The Journal of Nursing Research h VOL. 23, NO. 3, SEPTEMBER 2015
BRIEF REPORT
Effects of Horticultural Therapy on Psychosocial Health in Older Nursing Home Residents: A Preliminary Study Yuh-Min Chen1* & Jeng-Yi Ji2 1
PhD, RN, Associate Professor, School of Nursing, China Medical University & 2 MSN, RN, Project Instructor, School of Nursing, China Medical University.
ABSTRACT This preliminary study examined the effect of horticultural therapy on psychosocial health in older nursing home residents. A combined quantitative and qualitative design was adopted. Convenience sampling was used to recruit 10 older residents from a nursing home in Taichung, Taiwan. Participants joined a 10-week indoor horticultural program once a week, with each session lasting for about 1.5 hours. A single-group design with multiple measurements was adopted for the quantitative component of this study. Interviews held 1Y2 days before the intervention (T0) were used to collect baseline data. The two outcome variables of this study, depression and loneliness, were reassessed during the 5th (T1) and 10th (T2) weeks of the intervention. Generalized estimating equations were used to test the mean differences among T0, T1, and T2 measures. After the 10-week program, qualitative data were collected by asking participants to share their program participation experiences. The results of generalized estimating equation showed significant improvements in depression and loneliness. Four categories emerged from the qualitative data content analysis: social connection, anticipation and hope, sense of achievement, and companionship. Given the beneficial effects of the horticulture therapy, the inclusion of horticultural activities in nursing home activity programs is recommended.
KEY WORDS: nursing home, older adults, psychosocial health, horticulture therapy.
Introduction Moving into a nursing home is a stressful life event for older adults. Profound losses and adjustment challenges often have detrimental effects on psychosocial health (Walker, Curry, & Hogstel, 2007). Depression and loneliness are particularly common psychosocial problems experienced by residents of nursing homes (Chuang & Abbey, 2009; Lin, Wang, & Huang, 2007). Therefore, improving the psychosocial health of residents is a subject of concern in residential care practice. Horticultural therapy applies plants and horticultural activities to achieve specific treatment goals. It helps individuals learn
new skills, adjust to functional loss, and experience hopeful and nurturing feelings (American Horticultural Therapy Association, 2013). Horticultural therapy has beneficial effects on physical, psychosocial, and cognitive functions such as improving body coordination, encouraging social activity, and improving mood. This therapy has been used in a diverse range of healthcare and residential settings (Gonzalez, Harting, Patil, Martinsen, & Kirkevold, 2010; Tuziak, 2010). Horticulture is a popular leisure activity for older adults and is highly suited for use as a therapy. However, few empirical studies have focused on the effect of horticultural therapy on older residents of nursing homes, and further exploration is needed. The aim of this study was to examine the effects of horticultural therapy on psychosocial health in older nursing home residents.
