having no one to turn to. Some expressed regret about accessing the EHR.So I had to call and remind them. Call to ask, have you heard anything? You wait and wait and wait constantly, but you don’t want to nag, so you try to refrain [from calling], but eventually you can’t. Man, age 52, LGGOnly quickly in, quickly out. Woman, age 40, LGG(On experience of consultation) It’s so difficult to stop and say: -Wait! I need further explanation on this, I need to understand.… The information was like this, pow, pow, pow, pow, pow.…it is not until you get home that you start thinking, how the hell is this going to work out? (On providing negative information) Doctors have to get rid of their fear for talking about things! Man, age 67, LGGMany participants complained about lack of information due to delays, and the constant waiting and worrying were stressful. They also reported negative experiences when information was not adapted to their needs, preferences and timing, and when it contained too little or too much detail. Additionally, bad consultations were experienced when the physician appeared to be stressed or unprepared; was perceived as dishonest and hiding or omitting information; when the communication was unclear or when they did not seem competent regarding brain tumors. Some felt that their doctor was scared and avoided the topic, not being properly trained in delivering bad news.Good straightforward information; they told me how it is, which was a bit tough, but they said: “This is it.” Did it in a good way, that I appreciated. Man, age 56, GBMThe doctor asked if I wanted a new appointment for follow-up questions, but as I already had brought a list of questions, he cancelled another meeting to be able to stay and answer them.... for me it was good. Woman, age 36, LGGAfter the biopsy I e-mailed my neurosurgeon. He immediately called and told me what it was. (You got the diagnosis on the phone?) Yes… for me that was good. I have confidence in him. Man, age 26, LGGDespite information being shattering, participants were content with direct information provided by the physician when it was given gradually, adapted to them and when the doctor was responsive and allowed for questions. It was also important that the doctor had knowledge in the field.All respondents stated that being told the truth about diagnosis and prognosis was important, and they did not want to be told lies. However, they had different perceptions on what constituted “the truth” and how it should be told. We identified three categories.If something can be done, then I’d like to know, but otherwise I don’t want to know. I guess I’ll notice if it ends badly. Woman, age 76, LGGBeing told [about a poor prognosis] might just cause you to die faster, as you don´t see any hope. If you aren´t told, you can build up hope that makes you live longer. That is the reason I wouldn´t want to know. Woman, age 45, GBMA few participants stated that they wanted to know the truth, but only the good truth, meaning favourable information which would enable them to focus on what was positive. They felt it was better not to hear negative information, since receiving bad news could make them lose hope and become depressed. To cope with a poor prognosis, some wanted information to focus on short-term events, here and now. Even though they preferred not knowing the full prognosis, they still labelled information as “the truth” as opposed to being lied to.Maybe you don’t have to go into the details, but say enough, so that you know the kind of general direction you´re heading. Woman, age 36, LGGI want honest information, but if I want to know it all, that I don´t really know… that’s a difficult question to answer. Honest? It should be truthful but there must still be some hope. Man, age 56, GBMSome patients wanted truthful information on the overall prognosis, good or bad, but only the big picture. By not providing detailed information of the future and likely outcomes, hope could be preserved.I think the patient should have as much information as the doctor. There is no reason why the doctor should know more than me. Why should they have information that they haven’t shared with me? Man, age 67, LGGI kind of wish I had a prognosis, but there is no one really who wants to say those things, I am not sure why. I guess they want to keep positive, but to me it is just always going to be ringing in the back of my head. I just want to know. You know, if I have, let´s say, hypothetically speaking, I have 10 years, then I don´t want to plan for 20, if I have 5 years, I don´t want to plan for 10 and so on… Woman, age 26, HGGI think so [on wanting full information]. But I think I am a bit ambivalent also, because maybe not just now, but soon I think I´m getting ready for it. After all, you want to be able to plan your life. If you know that you only have a short time left, then I think it would become more important to be able to plan and focus the rest of your life on the right things. Man, age 41, LGGTo have control, most respondents wanted complete and detailed information, even though it might hurt. Reasons given were to be able to accept their fate, plan ahead, inform family, decide about the near future, such as if they should accept a proposed treatment, or to be able to choose how to live the rest of their life. Some expressed that even though they wanted the full truth, they wanted to be told gradually, as they needed time to be prepared.Most participants described having little or no previous experience of illness and health care, and so after diagnosis, they reported being in an unfamiliar context, environment and role. What to expect was, for most, unknown, making them feel vulnerable. They expressed a need for more support and information than simply on diagnosis and prognosis.When I followed the doctor´s orders and called the ward about the problems with my medication, the nurse answered: “ Aha, what am I supposed to do about that?” I was so angry, so I just said: - You know what, I’ll fix this some other way. And then I hung up, and cried…. Woman, age 45, GBMI don’t understand how it’s organized. Therefore, I don’t know who to ask, and I suspect there is some kind of system. You lie there waiting, not knowing what you’re waiting for. It’s much better to be informed, to have practical information. To say, you have an X-ray today, but we don’t know when, it might be tonight, but we’re not sure. It means a lot. To say you don’t know is also information. Man, age 56, GBMParticipants experienced lack of practical information, like descriptions of procedures, risks, long-term plans, but also on smaller everyday things: When? Where? How? Why? What are the rules here, how am I supposed to behave? Participants described feeling they were disturbing staff and felt humiliated when having to ask questions repeatedly. Not knowing and not understanding caused an additional layer of distress, aggravated when health practitioners did not recognise this. Participants requested fast-track contact ways, assigned staff, simple but accurate and preferably written information.I really don´t know what could have been better! The social worker has called me on the phone, nurses have called me, and all have been great! Man, age 64, GBMIn the radiation department a nurse came up to me and he recognized me! I really didn’t expect that when you haven’t had much contact. And it makes you really happy, it’s like being seen in a way. Woman, age 61, GBM(Patient remembering a situation of despair) He spoke to me in a natural way// I felt I was part of life again. He didn’t talk about the illness, but instead about himself, his work and hobbies. Being able to talk to someone like that was wonderful//I almost cried. Man, age 61, GBMIn order to handle the unknown, the support from staff was important. To