Offshore wind is one of the major fast-growing renewable energy industries, and sustainable implementation of offshore wind farms (OWF) is desired. Nature positive approaches have been proposed to promote biodiversity gain and improve ecosystem resilience. At the same time, coexistence has been considered a way to mitigate the race for ocean space and better integrate the development of the OWF industry. Here, we provide a systematic narrative synthesis review on nature positive approaches and coexistence in OWFs. We observed an increased interest in the topics over the last 5 years, with most of the documents coming from the northern hemisphere, in particular Europe and the North Sea. Literature is mostly related to bottom-fixed turbines, with relatively fewer documents available regarding floating offshore wind, which is a nascent industry. There is a lack of long-term in situ assessments of the impact of nature positive approaches. Whilst there are various biodiversity impacts of OWFs, the literature highlights the artificial reef effect and biodiversity protection and gain (diversity and abundance) for ecological and economically relevant groups. Coexistence strategies with OWF, such as fisheries, aquaculture, and marine-protected areas, bring positive and negative outcomes for the environment, and further investigation on their integration should be explored.