Methods A combined quantitative and qualitative design was adopted. Formal ethical approval to conduct the study was obtained from a university research ethics committee. Convenience sampling was used to recruit older residents from a nursing home in Taichung. The inclusion criteria were as follows: (a) aged 65 years or older, (b) score of 3 or higher on manual muscle testing for at least one upper limb, (c) resident of the nursing home for at least 3 months, (d) able to communicate, and (e) no diagnosed cognitive or mental impairment. In the nursing home, the head nurse helped to identify eligible residents for the researchers. Informed consent was obtained from each eligible candidate before data collection. Ten older residents participated in this study. Accepted for publication: January 29, 2014 *Address correspondence to: Yuh-Min Chen, No. 91, Hsueh Shih Rd., Taichung City 40402, Taiwan, ROC. Tel:+ 886 (4) 2205-3366 ext. 7106; E-mail: [email protected] The authors declare no conflicts of interest. Cite this article as: Chen, Y. M., & Ji, J. Y. (2014). Effects of horticultural therapy on psychosocial health in older nursing home residents: A preliminary study. The Journal of Nursing Research, 23(3), 167Y171. doi:10.1097/jnr.0000000000000063
167
The Journal of Nursing Research
Participants joined a 10-week indoor horticultural program once each week, with each session lasting for about 1.5 hours. The activity was conducted in the activity room of the nursing home. Native plants that were easy to look after and familiar to older residents were used in the program to increase participants’ interest and motivation to participate. The program included planting green bean seeds, propagating Echeveria peacockii by leaf cutting, propagating Asiatic wormwood by stem cutting, discussing proper plant care techniques, planting green bean sprouts, using basil and Asiatic wormwood in cooking, and drinking Asiatic wormwood tea. The activity also incorporated holiday celebrations into the course design such as decorating flowerpots for Mother’s Day and arranging cut flowers and foliage in baskets for the Buddha Festival. A single-group design with multiple measurements was adopted for the quantitative component of this study with loneliness and depression as the outcome variables. The questionnaires included a background data sheet, Geriatric Depression Scale-Short Form (GDS-SF; Sheikh & Yesavage, 1986), and the UCLA Loneliness Scale version 3 (Russell, 1996). The GDS-SF consists of 15 items requiring ‘‘yes’’ (1) or ‘‘no’’ (0) answers. Higher scores indicate higher levels of depression. A score above 5 is suggestive of depression. The UCLA Loneliness Scale version 3 has 20 items with responses ranging from ‘‘never’’ (1) to ‘‘often’’ (4). Higher scores indicate higher levels of loneliness. Both scales have demonstrated good psychometric properties in studies of older adults. In this study, Cronbach’s alpha coefficients of the UCLA Loneliness Scale version 3 and GDS-SF were .71 and .75, respectively. Data were collected by interview 1Y2 days before the intervention (T0). Two outcome variables, depression and loneliness, were reassessed on the 5th (T1) and 10th (T2) weeks of the intervention. Data were analyzed using SPSS/Windows 18.0 statistical software. Generalized estimating equations were used to test the mean differences among T0, T1, and T2 measures. Statistical significance was set at p G .05. After the 10-week program, qualitative data were collected by asking participants to share their program participation experiences. After each interview, the recorded data were transcribed verbatim for content analysis. Transcripts were analyzed using qualitative content analysis as proposed by Tesch (1990). The unit of analysis was statements that expressed a meaningful idea pertaining to the study object. Coding categories were refined until all meaningful data were coded into exclusive categories.
Results The mean age of participants was 75.3 (SD = 9.55) years, and 60% were men. Table 1 shows participant demographic data. The results of generalized estimating equation showed significant improvements in depression and loneliness. The score for depression decreased from 8.1 (SD = 3.28) at T0 to 5.2 (SD = 2.94) at T1 and 3.6 (SD = 2.76) at T2 (p G .001). At the end of this program, the mean score for depression fell below the cutoff value of 5. Among the 15 items of this scale, the mean 168
Yuh-Min Chen et al.