be seen, listened to, feeling that someone cared. Knowing whom to contact when in need, being able to ask clarifying questions, was important. Some patients had been allocated a specialized brain tumor nurse, physician or social worker who stayed in touch and who they could turn to for support, making them feel safe and taken care of.Our findings indicate that glioma patients have a need for individualized information regarding diagnosis and prognosis. In line with previous studies, those participating in our research expressed different preferences regarding how and when this should be provided as different patients need different levels of detail and timeframes to process mainly negative information , 21–23. We found that a mismatch between the patient’s preferences for information and what they experienced was provided by the physician, was not uncommon, which has been reported previously . When inSome participants sensed fear and avoidance among physicians when delivering bad information. This experience is supported by previous reports –32. ThesWe found that health practitioners need to acknowledge patients’ requirements for everyday practical information, which, when lacking, adds to patients feeling lost and vulnerable. Recognition of the fact that patients are often novices in the health care system, and not familiar with matters self-evident for staff, needs to be improved. Apart from being allocated a specialized team member, who was easy to contact and get to know, some participants also felt they would get support from meeting other brain tumor patients.In Sweden, the Brain Tumor Patient’s Association together with the health care has initiated several studies to improve patient care. These include communication between patients and the health care, patient and proxy needs and focus on the lived experience and psycho-social aspects. Additionally, Patient Reported Experience Measures (PREM) and Patient Reported Outcome Measures (PROM) are collected from all brain tumor patients for clinical routine and research . These ePatient-accessed EHR has been launched to increase patient empowerment. Studies in patients with chronic illness show positive effects such as improved satisfaction, communication, engagement and self-care –37. In SWe included participants from a defined region of Sweden and our findings may not be transferable to other regions or countries. The physicians informing participants were not interviewed so we cannot know if they experienced fear and avoidance, as perceived by some patients. Care was taken to include patients with different age, diagnosis, personal and socio-economic background. Despite this, it cannot be guaranteed that all perspectives were covered. Our study focused on those with glioma; therefore, we cannot know if our findings are valid for patients with other malignancies.In qualitative studies, the researcher can affect interviewing and analysis of data; therefore, two researchers took part in the interviewing and analysis, in order to increase reflexivity. These are physicians with a long clinical experience of oncology and palliative care of glioma patients.To achieve patient-centred consultations, information on disease and prognosis but also on practical issues, needs to be adapted to each patient regarding amount, detail and timing, since patients have different individual preferences. This can be challenging for medical staff, whose need for training and support must not be overlooked. We suggest asking the patient directly about their preferences for information, since not everyone wants to know it all. Finally, how sensitive data are made available to patients needs to be thoroughly considered when developing and implementing patient-accessed EHR systems.ESM 1(DOCX 13 kb)ESM 2(DOCX 160 kb)


Interdisciplinary rehabilitation programmes (IRP) are used in municipality settings to assist unemployed citizens with complex health and/or life issues. Individually tailored IRP activities help people develop their personal working life skills and increase their chances of re-entering the work force. The aims of this paper were to describe citizens’ wellbeing in terms of health aspects, explore the impact of stressful life events on wellbeing and obtain understanding of how IRP activities affect the participants’ development towards future employment.A mixed methods exploratory approach has been used. For data collection a quantitative longitudinal survey (baseline and 1-year follow-up) and qualitative interviews were conducted. Descriptive statistics were used for the analysis of survey data, while the data material from interviews was analysed using directed content analysis. Results were discussed with the theory of flourishing as a framework to develop understanding.At baseline, 146 respondents  filled in the survey and seven participants were interviewed. The analysis of survey data and interviews revealed five themes: (1) Stressful life events, (2) Positive emotions - how IRP-activities positively impacted wellbeing and physical capacity, (3) Appreciation of engagement, (4) Relationships, and (5) Meaning and optimal functioning. Results showed that IRP participants from the outset experienced high general pain intensity as well as distress, anxiety and depression. Life events relating both to physical health and work life were significant for their wellbeing. IRP activities supported participants’ positive development towards future employment in ways that were specific to each individual.From this study it can be derived that participants’ development took place around self-acceptance, acceptance by others, physical capacity, psychological resources and capacity to balance engagement to cultivate the best version of themselves. In future programmes, it may be emphasized that participants’ interest may be an important driver for wellbeing and future employment.ClinicalTrials.gov Identifier: NCT02641704, date of registration December 29, 2015. In 2013, the Danish government launched a series of labour market policy reforms. Among these were a reform of disability pension and flexi-job schemes (light jobs supported by subsidies). The overall goals were to get as many citizens as possible into work and so enable them to provide for themselves and to ensure that as few citizens as possible end up on permanent disability pension [IRP’s are typically designed with a focus on employment in the competitive labour market to help people develop their chances of re-entering the workforce , 3. The From 2014 to 2019, approximately 25–30% of all long-term unemployed persons embarked on IRP in Denmark. The target demographic for the programme were those with a complex set of problems for whom social-, employment- and health-related challenges created barriers to entering the labour market, putting them at risk of ending up on a permanent disability pension. In 2019, 5–7% of participants under 40 years of age and 1–3% of the + 40-year-old participants had gained regular, unsubsidized employment [The rehabilitation teams assigning individuals to IRP are made up of representatives from employment, health care, social affairs, and educational sectors in the municipalities. On the basis of their combined expertise, they recommended IRP components individually tailored to each participant on the programme. This approach caters for participants with a complex set of problems  and ensuIn 2017, Scott et al.  describePositive emotions, Engagement, Relationships, Meaning and purpose, and Accomplishments [In this project, scrutinizing citizens’ participation in IRP in Sonderborg Municipality, positive psychology will be used as a theoretical framework for analysis. Positive psychology may focus on those aspects that make life worth living and contribute most to the prospect of a positive