Facilitator for the Month: Bill Knight, Bristol, UK (Resources & Services Lead)
The following article is an open access article published in The Open Journal of Occupational Therapy.
The link is provided for the same at the end of the post.
Aims and Issues addressed by the article
This article aims to identify elements in gardening that can be effectively harnessed in Occupational practice and what features support or impede participation. Social and Therapeutic Horticulture is the process of using plants and gardens to improve physical and mental health, as well as communication and thinking skills (Thrive, 2020).
The study examines how and why occupational therapy practitioners across practice areas use gardening as an intervention. The respondents’ interpretation of the best and least desirable aspects of their facility’s garden and whether they contributed to its design was also examined.
It was chosen for the Journal Club as it provides an evaluation of key issues for Occupational Therapists to consider when planning Social and Therapeutic Horticulture interventions.
Why does it matter? How it fits to what already is known?
Social and Therapeutic Horticulture is a becoming increasingly recognised as an effective intervention as part of the Occupational Therapist’s toolkit. While few disagree with the potential wellbeing benefits of nature-based activities, due to the variable settings and influence of individual biosocial factors, it has been challenging to scientifically measure the general applicable benefits. As a result, much research has focused on qualitative, experiential data from participants.
In these times of Covid-19 social isolation, with the limited access to shared natural spaces, but an increasing focus on home gardens, gardening has become more relevant as an occupational tool.
Design of study
Questionnaire Survey (incl. open-ended)
Study methods
91 OTs or OTAs were contacted. A description and link to a 15-question online survey about gardening as an occupational therapy intervention was emailed to Western Michigan University Occupational Therapy alumni and posted on four OT Connections groups and the AOTA LinkedIn site.
The authors designed a short 15-question survey looking at the use of gardening as an occupational therapy intervention. The study was purposely kept short to encourage a higher participation rate. Fourteen of the survey questions were forced choice and one was open ended. The questions were designed to examine whether and how occupational therapy practitioners use gardening as a therapy intervention and what, if any, features in the garden support or impede participation. The survey also sought to examine whether (if present), the facility garden where occupational therapy practitioners work (or, if doing home care, their client’s garden) met the needs of both clients and practitioners. The open-ended question invited respondents to share their favourite story involving the use of gardening with a client. The survey was posted on Survey Monkey.
Descriptive statistics and a contingency analysis using Pearson’s chi-square with significance at .05 were used to interpret the data for the closed-ended question by means of SPSS Version 21. A content analysis was completed on the open-ended question. It was then sorted into categories based on occupational therapy practitioners’ responses.
Results
Of the initial pool of 91 respondents who answered the question about general demographic information, 92.86% (n = 65) identified as being occupational therapists and 7.14% (n = 5) identified as being occupational therapy assistants. For the 60 who responded affirmatively to using gardening with clients, the following findings were generated.
Of the 60 practitioners who responded to the question about why they use gardening as an occupational therapy intervention, overwhelmingly the responses supported a client-centered approach to treatment. Gardening was selected because it was determined to be meaningful, purposeful, fun, and beneficial for a client. A summary of the findings can be found in Table 4.
When asked if the respondents worked in a garden with their client and whether the practitioner helped to design the garden, 42 participants responded to the question. Of this group, 21.42% (n = 9) indicated that they did help to design the garden and 78.57% (n = 33) indicated they did not help design the garden. The association between whether an occupational therapy practitioner helped to design the garden and the frequency of using gardening as a therapeutic intervention was significant (x= 17.80, p = 007). Practitioners who helped to design the garden used it more frequently than those practitioners who did not.
When asked to share a favourite story about using gardening as an intervention, the predominant themes that emerged from a content analysis of the stories were as follows: Gardening as an occupational therapy intervention was (a) client centered, (b) provided for a sense of accomplishment, (c) functioned as an antidote for depression, (d) offered connection to the earth and with the practitioner, (e) was therapeutic, and (f) was meaningful and purposeful. Of the 54 shared, four are particularly noteworthy in acknowledging the meaning and purpose of gardening.
Environments that support active engagement and meaning are motivating and fun. Universally designed environmental contexts, including gardens, can support occupational engagement, and subsequently, flow, the just right challenge, and mindfulness. The importance of a just right environment is paramount to enhance the effectiveness of this time-honored activity.
While it is evident from this study that occupational therapy practitioners use gardening as an intervention in highly evidence-based climates, such as health care and education (Müllersdorf & Ivarsson, 2012), there is a paucity of evidence from the profession validating its effectiveness. Further, there is a disconnection within the profession in translating this intervention into measurable outcomes. Frequency of gardening as a therapeutic intervention and practitioner involvement in designing the garden was significant (p = .007), suggesting that for respondents, environmental context supports engagement and heightens the meaningfulness and purposefulness of gardening.