score for ‘‘Do you often feel bored?’’ showed the maximum decline (.80 T .42 at T0 to .10 T .32 at T2). The score for loneliness decreased from 42.9 (SD = 9.26) at T0 to 34.2 (SD = 7.54) at T1 and 35.9 (SD = 6.08) at T2 (p G .001). Among the 20 items of this scale, the mean score for ‘‘How often do you feel that people are around you but not with you?’’ showed the maximum decline (3.0 T 1.16 at T0 to 2.10 T .88 at T2). The results support that horticultural therapy improves depression and loneliness in older residents of the nursing homes. In terms of qualitative data, four categories emerged from the content analysis: social connection, anticipation and hope, sense of achievement, and companionship. Social connection was the most frequently mentioned experience gained from participating horticultural activity. The horticultural activity in this study offered participants a new topic to chat about with their peers. Participants enjoyed sharing their horticultural experiences and personal knowledge with others. They even helped each other while performing other institutional activities. Through the activity process, they became more socially active and formed supportive relationships with others. The horticultural activity offered older residents the opportunity to connect to other residents. For example, one participant stated: ‘‘This activity helped me establish friendships with several of my partners. During the class, I could share my horticultural experience with others. Group members become more familiar with each other.... We also chat about plants and everyday life during other activities.’’ Anticipation and hope were the second most frequently mentioned experience. Growing plants provided something for participants to look forward to every day. Participants described watching their plants grow and bloom as an anticipating and exciting event in their lives. They expressed their eagerness to watch the process of sprouting and blooming. The existential and developmental characteristics of plants facilitated a sense of hope throughout the entire therapeutic process. For example, one participant stated: ‘‘I am so happy to see my Echeveria peacockii grows day by day. It gives me a sense of hope. I check it everyday. I look forward to find new leaves and to see how big it will grow.’’ Sense of achievement was also a common experience. At the beginning of this program, almost no participants believed that they still had the ability to grow anything successfully. Participants felt joyful and surprised to see the plants grow. They felt especially happy and proud when their families and other residents complimented them on their plants. Participants gained a sense of achievement by completing a task with a visible product. One participant stated: ‘‘Through my care, the plants are still alive and even grow up! I almost can’t believe. It means that this time I am successful. I am so happy to share them with my son.’’ The last category, companionship, is a special experience. Some participants expressed that they perceived their plants as good companions that reduced their sense of loneliness. They talked to their plants to encourage them to grow. Moreover, when they felt lonely, participants talked to the plants
Horticultural Therapy
VOL. 23, NO. 3, SEPTEMBER 2015
TABLE 1.
Demographic Characteristics Muscle Power of Upper Limb Case Age (Year) Gender A
60
Male
Education
Length of Residency (Year)
Right
Left
5.2
5
5
Junior high
Comorbidity 1. Hypertension 2. Diabetes 3. Anemia
B
79
Female
Elementary school
2.4
5
5
1. Hypertension 2. CAD 3. CVA 4. Diabetes
C
65
Male
Senior high
0.5
3
5
1. Gout 2. Diabetes 3. Liver cirrhosis 4. Chronic bronchitis
D
78
Female
Illiterate
1.2
5
5
1. Hypertension 2. CHF 3. L-spine injury
E
82
Female
Illiterate
7.5
2
5
1. Hypertension 2. CVA
F
85
Female
Elementary school
1.1
4
4
1. Hypertension 2. CHF 3. Diabetes
G H
81 84
Male Female
Junior high Elementary school
2.2 3.2
5 4
5 4
1. Bladder cancer 1. Hypertension 2. CHF 3. Diabetes 4. CKD
I
79
Female
College
9.5
5
5
1. Hypertension 2. CHF
J
65
Male
College
5.1
3
5
1. CVA
Note. CAD = coronary artery disease; CVA = cerebrovascular accident; CHF = congestive heart failure; CKD = chronic kidney disease.
and perceived the plants to be good listeners. They formed special affective bonds with their plants. For example, one participant stated: ‘‘I say hello and talk to my plants everyday to encourage them to make every effort to grow up. It seems that the little plants can understand what I say to them because they grow healthily. They respond to my encouragement and make me feel that I am not alone.’’