future and a flourishing and fulfilling life –19, but ishments . The PERishments . To our ishments . CombiniThis project’s overall aims are to describe characteristics of citizens assigned to IRP in Sonderborg Municipality in Denmark and understand the personal development they undergo as a result of their rehabilitation activities . In thisSpecifically we aim to: 1) describe participants’ wellbeing in terms of physical and mental health aspects at baseline and one-year follow-up , 2) explore the impact of stressful life events on participants’ wellbeing using the psychological construct of flourishing as a criterion, and 3) obtain an understanding of how IRP activities affect the participants’ development towards future employment using the PERMA model as an analytical framework.A mixed methods exploratory approach  was usedThis study is part of a larger project, and a complete description of methods used for the project has previously been described in Andersen et al. .ClinicalTrials.gov, number NCT02641704.The study was conducted in accordance with the WMA Declaration of Helsinki ethical principles . The probeing unemployed and aged 18 to 65 years,being at high risk for permanent disability pension because of complex challenges involving social, employment and/or health problems,not being ready to enter the labour market and requesting continued education or retraining of skills due the complex nature of their problems,Participants were long-term unemployed citizens enrolled in an IRP in Sonderborg Municipality, Denmark. Criteria for enrollment into the IRP programmes were defined by the Danish Ministry of Labour in the following way , 26:beinAt a national level, the overall aims and content of IRP are uniform and aimed at enhancing the citizen’s work ability . The munInterview participants were selected with a purposeful strategy aiming at including interview participants providing in-depth information for answering our study aims , 28. We n = 7) were sent written information and written informed consent was obtained (n = 7). Confidentiality was secured by presenting participants under ID  during an observation of a physical training session. Interview participants were recruited stepwise and the collection of data stopped when we had a rich variety of responses. All participants (ID Table . All parn = 3) or in a designated room in the municipality social service office (n = 4). Interviews were audio-recorded and subsequently transcribed verbatim. Subsequently, participants were invited to read and comment on the accuracy of the transcription. Two participants accepted this offer.Interviews were individual face-to-face interviews (duration: 44–145 min) and they were conducted from September 2016 until August 2017 by the first author (LNA). The first author (LNA) is an experienced interviewer. Depending on the participant’s preference, interviews took place either in the participant’s private home (All interview participants gave informed written consent to participate in the interview part of the study (not applicable for the quantitative part).The semi-structured interviews were conducted using an interview guide as a flexible framework for questioning and dialogue with participants. The interview guide was developed based on the overall aims of the study  and themThe qualitative data material from interviews was analysed using directed content analysis, a qualitative method that uses a pre-determined framework to guide analysis , 31. “StData was coded using “stressful life events” , 20, 21 After the coding process and sorting out the text elements in the predetermined themes, themes were reviewed for usefulness. The headings in the results section Table  represenFirst, the transcripts were examined, read and re-read to allow familiarization and to chart content relevant to developing an understanding of citizens’ wellbeing and participation in IRP. Categorization was deductive, but coding was flexible with new codes being added and existing codes being modified to allow new subthemes to emerge (LNA coded transcripts and content discussed with MJS and KKR) , 31. TheQuotations from the participants were used to give valuable insight but also evidence to the data collected from semi-structured interviews of IRP participants. The quotes illustrate and support the claims made by the researchers. All quotations used in the present paper were translated from Danish to English by a professional translator .Questionnaires were sent via postal mail to all citizens assigned to IRP, initially at baseline and then at follow-up after one year. The questionnaire was designed to give an impression of the participants as regards their sex, age, height and duration of participation in IRP, and asked standardized questionnaires to describe self-reported general pain, distress, anxiety and depression, loneliness, physical fitness and physical activity.In February 2016, a postal questionnaire was sent to all citizens who had been assigned to IRP during the previous year in Sonderborg Municipality and subsequently to all newly assigned citizens from February 2016 to March 2017. Two weeks later, a telephone reminder was sent to those who had not responded. Four weeks after baseline, the questionnaire was re-sent to non-responders. One-year follow-up questionnaires with the same questions were sent between February 2017 and March 2018 to all citizens who had returned the first questionnaire. If this was not returned a second letter with the same questionnaire was sent.General pain was measured on a Visual Analogue Scale (VAS). The scale measures pain during the last seven days and uses a 100 mm VAS anchored with ‘no pain’ at 0 mm and ‘worst imaginable pain’ at 100 mm [t 100 mm .Distress, anxiety and depression was evaluated using the Patient Health Questionnaire-4 (PHQ-4), which is a 4-item screener for anxiety and depression [pression . It combpression . Responspression , 35. Thepression .Loneliness was assessed with the Three-Item Loneliness Score (T-ILS) [ (T-ILS) . Answers (T-ILS) . A T-ILS (T-ILS) .Physical fitness was evaluated using a numeric rating scale with illustrations and verbal anchors for the extremes for five components [mponents . One quemponents , 39. ThePhysical activity was measured with a single question “This question is about how much you move and exert yourself physically during your leisure time” from the Saltin-Grimby Physical Activity Level Scale. The answer was recorded on a 4-point Likert scale measuring a range from almost completely passive to strenuously active [y active –42.General pain, PHQ-4, T-ILS and physical fitness: As the data were not normally distributed, the change from baseline to follow up was assessed using a one-sample Wilcoxon signed rank test. The proportion of participants with positive screening results for distress, anxiety and depression  and physical activity were reported using frequencies and percentages. The change from baseline to follow up was assessed using the chi-squared test.p = 0.04), and more often had one or more children living at home (p = 0.031).At baseline 427 IRP participants were invited, and the proportions were 146 (34%) men, 274 (64%) women and for 7 were sex not recorded. The baseline survey was completed by 104 women (71%) and 42 men (29%) (response rate of 34%). The proportions of sex were equivalent among completers and non-completers, see Fig. So I have had problems with my back, and I can’t count the number of times I’ve had to get hold of the doctor on call and could hardly get out of my bed. (participant 7)It was after I had my son, there’ve been so many things, because there’s always been something wrong (...) so I get pains in my neck and shoulder, some arthritis. (participant 5)Based on the self-reported questionnaire data , and now time’s up (clap), it