Implications
Results of this study support this contention by Fieldhouse that practitioners “cannot bestow meaning on occupations used in therapy” (2003, p. 287). Rather, meaning must derive from client-centered therapy. Occupational therapy practitioners were nearly twice as likely to use gardening as an occupational therapy intervention because it is a meaningful, purposeful, and motivating activity for their clients, rather than because the practitioner likes to garden. There is a need to acquire an evidence base of the clinical effectiveness, meaning, and purpose of gardening as an occupational therapy intervention based on the positive health benefits that have been identified with engagement in it. The results of the pilot survey along with AOTA’s priority for translational, intervention, and health services research (2011) suggests that further rigorous randomized controlled trial research to evaluate the effectiveness and efficacy of gardening as a client centered, meaningful and purposeful activity for occupational therapy and our engagement in the design of the garden is warranted. Equally as important, phenomenological research endeavours will help to elucidate the meaning and value that gardening as a therapeutic intervention provides to the clients with whom we work.
Conclusion
This study highlights the practical considerations to improve the effectiveness of Nature interventions. Based on results of this study, a suggested next step is evidence-based translational and intervention research to validate the efficacy of gardening as an occupational therapy intervention and occupational therapy practitioners’ professional value as implementers of such intervention. Assessing the effectiveness of the role of occupational therapy practitioners in facility garden design is also important to consider.
Facilitators Comments-
I liked the recognition that meaning can only be derived from the client’s individual participation in the activity and their interest e.g. there is a need for client centredness to identify the appropriateness of the horticultural intervention. By involving clients in garden design, the responsibility and control may improve their motivation. The open-ended question enabled richer, more qualitative data to be captured which may have been lost in the quantitative figures. Ultimately however this is a snapshot of the occupational Therapists’ subjective evaluation of effectiveness rather than being driven from the client’s perspective (although with a client-centred approach, these should be similar). The study provides some useful guidelines for future horticultural interventions.
The article is now open for discussion. Don’t forget to share your thoughts and views on it in the comment section below:
The link for the full article can be found at: https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=1128&context=ojot
Open for discussion
I was very lucky to be supported on my 3rd year placement to implement a gardening group in a forensic mental health setting. (I will note that I trained in horticulture before OT). The sense of purpose the clients demonstrated, their response to being trusted with a caretaking role/gentle responsibility, their personal achievement when seeds germinated and the positivity of the group, including the officers and allied health staff as everyone worked towards a common goal was overwhelming and so rewarding. I particularly noted that the trust given to our clients, when working with tools that could easily have been used as weapons, was paid back tenfold. Obviously there were many confines in the group practice, the materials and plants we could use and the design of the space, but every single client was involved, whether it was choosing their favourite veggies to grow, sowing seeds with gloves on due to sensory aversions, digging and raking to let off some steam, watering as part of a morning routine or harvesting and engaging in cooking. My highlight was when a chap who rarely showed any emotion just lit up when his saw his seeds had germinated and he got to plant them out. The sense of shared ownership calmed clients and supported collaboration. A very enriching experience and I will carry it with me always. I sf it's made specific enough to suit individual goals, inclusion, choice and control, then it's a great intervention in any setting and the growing body of evidence backs this up.
I really enjoyed this article as I have personally always found gardening to be incredibly therapeutic, even when I was a child when I would help my mother in her garden to pick her freshly grown strawberries.
As a student completing my MSc OT degree, I have witnessed first-hand on placement the impact that gardening can have on a client. I remember one client during my mental health placement who consistently had issues surrounding discipline and engagement in interventions - the one intervention which he never missed was gardening, as he was the sole person in charge of maintaining the garden and for keeping all of the flowers and herbs alive for the rest of the clients who attended the facility.
Gardening is a very versatile intervention, as it can be graded to meet the needs of the individual, and it also provides so much amazing sensory input, and it can teach other skills such as planning and completing executive functions.
In line with the future implications of the study, I hope that further studies can be conducted in order to provide a stronger evidence base to clinically support this intervention, as gardening can be used in so many ways to support the needs and goals of our clients.
At my hospice I run weekly STH sessions for a group of day services patients (with the support of volunteers), and we have a planning session at the beginning of the year to decide what they would like to grow, and plan out our sessions across the year. We have allotment plots and a patio that patients work with.
Currently as the group can not meet face to face, I write a monthly newsletter, keeping them connected to nature, and each other. They have been able to be updated on the growing of the plants and vegetables they planted before they went into shielding. They have sent in photos to be put into the newsletter – all have been motivated to start growing veg at home (with their families' support) as they have missed the weekly hands-on connection. I send them out a little activity that they can do each time, too.
I completed the Thrive ‘Award in STH’ last year which was a great way to consolidate my learning. I am still learning, and that wont stop.
I am a committee member of the Social and Therapeutic Horticulture for Palliative Care specialist interest group (@STH4PC on Twitter). I am one of many OTs in this specialist interest group who use STH within palliative care, in day services and with patients (and their loved ones) on inpatient units.