Discussion This study supports the therapeutic effects of horticultural programs on psychosocial health in older nursing home residents. In terms of quantitative measurements, scores for both loneliness and depression decreased significantly during and
after the horticultural program intervention. These findings are consistent with other studies (Gonzalez et al., 2010; Hayashi et al., 2008; Tse, 2010). The significant decrease in loneliness supports the therapeutic effect of horticultural programs in reducing perceived loneliness. As indicated by Tse, gardening is a good strategy to foster socialization and decrease perceptions of loneliness. The data also support that horticultural programs improve depression among participants. In this study, the score for depression decreased from 8.1 at T0 to 5.2 at T1 and 3.6 at T2. A score greater than 5 is suggestive of depression. Therefore, the postintervention mean score for depression in this study indicates that participants were no longer depressed. Engaging in pleasant activities holds the potential to alleviate depression (Gonzalez et al., 2010). 169
The Journal of Nursing Research
Horticultural activity is a useful tool for enhancing positive mood (Hayashi et al., 2008). In addition, participants expressed that participation in the program provided positive benefits, including social connection, anticipation and hope, sense of achievement, and companionship. All of these potentially reduce perceptions of loneliness and depression and thus may improve psychosocial health. During the horticultural activity, the participants often proactively and happily interacted with other participants. Positive social interactions and meaningful conversations among residents of nursing homes are difficult to develop spontaneously. Healthcare providers should actively introduce a theme of mutual interest to facilitate conversation and social bonding (Bergland & Kirkevold, 2008). Using horticulture as a medium, the activity introduced in this study offered participants the opportunity to connect to others and to enhance interpersonal relationships. In addition to developing relationships with other residents, participants also developed affective bonds with their plants. In nurturing their plants, the plants seemed to enrich the lives of participants. The growth of the plants provided pleasant surprises for participants. They anticipated seeing each new stage of plant growth. This anticipation conveyed hope for the future. The vitality of the plants inspired a sense of hope in participants. Importantly, hope impacts an individual’s attitudes toward life and strengthens psychological functioning (Kim, Kim, SchwartzBarcott, & Zucker, 2006). Caring for plants also promotes confidence. At the beginning, nearly all participants doubted their ability to successfully cultivate plants. However, they gradually gained in self-confidence as the activity progressed and looked forward both to the next program session and to the growth of their plants. Overall, horticultural activity has various healing potentials for psychosocial health. Finally, the results of this study should be interpreted in light of limitations imposed by the small sample size used and the lack of a randomized controlled trial. Further research should conduct a randomized controlled trial and adopt a substantially larger sample size to accomplish a more rigorous evaluation of the effect of horticultural therapy on the psychosocial health of elderly nursing home residents.
Implications for Practice Physical activity is a vital component of healthy living (Chen, 2010). Nursing home residents often face restrictions on physical activity choices and ability to participate. The staff of nursing home should offer resources to residents that enable these residents to pursue meaningful activities that enhance their psychosocial health. Horticultural programs hold the potential to address the needs of various levels of participant ability while
170
Yuh-Min Chen et al.
achieving therapeutic goals. Given the various beneficial effects of horticultural therapy, the inclusion of horticultural activities into the program design of nursing homes is recommended.
References American Horticultural Therapy Association. (2013). Horticultural therapy. Retrieved from http://ahta.org/ Bergland, Å., & Kirkevold, M. (2008). The significance of peer relationships to thriving in nursing homes. Journal of Clinical Nursing, 17(10), 1295Y1302. doi:10.1111/j.1365-2702.2007.02069.x Chen, Y. M. (2010). Perceived barriers to physical activity among older adults residing in long-term care institutions. Journal of Clinical Nursing, 19(3Y4), 432Y439. doi:10.1111/j.1365-2702.2009 .02990.x Chuang, Y. H., & Abbey, J. (2009). The culture of a Taiwanese nursing home. Journal of Clinical Nursing, 18(11), 1640Y1648. doi:10 .1111/j.1365-2702.2008.02698.x Gonzalez, M. T., Harting, T., Patil, G. G., Martinsen, E. W., & Kirkevold, M. (2010). Therapeutic horticulture in clinical depression: A prospective