was almost like interval training, constant time pressure, and I felt like a top spinning on its head. (participant 3)For those with job experience, their workload and their managers’ handling of difficult situations were described as important for the participants’ ability to cope with job-related stress. Participant 6 described how her work-related self-esteem progressively decreased, and how she felt after she was fired from her job:I loved being at work, I was good at my work, but it wasn’t there anymore. I would think, “Now I simply can’t sink any lower,” I had lost my job, my house, my boyfriend, and I was massively in debt. (...) “if a tree comes up now, you’ll drive into it”, and I’m sure I would have done it. But no tree appeared , there was a roundabout instead, and so I drove home to my parents and said: “I got to get to a doctor now”, and then I could let go (...) all I did those first couple of years was sleep. (participant 6)Survey results support the participants’ reports of stress and low levels of wellbeing. A large proportion of participants report moderate (27%) or severe (38%) distress. Of these, 66% scored three or more on one of the subscales indicating either anxiety and/or depression at baseline  from being a lump where there weren’t any muscles left, she (the physiotherapist) really got my body working again, now I keep it going myself with the things she taught me. (participant 6)In line with participants’ personal accounts of limited physical capacity at the outset of the IRP, the survey baseline results indicate that participants generally scored low on questions relating to physical fitness and indicated an overall sedentary lifestyle  now I am totally dependent. I started by just training physical training, and ‘Hey, man’ I can run, I got hooked on it. It was a revelation to see the physical effect of me becoming happy. (participant 3)Participant 3 went on to describe how participation in IRP slowly changed her way of engaging with her children. She experienced an improvement in her ability to concentrate, and learned to be aware of engagement in the here-and-now situation:I have got good at living in the moment (...) ‘Holy’ I have been so out of it, no good to anyone. That’s where I can feel the difference, I am very attentive – multi-tasking, forget it, I simply can’t do it anymore. (participant 3)Activities in IRP did not only facilitate participants’ engagement in activities. Participant 3 explained how she learned to balance her desire for increased wellbeing with developing her work ability, and described how the coordinator assisted her in building up her work ability with a realistic progression in work load:I have to try myself out as regards my work. I have got my qualifications (...) now I have to get it to balance out ‘what I am able to do’. (...) the risks of ending up down there again, they are there if give it everything I’ve got without a coordinator being there to say: ‘No, that twice three hours, now stop’. (participant 3)Participant 3’s development is one example of how participants in individualized ways described how interest in physical activity was sparked by an appreciation of its positive effect on wellbeing:I landed on the floor but I arrived in a transit lounge (= IRP) that could focus on the fact that you have a good and exciting life story, there’s something to grasp hold of. For a while, I couldn’t get up off the floor, what she (the coordinator) told me gave me optimistic motivation, enough to keep at the back of your mind that I wasn’t completely on the scrapheap. (participant 3)Overall, participants felt they were met with recognition and acceptance from others in IRP. Participant 2 told us how her collaboration with the coordinator was marked by acceptance, which was reflected in individual consideration of when and how starting internship. Participant 3 experienced how acceptance of her life situation and health issues by the IRP professionals helped her accept her route to future employment:I’m not good at boxes, but in this resource programme they really have said, yes, we can see that (...) My resources are there, there are just not in a measurable box. The council had to think outside the box because she (the coordinator) said that’s not you, not at all (about the list of internship places). (participant 3)Personal relations with the coordinators were described by participants as important for the development both of work skills and, of the social skills that were important prerequisites for employment. Participant 1 described the impact of personal interaction with his coordinator:” (…) it helps me to be more social.” While a trusting relationship with a coordinator who acts as a support and guide in learning self-management was explained by participant 5. She described, for example, the experience of doubting whether she should participate in an experiment proposed by her psychologist, and her coordinator offered reassurance by phone about decision-making:” It is as though she (the coordinator) is the adult, she has to say, ‘But that is what you have decided”.Social relations impacted on participants’ development. Participant 3 described how going to IRP gave her a feeling of being supported and accepted as she was. The coordinator made her life story an integral part of her individualized IRP:To feel that you don’t represent anything that anyone can relate to. I had cut myself off from pretty much everyone, it was very lonely, even though I had a large family. It was lonely even though I wasn’t lonely, for inside it felt very lonely and wrong. (participant 3)The absence of trusting relationships was highlighted by participants as important for their experience of loneliness. Relations with spouses or near relatives offered this type of support for some participants:Something that has affected me is that he (husband) has fought his own battles but also our battles. He could see that I wasn’t able to fight. He has been along to every interview. (...) He’s good with words, so he could say the things I couldn’t say, I just sat there like a grey mouse. (participant 3)In addition to the fellowship created with their coordinator, other participants found that s/he provided them with the opportunity to share their thoughts. The personal interaction with the coordinator gave participants feelings of being cared for, which was significant for dispelling their feelings of loneliness, for example when interest was shown in their personal development, as described by participant 5: “They were so positive, at times more stressed (=happy) than I was – yes, you could do it, yeay!”More than a third of participants in the survey scored seven or more at baseline on the T-ILS, which indicates loneliness. One year later, this was significantly reduced to less than one in five, with men showing the largest reduction Table . These rA lot of people say, if they have been down, that now I’m going back to being my old self (...) But you should never go back, for that was what made you ill. (participant 3)When participant 3 reflected on her progress, she realized not only had she found direction in her working life, but she had also developed a more meaningful life in general:I could contribute a whole lot at work, but that was all I could do, that was pretty pathetic. At that level I feel I have been enriched, I have really come a long way. (participant 3)In addition, participant 6 found that talks with her coordinator were conducive to finding a direction for her working life, and participant 5 described a significant sense of community with other IRP participants in physical activity sessions, which contributed to a sense of being happier: “You can see how the others change, and that makes you happy”.Participant 3 described how she developed understanding and