We are very lucky to have Dr Joe Sempik in our membership. Joe is the author of ‘Health, well-being and social inclusion: therapeutic horticulture in the UK’ as well as other publications and research papers. Just this morning, in fact, Joe held a tutorial on data collection for us. STH4PC use a distress thermometer tool to measure the before and after self-rated scores. This tool helps to demonstrate the reduction of distress following engagement in an STH session.
We have also been been lucky enough to have Dr Garuth Chalfont in our membership. Garuth has talked to us regarding garden design for patients with dementia. Garuth wrote ‘the dementia green care handbook’.
OTs are well placed to lead STH sessions within palliative care. Connecting patients with nature is fantastic for increasing a patient's sense of wellbeing.
Hi Allison, so agree, it's the freedom of choice and autonomy that gardening provides that enpowers clients. The responsibility of nurturing plants, (with the structure of watering, pruning and feeding), can provide such a sense of accomplishment. The ability to share the produce with others, can generate such self-esteem and pride. There are so many overlaps with OT and STH - gardening can be such a useful activity in the OT toolkit :)
I have found that horticulture interventions provide my clients with learning disabilities the freedom to express themselves. They are able to make choices - experience success and failure in a safe place. Their faces light up when a vegetable is ripe for picking, and they are able to share their produce with others. instead of being the ones on the receiving end of care, they are able to be the providers. Having worked with people with epilepsy - and the associated memory problems, as you have pointed out with dementia service users, gardening interventions have been a great way of helping them to practice activities that are familiar and help develop self esteem.
I started out as a horticulture therapist and found it so valuable, I went on to do my OT training so I could provide even better service to people.
Hi Kristinia,
so great to hear this - the range of gardening activities are often so diverse and flexible, enabling interventions to be more easily tailored around the client's particular interests.
I love this article especially coming into spring and summer where people may be more inclined to try gardening! I would be interested to see what the clients who are involved look forward to in gardening or what they think they get out of it. When I was an OT student, one of the placements I was in was in a mental health setting and we had a community garden. Some of the clients loved planting, watering the plants and even educating the therapists and other clients about the plants. We had one client who HATED the activity of gardening but LOVED harvesting the herbs and lettuce we planted because she could bring it back to the kitchen to add to the lunches we prepared. I asked her what she liked about the garden and it was essentially that she liked being able to contribute her harvest to the lunch because it was like a gift to the people she cared for! It is always so special to me to work in such a client centred profession where we can make something out of anything that is meaningful for a client :)
Hi James, Thrive does some excellent work especially in promoting Social and Therapeutic Horticulture as an effective approach. I sometimes found with the dementia residents that gardening enabled them to connect more fully with themselves by recalling their past gardening experiences. It's so important to design gardens for access and inclusivity while minimising risk; sometimes just sitting passively in nature can have wellbeing benefits.
I have recently studied the OU open learn short course on Designing space for dementia care, am interested in the work of Thrive and on behalf of my father in law who lives with vascular dementia applied to the gardening for disabled trust for a wheelchair accessible raised flower bed. I am a firm believer in nature as healer ; perhaps because i hail from the open spaces north of the border.
When we designed a therapeutic garden in one of the carehomes, we also considered how their visitors could use the gardening as a focus for connecting with their relatives (who often had dementia). It also provided a place for residents to connect with one another away from the confines of the carehome😀.
Definitely, I think the flow concept will be useful when we're further on with the project, many of the service users have cognitive impairment and it would be great to use gardening activities to build confidence, esteem, performance skill etc without pressure of a predetermined notion of success.
Hi Anna, agree, I like the way the article has incorporated many of the key benefits of gardens which provides a nice broad assessment for discussion. I was particularly interested in their reference to 'Flow' (proposed by Mihaly Csikszentmihalyi) as a means of engagement which requires less effort than Mindfulness. It may therefore be more appropriate for cognitively impaired clients ? e.g. Gardening groups in carehomes for dementia patients. Gardening feels particular suitable in encouraging Flow due to it's lack of deadlines and freedom of choice (and pace) with the gardening activities.
I work as an occupational therapist with people living with complex mental health problems and am just beginning to get involved - at the design stage - with a garden project that will be used as an environment to facilitate interventions. The article provides a good summary in support of gardening as a meaningful activity, it reminded me about the terminology around the flow/just right challenge and on reflection I agree a collaboratively designed garden provides a fantastic opportunity to build skills within all aspects of the biopsychosocial spheres. It provided peace of mind also that measuring the effectiveness of gardening as an intervention is a challenge :-)
Hi Jessica, totally agree. It's an occupation that often resonates with clients, bringing up their memories and experiences, especially useful with dementia. I think it t is useful in empowering clients through the responsibility for planning and nurturing growth at a pace they decide - countering the lack of control and self-determination often associated with Mental Health. The sharing of produce is a strong social connector !😀
Nice article! Horticulture activities are so meaningful in mental health interventions. The clients, many times, can feel proud about what they did. Especially when plants bear fruit. Thanks for sharing. Greetings from Argentina. 😊