study of active components. Journal of Advanced Nursing, 66(9), 2002Y2013. doi:10.1111/j.1365-2648.2010.05383.x Hayashi, N., Wada, T., Hirai, H., Miyake, T., Matsuura, Y., Shimizu, N., I Horiuchi, S. (2008). The effects of horticultural activity in a community garden on mood changes. Environmental Control in Biology, 46(4), 233Y240. doi:10.2525/ecb.46.233 Kim, D. S., Kim, H. S., Schwartz-Barcott, D., & Zucker, D. (2006). The nature of hope in hospitalized chronically ill patients. International Journal of Nursing Studies, 43(5), 547Y556. doi:10.1016/j.ijnurstu .2005.07.010 Lin, P. C., Wang, H. H., & Huang, H. T. (2007). Depressive symptoms among older residents at nursing homes in Taiwan. Journal of Clinical Nursing, 16(9), 1719Y1725. doi:10.1111/j.1365-2702.2007 .01743.x Russell, D. W. (1996). UCLA Loneliness Scale (version 3): Reliability, validity and factor structure. Journal of Personality Assessment, 66(1, Suppl.), 20Y40. doi:10.1207/s15327752jpa6601_2 Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric depression scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5(1Y2), 165Y173. doi:10.1300/J018v05n01_09 Tesch, R. (1990). Qualitative research: Analysis types & software tools. Oxford, UK: Routledge Falmer. Tse, M. M. Y. (2010). Therapeutic effects of an indoor gardening programme for older people living in nursing homes. Journal of Clinical Nursing, 19(7Y8), 949Y958. doi:10.1111/j.1365-2702.2009 .02803.x Tuziak, H. (2010). Getting ‘‘reconnected’’ to nature. Canadian Nursing Home, 21(1), 19Y21. Walker, C. A., Curry, L. C., & Hogstel, M. O. (2007). Relocation stress syndrome in older adults transitioning from home to a long-term care facility: Myth or reality? Journal of Psychosocial Nursing and Mental Health Services, 45(1), 38Y45.
BRIEF REPORT
Effects of Horticultural Therapy on Psychosocial Health in Older Nursing Home Residents: A Preliminary Study Yuh-Min Chen1* & Jeng-Yi Ji2 1
PhD, RN, Associate Professor, School of Nursing, China Medical University & 2 MSN, RN, Project Instructor, School of Nursing, China Medical University.
ABSTRACT This preliminary study examined the effect of horticultural therapy on psychosocial health in older nursing home residents. A combined quantitative and qualitative design was adopted. Convenience sampling was used to recruit 10 older residents from a nursing home in Taichung, Taiwan. Participants joined a 10-week indoor horticultural program once a week, with each session lasting for about 1.5 hours. A single-group design with multiple measurements was adopted for the quantitative component of this study. Interviews held 1Y2 days before the intervention (T0) were used to collect baseline data. The two outcome variables of this study, depression and loneliness, were reassessed during the 5th (T1) and 10th (T2) weeks of the intervention. Generalized estimating equations were used to test the mean differences among T0, T1, and T2 measures. After the 10-week program, qualitative data were collected by asking participants to share their program participation experiences. The results of generalized estimating equation showed significant improvements in depression and loneliness. Four categories emerged from the qualitative data content analysis: social connection, anticipation and hope, sense of achievement, and companionship. Given the beneficial effects of the horticulture therapy, the inclusion of horticultural activities in nursing home activity programs is recommended.
KEY WORDS: nursing home, older adults, psychosocial health, horticulture therapy.
Introduction Moving into a nursing home is a stressful life event for older adults. Profound losses and adjustment challenges often have detrimental effects on psychosocial health (Walker, Curry, & Hogstel, 2007). Depression and loneliness are particularly common psychosocial problems experienced by residents of nursing homes (Chuang & Abbey, 2009; Lin, Wang, & Huang, 2007). Therefore, improving the psychosocial health of residents is a subject of concern in residential care practice. Horticultural therapy applies plants and horticultural activities to achieve specific treatment goals. It helps individuals learn
new skills, adjust to functional loss, and experience hopeful and nurturing feelings (American Horticultural Therapy Association, 2013). Horticultural therapy has beneficial effects on physical, psychosocial, and cognitive functions such as improving body coordination, encouraging social activity, and improving mood. This therapy has been used in a diverse range of healthcare and residential settings (Gonzalez, Harting, Patil, Martinsen, & Kirkevold, 2010; Tuziak, 2010). Horticulture is a popular leisure activity for older adults and is highly suited for use as a therapy. However, few empirical studies have focused on the effect of horticultural therapy on older residents of nursing homes, and further exploration is needed. The aim of this study was to examine the effects of horticultural therapy on psychosocial health in older nursing home residents.