from that the possibility to progress and build a new and more balanced life:I am not as I was in the old days, I’ll never be that again, but I can certainly accept things as they are”. Participant 3 has developed a sense of having mastered work-related activities successfully, because she has identified realistic job opportunities she is passionate about: “I know my stuff, I just hadn’t realised what it was I was supposed to work with”. Both experienced feeling better through mastering internships successfully. Participant 3 further elaborated that, based on her life values, her functioning as a human being had improved:It’s ok if I am to die – no, of course I hope I am not. If I had had to say goodbye when I was in tenth gear, that would have been sad, ‘cos then I hadn’t a clue about anything, or how you can live harmoniously and in touch with yourself. But I found the resources that give me a quality of life, and that’s what it’s all about, of course, giving life quality. (participant 3)Different ways of developing competencies to attain personal goals were described. Participant 4 learned how to balance work tasks without getting pain, while participant 6 described developing the ability to distribute her resources to master activities in an acceptable way that gave a sense of accomplishment: “The results from this mixed methods study, combining survey and interview data to investigate citizens’ experiences when assigned to a IRP in Denmark, indicate that as a whole these citizens were confronting pain as disrupting their wellbeing and functional ability. In addition, the participants’ experiences of work as regards job content, workload and working environment induced stress and had a bearing on their depressive feelings. In addition, some participants’ negative beliefs about themselves were experienced as being related to depression. Participants’ experiences of distress were supported by the survey results, which showed that more than one third of the participants experienced distress and a large proportion of them experience anxiety, depression and loneliness.IRP participants’ descriptions of stressful life events and how they impacted on their health and wellbeing are consistent with findings from Cleland et al.  who haveFor many of the participants, the road to flourishing was paved partly by positive experiences deriving from physical training sessions. In the survey, IRP participants generally reported sedentary lifestyles and low physical fitness but, over time, an increase in self-reported endurance was observed. In the interviews, participants described positive training experiences and the building up of physical capacity not only as a means to better physical health but also as a form of stress management and a source of positive feelings .Positive emotions are one element out of five that underpin the construct of flourishing and the PERMA model , 22. FloPopulation studies have shown that flourishing is inversely related to levels of functional limitation . TherefoIRP participants felt they were being met with acceptance from others. They felt the backing of IRP professionals, who supported participants in their acceptance of past and present situations, which enabled them to view themselves more positively. Self-acceptance and increased flourishing were accomplished through recognition and acknowledgement of individual strengths by others, which in turn nourished positive emotions and motivation for rehabilitation and future employment , 52–54..Participants found that IRP activities taught them to focus on the present moment  and their engagement in co-decisions about IRP activities stimulated their feelings of curiosity and development of interest for work-related activities , 54. IntCompared to both the general Danish population and populations in 15 other countries, IRP participants reported high levels of loneliness at baseline with some improvement at follow-up , 56. TheParticipants described how their individual life stories (past/present/future) were taken into account when the individual IRP programme components were planned, which led to a sense of meaningfulness and to a sense of connectedness with others , 22, 58.Through the IRP activities, participants learned how to manage their personal resources in order better to cope with life situations, and in so doing they achieved a sense of personal accomplishment. A sense of accomplishment was also generated when participants were given opportunities to find types of work that were meaningful and at the same time realistic, given their life story , 62. GivThe positive long-term development of anxiety, depression and loneliness should be interpreted with caution, as we had a low response rate at follow-up, and selection bias cannot be ruled out, even though acceptable response rates from 25% have been suggested , 64. TheRegarding loneliness, a conservative approach to estimating loneliness was used. Because there is no consensus about estimates for loneliness, we have used the limit of 7 proposed by Lasgaard et al.  to estimIn future studies it may be relevant to explore issues relating to specific subgroups, such as age or sex. Our empirical data allowed to make descriptions by gender from the quantitative data however our empirical data did not allow to discuss on sex subgroups in relation to the research questions.We collected data in the qualitative and quantitative parts of the study concurrently . It was Merging data is challenging and using visual aids as joint displays may have provided a beneficial structure for the integration of data in the present study , 67. We IRP participants experience high general pain levels and a large proportion of participants experienced distress, depression and anxiety. Various stressful life events relating to both physical health and work life are described by participants as significant for their wellbeing. IRP activities can build participants’ positive development in individualized ways through activities directed towards future employment. Features that participants developed through participation in IRP activities relate to self-acceptance, acceptance from others, physical capacity, psychological resources, and learning to balance engagement to cultivate the best version of themselves and the development of interest as a driver for wellbeing and future employment possibilities. In the future it may be worth to investigate how physical activity impact not only physical capacity for IRP participants, but also positive emotions and stress management.


Free play is important in early childhood and offers physical and mental health benefits. Outdoor play offers opportunity for children to use natural elements and promotes physical activity, among other health benefits, including exploring their environment and taking risks. Risky outdoor play may involve challenges, heights, speed, and the potential for injury, but has been associated with increased physical activity levels, decreased sedentary behaviour, improved mental health, and social benefits. The integration of loose parts, or open-ended, unstructured materials, into play environments, has been associated with positive social behaviours, creativity, and improved problem-solving, confidence, and resilience. As opportunities for risky play in early childhood are determined by adults, including early childhood educators, it is important to understand their perspectives on these types of play. The purpose of this study was to explore early childhood educators' perspectives of risky play, in the context of the Physical Literacy in the Early Years (PLEY) intervention. PLEY was a mixed methods study that aimed to evaluate a loose parts intervention in early childcare settings. This paper used Qualitative Description to explore educators' perspectives. Data