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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.
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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.
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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.
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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.