Methods A combined quantitative and qualitative design was adopted. Formal ethical approval to conduct the study was obtained from a university research ethics committee. Convenience sampling was used to recruit older residents from a nursing home in Taichung. The inclusion criteria were as follows: (a) aged 65 years or older, (b) score of 3 or higher on manual muscle testing for at least one upper limb, (c) resident of the nursing home for at least 3 months, (d) able to communicate, and (e) no diagnosed cognitive or mental impairment. In the nursing home, the head nurse helped to identify eligible residents for the researchers. Informed consent was obtained from each eligible candidate before data collection. Ten older residents participated in this study. Accepted for publication: January 29, 2014 *Address correspondence to: Yuh-Min Chen, No. 91, Hsueh Shih Rd., Taichung City 40402, Taiwan, ROC. Tel:+ 886 (4) 2205-3366 ext. 7106; E-mail: [email protected] The authors declare no conflicts of interest. Cite this article as: Chen, Y. M., & Ji, J. Y. (2014). Effects of horticultural therapy on psychosocial health in older nursing home residents: A preliminary study. The Journal of Nursing Research, 23(3), 167Y171. doi:10.1097/jnr.0000000000000063
167
The Journal of Nursing Research
Participants joined a 10-week indoor horticultural program once each week, with each session lasting for about 1.5 hours. The activity was conducted in the activity room of the nursing home. Native plants that were easy to look after and familiar to older residents were used in the program to increase participants’ interest and motivation to participate. The program included planting green bean seeds, propagating Echeveria peacockii by leaf cutting, propagating Asiatic wormwood by stem cutting, discussing proper plant care techniques, planting green bean sprouts, using basil and Asiatic wormwood in cooking, and drinking Asiatic wormwood tea. The activity also incorporated holiday celebrations into the course design such as decorating flowerpots for Mother’s Day and arranging cut flowers and foliage in baskets for the Buddha Festival. A single-group design with multiple measurements was adopted for the quantitative component of this study with loneliness and depression as the outcome variables. The questionnaires included a background data sheet, Geriatric Depression Scale-Short Form (GDS-SF; Sheikh & Yesavage, 1986), and the UCLA Loneliness Scale version 3 (Russell, 1996). The GDS-SF consists of 15 items requiring ‘‘yes’’ (1) or ‘‘no’’ (0) answers. Higher scores indicate higher levels of depression. A score above 5 is suggestive of depression. The UCLA Loneliness Scale version 3 has 20 items with responses ranging from ‘‘never’’ (1) to ‘‘often’’ (4). Higher scores indicate higher levels of loneliness. Both scales have demonstrated good psychometric properties in studies of older adults. In this study, Cronbach’s alpha coefficients of the UCLA Loneliness Scale version 3 and GDS-SF were .71 and .75, respectively. Data were collected by interview 1Y2 days before the intervention (T0). Two outcome variables, depression and loneliness, were reassessed on the 5th (T1) and 10th (T2) weeks of the intervention. Data were analyzed using SPSS/Windows 18.0 statistical software. Generalized estimating equations were used to test the mean differences among T0, T1, and T2 measures. Statistical significance was set at p G .05. After the 10-week program, qualitative data were collected by asking participants to share their program participation experiences. After each interview, the recorded data were transcribed verbatim for content analysis. Transcripts were analyzed using qualitative content analysis as proposed by Tesch (1990). The unit of analysis was statements that expressed a meaningful idea pertaining to the study object. Coding categories were refined until all meaningful data were coded into exclusive categories.