were collected from 15 focus groups with early childhood educators. Four themes were identified through thematic analysis. The first explains how risky play with loose parts contributes to evolution in educator perceptions; the second describes how educators' perceptions of risk are connected to institutions and systems; the third illustrates how educators developed strategies to facilitate risky play with loose parts; and the fourth demonstrates how educators perceive risky play as beneficial for children's healthy development. This project highlights societal shifts in play and how loose parts and risky play fit into the ongoing evolution in play, from the perspectives of early childhood educators. While risky play is inherently, of course, risky The Canadian Position Statement on Active, Outdoor Play states, “access to active play in nature and outdoors - with its risks - is essential for healthy child development”, highlighting both the importance of risky play, and the outdoor context as space for facilitating risky play Risk-taking opportunities in early childhood are also largely influenced by adults, including educators There is overlap between risky play, outdoor play, physical activity, and learning environments Ecological approaches, or those that situate health across the context of complex, multi-level environments, from the micro to the macro level, are often employed in health promotion research, particularly in relation to physical activity Expanding on existing literature, we explored the perspectives of early childhood educators who took part in the Physical Literacy in the Early Years (PLEY) project, an outdoor loose parts play intervention 2.2.1.This paper qualitatively describes educator perceptions of preschooler's risky outdoor play collected as part of a mixed methods intervention study, the Physical Literacy in the Early Years (PLEY) project (registered ID# ISRCTN14058106). The purpose of the PLEY project was to evaluate a loose parts intervention in regulated early childcare settings, including its impact on physical activity and outdoor play, and educator and parent perceptions. The PLEY intervention involved integrating loose parts  into the outdoor play spaces of 11 childcare centres across Nova Scotia for periods between six and eight months. The project used a socioecological approach and the RE-AIM framework to explore multiple levels of influence and understand the impact of the intervention Qualitative data were collected using Qualitative Description methodology. Qualitative Description is an exploratory methodology which, while less interpretive than other qualitative methodologies, is focused on describing the lived experiences of participants, from their perspectives 2.2.Early childhood educators from childcare centres involved in the PLEY intervention were invited to take part in focus groups. Fifteen focus groups took place, nine of which occurred three months following the intervention, and six of which occurred six months following the intervention. Each intervention site was represented in the focus groups and included early childhood educators from a variety of sites, with between three to five educators taking part in each focus group. Focus groups each lasted approximately 45–60 minutes and included questions regarding the intervention, active outdoor play, loose parts, and risk-taking. All focus groups were audio recorded and facilitated by a member of the research team and a notetaker.Audio data from focus groups were transcribed verbatim, organized using Microsoft Word (version 16.16.3) and imported into QSR NVivo 11 for analysis. Thematic analysis was guided by the methods of Miles and Huberman 3.Four themes were identified through Qualitative Description and thematic analysis. The first theme describes how risky play with loose parts uncovers evolution in educator experience, perceptions, and practice; the second theme presents how educators' perceptions of risk are connected to institutions, systems, and discourses of safety; the third theme demonstrates how educators developed strategies to facilitate risky play with loose parts; and the final theme explores how educators perceive risky play as beneficial for children's healthy development.3.1.“we knew every inch of the woods all through our neighborhood and parents weren't with us, I'm not sure if that happens as much anymore”. They related these perspectives of risky play to their work as early childhood educators, with one saying, “when you've been in the business for so long you're ingrained of just keep them safe, make sure they're safe, the times are changing where risk is part of their play now”, suggesting that attitudes around risky play have changed. One participant noted the loose parts intervention helped reveal this evolution in perspectives regarding risky play, saying “perhaps before there wasn't enough risk taking, [...] I started to say to myself, I think we better stop saying, ‘be careful, be careful’ all the time” noting the loose parts intervention as helpful in facilitating reflection on risky play.The first theme highlights how risky play and the loose parts intervention brought to light how educators' background, experience, and history contributed to their perceptions. As part of this theme, educators reflected on the historical and societal shifts that have occurred in the way children play. Participants reflected on their own experiences, including where and how they were raised, and played, and how their own experiences contributed to their feelings about risky play. One educator said, for example, “more free with the risk-taking outside”, while another said, “when they're outside they have the space to explore, they have the room to just run and jump”. Another common perspective was that educators were mindful of the responsibility associated with caring for other people's children. One said, “it's someone else's child and you want them to be in one piece at the end of the day”. Several participants noted they were more comfortable with risky play with their own children, with one saying, “I don't want other people's kids to get hurt, but like, I let my own kid do something and they get hurt I’d be like well you know that's my kid”. Some participants reflected on how their own upbringing impacted their perspective on risky play, with one saying, “as a child I did everything so I'm able to let them”. Similarly, another participant said, “we had strict rules of what happened in our house and it wasn't the risk play”, and one considered, “I wonder if my opinions would change if I was more of a risk taker as a child”.Educators also reflected upon how they each have their own individual comfort level with risky play. Many participants described how they were more comfortable with risky play outside than inside. One said they were “I think there's a change, there's an awareness that wasn't there before”, while another said, “we're seeing a shift within our own organization”. Connecting to the earlier theme of confidence, a participant said, about children's risk-taking with loose parts, “it's building the children's skills and confidence and then as that's happening, yours is also being built which means that there's this beautiful sort of mutual respect”. Similarly, a participant said, “the more educated you get about it [...] you feel more confident in yourself to let your children take the risks”. Others discussed how their participation in the outdoor loose parts play intervention changed “our mindset” or “changed my whole perception of risk”. To sum, one educator said, “we see the benefits of it now, not the scariness of it”. Finally, some participants noted the impact of the intervention more broadly, saying, for example, “I feel like being a part of this has allowed the company to loosen up a little bit”, indicating that the outdoor loose parts play intervention contributed to changing perceptions of risky play institutionally. Educators recognized shifts in how risky play was perceived over time, that were contributed to by their own history, education, and experiences. The outdoor loose parts play intervention offered an opportunity for further learning and experiences, contributed to shifts in educator perceptions of risky play, and increased comfort in risky play.Educators also noted that they were progressively becoming more comfortable with risky play, and that this was facilitated by their participation in the outdoor loose parts play intervention. Educators relayed that systemic, environmental, and cultural shifts were happening regarding risky play, in association with the intervention. One said, for example, 3.2.