Results The mean age of participants was 75.3 (SD = 9.55) years, and 60% were men. Table 1 shows participant demographic data. The results of generalized estimating equation showed significant improvements in depression and loneliness. The score for depression decreased from 8.1 (SD = 3.28) at T0 to 5.2 (SD = 2.94) at T1 and 3.6 (SD = 2.76) at T2 (p G .001). At the end of this program, the mean score for depression fell below the cutoff value of 5. Among the 15 items of this scale, the mean 168
Yuh-Min Chen et al.
score for ‘‘Do you often feel bored?’’ showed the maximum decline (.80 T .42 at T0 to .10 T .32 at T2). The score for loneliness decreased from 42.9 (SD = 9.26) at T0 to 34.2 (SD = 7.54) at T1 and 35.9 (SD = 6.08) at T2 (p G .001). Among the 20 items of this scale, the mean score for ‘‘How often do you feel that people are around you but not with you?’’ showed the maximum decline (3.0 T 1.16 at T0 to 2.10 T .88 at T2). The results support that horticultural therapy improves depression and loneliness in older residents of the nursing homes. In terms of qualitative data, four categories emerged from the content analysis: social connection, anticipation and hope, sense of achievement, and companionship. Social connection was the most frequently mentioned experience gained from participating horticultural activity. The horticultural activity in this study offered participants a new topic to chat about with their peers. Participants enjoyed sharing their horticultural experiences and personal knowledge with others. They even helped each other while performing other institutional activities. Through the activity process, they became more socially active and formed supportive relationships with others. The horticultural activity offered older residents the opportunity to connect to other residents. For example, one participant stated: ‘‘This activity helped me establish friendships with several of my partners. During the class, I could share my horticultural experience with others. Group members become more familiar with each other.... We also chat about plants and everyday life during other activities.’’ Anticipation and hope were the second most frequently mentioned experience. Growing plants provided something for participants to look forward to every day. Participants described watching their plants grow and bloom as an anticipating and exciting event in their lives. They expressed their eagerness to watch the process of sprouting and blooming. The existential and developmental characteristics of plants facilitated a sense of hope throughout the entire therapeutic process. For example, one participant stated: ‘‘I am so happy to see my Echeveria peacockii grows day by day. It gives me a sense of hope. I check it everyday. I look forward to find new leaves and to see how big it will grow.’’ Sense of achievement was also a common experience. At the beginning of this program, almost no participants believed that they still had the ability to grow anything successfully. Participants felt joyful and surprised to see the plants grow. They felt especially happy and proud when their families and other residents complimented them on their plants. Participants gained a sense of achievement by completing a task with a visible product. One participant stated: ‘‘Through my care, the plants are still alive and even grow up! I almost can’t believe. It means that this time I am successful. I am so happy to share them with my son.’’ The last category, companionship, is a special experience. Some participants expressed that they perceived their plants as good companions that reduced their sense of loneliness. They talked to their plants to encourage them to grow. Moreover, when they felt lonely, participants talked to the plants
Horticultural Therapy
VOL. 23, NO. 3, SEPTEMBER 2015
TABLE 1.
Demographic Characteristics Muscle Power of Upper Limb Case Age (Year) Gender A
60
Male
Education
Length of Residency (Year)
Right
Left
5.2
5
5
Junior high
Comorbidity 1. Hypertension 2. Diabetes 3. Anemia
B
79
Female
Elementary school
2.4
5
5
1. Hypertension 2. CAD 3. CVA 4. Diabetes
C
65
Male
Senior high
0.5
3
5
1. Gout 2. Diabetes 3. Liver cirrhosis 4. Chronic bronchitis
D
78
Female
Illiterate
1.2
5
5
1. Hypertension 2. CHF 3. L-spine injury
E
82
Female
Illiterate
7.5
2
5
1. Hypertension 2. CVA
F
85
Female
Elementary school
1.1
4
4
1. Hypertension 2. CHF 3. Diabetes
G H
81 84
Male Female
Junior high Elementary school
2.2 3.2
5 4
5 4
1. Bladder cancer 1. Hypertension 2. CHF 3. Diabetes 4. CKD
I
79
Female
College
9.5
5
5
1. Hypertension 2. CHF
J
65
Male
College
5.1
3
5
1. CVA
Note. CAD = coronary artery disease; CVA = cerebrovascular accident; CHF = congestive heart failure; CKD = chronic kidney disease.