“as a teacher you just tend to feel responsible”, a sentiment that was common among the educators in this project. Connecting to the above subtheme around individual comfort with risk, one participant said risky play had taken them “out of my comfort zone for risk because I think of the worst scenario, not the best scenario”. Others connected this to the above subthemes of perceptions of risky play changing over time, with one saying, “I've been in the field for a long time [...] years ago it was ‘no you can't do that’ [...] it's a hard thing to let go of [...] nobody wants to see children be hurt but the more you let them do things you realize that yah it's risky but it's not usually that bad”. One participant said that their role is about “keeping everybody safe [...] I want to support the risky play, but at the same time we have to be careful”, which was aligned with many participants who noted that there is a balance to be found between encouraging risk and ensuring safety.Educators in this project also connected their perceptions of risky play to institutions and systems, and broad discourses around responsibility and safety. As part of this theme, educators articulated their fear of children getting hurt and being responsible for that injury. All participants discussed situations and experiences where they had experienced fear, worry, and anxiety associated with risky play. One said, “with the risk taking comes a lot of paperwork too”. Many participants discussed the protocols and requirements associated with an injury. One said, “you're writing the accident report in your head” in regard to watching risky play take place, while another said, “I mean every child's going to have a fall, every child is going at some point [...] you need a band-aid [...] but apparently now it's like any mark [...] it needs to be written up”, noting a bit of fatigue with reporting, but also acknowledging that injuries may happen in risky play. Others acknowledged the obligations around risk to be important, with one saying, “the policy is about accountability [...] our actions reflect on the centre”. Other participants reflected on the importance of communication, saying, “that's the way that administration would look at it, ‘how are you going to do this safely? Tell me why you want to do it’”, highlighting the connection between their perception of risk and that of the administration.Closely connected to the fears and worries that come with risky play, educators discussed their perceptions of rules, regulations, reporting, and responsibility. A common perception was that 3.3.“for me it was just the teaching strategy of letting her take the risk and letting her come to her own conclusions”. Another said, “If you're scared they're going to be scared, so just, you know, be nearby and let them try”. Educators also often discussed how they speak to children engaging in risky play. One noted the importance of being “more mindful of what I'm saying to them in those moments and if I need to say anything at all” and the value of “being supportive and not restrictive”. Many discussed the strategy of asking questions, with one saying, “I've been trying to steer away from ‘be careful’ and kind of phrase, like, more open-ended questions, like ‘what would happen if you step your foot there?’”. Others discussed the importance of providing encouragement, with one saying, “I wanted to let her be independent, let her be creative and definitely gave her words of encouragement, like ‘this is awesome [...] look at how you're balancing’”. Finally, some participants discussed switching out with one another as educators, with one saying, “maybe I'm going to step back because I know you're a little more comfortable and you can facilitate this”, acknowledging again that individual educators will have varying comfort with risk.Through this project, educators also reflected on the strategies they developed to support risky play and the use of loose parts. Observation was a key strategy noted by many of the participants in facilitating risky play. Educators discussed the importance of stepping back, staying close without interrupting, and letting children lead. One participant said, “we've just recently had new staff that have come in so we kind of had to go through the whole process all over again explaining it and expectations but also like comfort levels and kind of where we're at with risk taking”. Additionally, many participants discussed the importance of talking to parents about risky play. One said, “we have lots of parent nights dedicated to it [...] we do try to really open up that as a talking point with our families so they're comfortable with things that we're doing with their children”, while another said, “talking it through with our parents and our families is really important because I don't want them to just walk in and think it's like [...] we're not being careful or thoughtful, that we're not being intentional, because we know the benefits”. Others connected this more directly to the loose parts intervention, noting that “it created a dialogue” and “gave us more tools to go and say this is why we're doing this [...] And how we're going to do this effectively”, demonstrating the importance of clear communication with families regarding risky play and loose parts.Relatedly, educators mentioned the importance of communication in facilitating risky play and outdoor loose parts play. As mentioned, educators have individual experience, background, and comfort levels with risky play, and communicate with one another to ensure educators feel comfortable supervising each activity. Others discussed how risky play warranted communication when there were staff changes, with one saying, 3.4.“they're up so high and they could fall down and hurt themselves, but there's so much more that they learn from it”. Some described risky play as a natural and important part of healthy development, saying, “it's part of growing up”. Others noted how children wanted to engage in this type of play, with one saying, “I think it was just, it was something they craved, like they kind of needed to explore it, they needed to see if they could”. In addition, educators noted that risky play was perceived as “thrilling to them” and that it made “outside time more exciting”. Participants discussed the importance of boundary-pushing and thrill-seeking associated with risky play. One educator said, for example, “they're pushing the boundaries to see how far they can go”. Another participant said, “it's also the forbidden fruit, my mother doesn't let me do that, but I can do that at the daycare”, describing their perception of how children enjoyed risk-taking opportunities.The final theme describes how educators perceived risky play as beneficial for children's healthy development. Participants discussed their perceptions that children should take risks and want to take risks, and frequently discussed how risks come with rewards. One said, for example, “the big improvement I think has been the children, you know who are really now taking more risks, and using a lot more problem solving”. Participants also discussed how the children self-assessed risks and developed risk-management skills. One said, for example, “the class independently decided that's too high, we should not jump from here”, while another said, “I think they know like where their limits are”. Many educators discussed their perception that risky play promoted confidence. One said, for example, “you really saw the child sort of push themselves out of their comfort zone”, while another said, “I think the more risk they take, the more confidence they have”. This confidence was also associated with pride and was perceived to have long-term health benefits: “it's a sense of pride, it's a sense of accomplishment and that's huge cause [...] that's what they see in the future and them taking risks in adulthood”.Educators also described their perception that risky play promoted problem-solving, social skills, and confidence. One participant noted that, “really push themselves physically”, and how, “over time they're just taking bigger risks, using more muscles you know, using different muscles”. By taking risks, children were developing critical fundamental movement skills, such as coordination and balance, and improving muscular strength and endurance: “you can really see that their coordination is improving, their balance is improving”; “his muscle development was not quite there [...] and his parents had mentioned that he had come a long way [...] and he was enjoying the experience.Participants also mentioned the value of risky play for supporting children's physical health and well-being. One participant noted that risk taking during outdoor loose parts play allowed children to “I notice a lot more of that with the loose parts, like the risk-taking opportunities are awesome”. Another added, about the loose parts intervention, “it really added to our play and to their risks”. Others discussed how children were more ready and prepared to take risks, with one saying, “they were more eager to take risks [...] like after using these materials in different ways, they were more eager”, and another agreeing, “they're taking more risks than they would have, or higher risks than they would have”. Regarding the loose parts, another participant said, “it gives them the opportunity to scale their risk, depending on what they're comfortable with”.Finally, there seemed to be consensus among participants that the loose parts intervention provided more opportunity for risky play. One educator said, 4.Through Qualitative Description, we identified four themes that can be analyzed using an ecological lens, specifically, the model developed by van Rooijen and Newstead (2017) to explore professional attitudes toward risky play Through this project, educators reflected on personal and professional development in association with risky play. Educators noted differences between themselves and their colleagues regarding risk taking, acknowledging the influence of their own upbringing and personal experiences. This is important, as educators' perceptions of outdoor play, specifically their beliefs and personal experiences, can influence their teaching and practice, as highlighted in van Rooijen and Newstead's (2017) model which devotes a layer of influence related to professionals' attitudes toward risk Educators also reflected on how their participation in the outdoor loose parts play intervention improved their comfort with risky play. Through this intervention, educators had the opportunity to develop strategies that facilitated their engagement in risky play. Educators noted observation as a key strategy in supporting risky play. They also discussed the importance of communication regarding risky play and being mindful of how risk is framed. This aligns with strategies suggested when assessing risk taking during outdoor play, including considering both the child's and educators' comfort and abilities Through this project, educators also discussed how supporting risky play in the childcare setting comes with challenges and responsibilities. Although educators recognized the importance of risky play, they reflected on the need to balance risk and safety. Educators did express fear and anxiety associated with children injuring themselves through this type of play in the childcare setting. A growing culture of child safety with risk mitigation strategies and childcare centre regulations have impacted the way early childhood educators practice and support risky play; Educators voicing these concerns, and the fears of being perceived as irresponsible, is consistent with previous literature In this study, educators discussed how risk-taking in outdoor play is perceived as fun and thrilling, and how they believed this type of play was rewarding and important. This finding suggests that risky play is generally perceived positively and was encouraged in the participating child-care settings. This is an important finding, as educators' attitudes toward risky influences their practice Educators also discussed how they perceived the loose parts intervention to have a positive impact on the way children engaged in risky play. Educators described how the intervention facilitated children's physical activity and physical literacy and contributed to the development of fundamental movement skills such as balance and coordination, while also improving confidence. This finding is aligned with literature that suggests loose parts diversify the play experience and afford more opportunity to engage in risky play, through physical activities like climbing and balancing, as well as through controlling their environments, and allowing children to explore Important connections can be drawn between the themes identified in this project and across the levels of the model developed by van Rooijen and Newstead (2017) Through this project we were able to explore educators' perceptions of risky play in the context of an outdoor loose parts intervention. Educators seem to recognize and appreciate the value of healthy risk taking during outdoor play for child development, and how loose parts materials provide a mechanism for children to explore and challenge themselves. Educators discussed how they negotiate risky play, and shared strategies they use to ease. Future studies are needed to further explore, evaluate, and assess the strategies used by educators here, to determine their efficacy in facilitating risky play, and to identify additional strategies. Future research should also further explore how risky play is communicated in childcare settings: with and between educators and administration, with parents and families, and with children.This project has several strengths and limitations. A strength of this project is its contribution to the literature by adding a qualitative exploration of early childhood educators' perceptions of outdoor risky play in the context of a loose parts intervention. An additional strength is its use of an ecological framework and the recently developed model of van Rooijen and Newstead (2017) Through this study, we found that risky play with loose parts contributes to an ongoing evolution in educator perceptions, and that those educator perceptions are intertwined with institutional, systemic, and cultural influences. We also found that educators facilitate risky play with loose parts by learning and developing new strategies, and that they perceive risky play to be an important part of healthy child development. Sharing these insights with other early years stakeholders may provide a better understanding on the benefits of risky play and the associated contribution offered by loose parts materials.