and perceived the plants to be good listeners. They formed special affective bonds with their plants. For example, one participant stated: ‘‘I say hello and talk to my plants everyday to encourage them to make every effort to grow up. It seems that the little plants can understand what I say to them because they grow healthily. They respond to my encouragement and make me feel that I am not alone.’’
Discussion This study supports the therapeutic effects of horticultural programs on psychosocial health in older nursing home residents. In terms of quantitative measurements, scores for both loneliness and depression decreased significantly during and
after the horticultural program intervention. These findings are consistent with other studies (Gonzalez et al., 2010; Hayashi et al., 2008; Tse, 2010). The significant decrease in loneliness supports the therapeutic effect of horticultural programs in reducing perceived loneliness. As indicated by Tse, gardening is a good strategy to foster socialization and decrease perceptions of loneliness. The data also support that horticultural programs improve depression among participants. In this study, the score for depression decreased from 8.1 at T0 to 5.2 at T1 and 3.6 at T2. A score greater than 5 is suggestive of depression. Therefore, the postintervention mean score for depression in this study indicates that participants were no longer depressed. Engaging in pleasant activities holds the potential to alleviate depression (Gonzalez et al., 2010). 169
The Journal of Nursing Research
Horticultural activity is a useful tool for enhancing positive mood (Hayashi et al., 2008). In addition, participants expressed that participation in the program provided positive benefits, including social connection, anticipation and hope, sense of achievement, and companionship. All of these potentially reduce perceptions of loneliness and depression and thus may improve psychosocial health. During the horticultural activity, the participants often proactively and happily interacted with other participants. Positive social interactions and meaningful conversations among residents of nursing homes are difficult to develop spontaneously. Healthcare providers should actively introduce a theme of mutual interest to facilitate conversation and social bonding (Bergland & Kirkevold, 2008). Using horticulture as a medium, the activity introduced in this study offered participants the opportunity to connect to others and to enhance interpersonal relationships. In addition to developing relationships with other residents, participants also developed affective bonds with their plants. In nurturing their plants, the plants seemed to enrich the lives of participants. The growth of the plants provided pleasant surprises for participants. They anticipated seeing each new stage of plant growth. This anticipation conveyed hope for the future. The vitality of the plants inspired a sense of hope in participants. Importantly, hope impacts an individual’s attitudes toward life and strengthens psychological functioning (Kim, Kim, SchwartzBarcott, & Zucker, 2006). Caring for plants also promotes confidence. At the beginning, nearly all participants doubted their ability to successfully cultivate plants. However, they gradually gained in self-confidence as the activity progressed and looked forward both to the next program session and to the growth of their plants. Overall, horticultural activity has various healing potentials for psychosocial health. Finally, the results of this study should be interpreted in light of limitations imposed by the small sample size used and the lack of a randomized controlled trial. Further research should conduct a randomized controlled trial and adopt a substantially larger sample size to accomplish a more rigorous evaluation of the effect of horticultural therapy on the psychosocial health of elderly nursing home residents.
Implications for Practice Physical activity is a vital component of healthy living (Chen, 2010). Nursing home residents often face restrictions on physical activity choices and ability to participate. The staff of nursing home should offer resources to residents that enable these residents to pursue meaningful activities that enhance their psychosocial health. Horticultural programs hold the potential to address the needs of various levels of participant ability while
170
Yuh-Min Chen et al.
achieving therapeutic goals. Given the various beneficial effects of horticultural therapy, the inclusion of horticultural activities into the program design of nursing homes is recommended.
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