Summary: Although horticultural interventions have potential therapeutic effects on patients’ clinical and psychological outcomes, there is a lack of scientific research based on the experience of elderly post-stroke patients involved in therapeutic gardening during their rehabilitation program. This paper explores post-stroke patients’ experience of a person-centered therapeutic gardening intervention within their rehabilitation programs, by: 1) deepening the comprehension of their own psycho-social experience; and 2) evaluating whether therapeutic gardening is perceived by patients as an occasion to foster their engagement toward rehabilitation and self-care. A qualitative phenomenological study was conducted based on semi-structured interviews and diaries of 22 neurological post-stroke patients. Five main themes were identified from interviews and diaries: 1) the positive experience of nature, 2) therapeutic gardening as a protected self-expression space, 3) contact with nature as a boost for self-efficacy, 4) the plant as a catalyst of the patient-therapist relationship, 5) therapeutic gardening as a bridge between the hospital environment and the outside world. Post-stroke patients who engage in therapeutic gardening perceived it as a way to foster their active role in medical care, enabling a proactive and positive attitude towards disease management. It is of vital importance that therapeutic gardening interventions are appropriately evaluated in order to develop the existing evidence base.
Keywords: Horticulture, gardening, patient engagement, phenomenology, qualitative research, patients’ experiences, stroke, rehabilitation, patient-centered care.
Citation: Barello S, Graffigna G, Menichetti J, Sozzi M, Savarese M, Bosio AC, Corbo M. The value of a therapeutic gardening intervention for post-stroke patients’ engagement during rehabilitation: an exploratory qualitative study. J Participat Med. 2016 Jun 21; 8:e9.
Published: June 21, 2016.
Competing Interests: The authors have declared that no competing interests exist.
Stroke is a leading cause of disability worldwide and even with stable incidence rates the prevalence is expected to increase due to a worldwide aging population.  Patients with stroke often experience anxiety, depression, lack of meaningful activities and life purposes, and restriction of social participation within their daily lives.  The adjustment process to improve well-being, quality of life and social participation after stroke is physically and emotionally demanding, often gradual and prolonged.  Many patients report poor quality of life up to a 5-year post-stroke follow-up. 
Post-stroke patients usually participate in rehabilitation programs to improve the recovery of their physical and mental functions. However, engaging patients in their care can be tedious, difficult, and sometimes discouraging to patients. Thus, there is a need for innovative and multidisciplinary therapeutic protocols in order to increase post-stroke patients’ engagement in their rehabilitation [6-9]. Finding effective solutions to actively engage patients in rehabilitations programs is a key priority to obtain positive health benefits. 
Among the more recent advancements in rehabilitation programs, horticultural therapy is gaining more attention as a way to enhance patients’ engagement.  Person-centered therapeutic gardening is demonstrating a wide range of benefits for different populations of patients  and for a variety of clinical conditions, including depression, stress, and anxiety.  For example, outcomes attributed to patients’ participation in therapeutic gardening interventions included increased motivation and physical functioning, resulting in greater levels of independence and autonomy.  Reported benefits of therapeutic gardening include reducing pain, improving attention, lessening of stress, modulation of agitation, increasing socialization, self-esteem and life satisfaction, lowering the number of medications and the frequency of setbacks.  These benefits may be important factors in improving patient engagement, quality of life and reducing the costs of health care.  A systematic review of controlled trials and observational studies for nature-assisted therapy reported significant improvements in a variety of outcomes among diverse populations of patients, spanning from obesity to schizophrenia.  Unfortunately, although therapeutic gardening holds potential for improving clinical and psychological outcomes, no studies have focused on the experience of post-stroke patients who have been involved in therapeutic gardening during their rehabilitation program. 
The aim of this study was to explore the post-stroke patients’ experience of a person-centered therapeutic gardening as part of their rehabilitation intervention by: 1) deepening our comprehension of the psycho-social experience of post stroke patients regarding their involvement in therapeutic gardening and 2) exploring whether therapeutic gardening is perceived by patients as an opportunity to foster their engagement toward rehabilitation and self-care.
In-depth semi-structured qualitative interviews were conducted to explore the patients’ experience related to their participation in a person-centered therapeutic gardening intervention. Data were analyzed according to the qualitative phenomenological approach.  Phenomenology is a qualitative method which offers a way to gain knowledge on a patient’s subjective experiences and give meaning to phenomena in their life.  By adopting a phenomenological attitude and thus reducing preconceived assumptions, theories and thoughts, the researcher can unveil how phenomena are experienced and signified by individuals.  Moreover, this methodological approach might offer concrete insights to develop care interventions suited to the patients’ needs and attitudes.
Subjects, Setting, and Procedure
Sample selection and ethical approval.
The participants were recruited on a voluntary basis from a rehabilitation hospital in North Italy, which is a pioneer in introducing therapeutic gardening as part of the rehabilitation program. They were selected from a list of patients taking part in a rehabilitation program for post-stroke patients at the hospital. The sampling strategy used in this study was that of purposive sampling. As noted by Giorgi , in purposive sampling, participants are individually selected according to their knowledge of the phenomenon. Thus, in this study, all potential participants were approached to take part, irrespective of age or length of time spent in the rehabilitation hospital. The potential participants who had expressed an interest in the project, discussed with their therapist to determine their suitability to participate in the study. The authors collaborated with the patients’ therapist to apply selection criteria to potential study participants. Patient inclusion criteria were: adults aged 50 or more; confirmed diagnosis of cerebral stroke, either ischemic or hemorrhagic; first acute event; being still physically active and interested in engaging in gardening sessions; Mini Mental State Exam score > 24/30; Cumulative Index Rating Scale < 5; ability to converse in Italian; willingness to participate to the study; and cognitive capabilities and medical condition conducive to participation. Exclusion criteria included: patients with psychiatric disorders and focal neuropsychological deficit (eg, aphasia, neglect); individuals who could not speak; individuals who were confused; patients who refused to sign informed consent. In phenomenological research, the aim is not to generalize findings to the broader population; rather, the focus is on obtaining theoretical richness of data in order to gain a deeper comprehension of a phenomenon. Thus, it is essential that participants are able to understand the aims of the study and to express their thoughts and feelings about the phenomenon.  The study was conducted according to the Declaration of Helsinki, the European Guidelines on Good Clinical Practice. Informed written consent for participation in the study was obtained from each participant, including permission to audio-tape, transcribe, and analyze the interviews.
Setting and description of intervention.
The therapeutic gardening intervention featured 10 bi-weekly sessions along the standard patients’ physical rehabilitation process that consisted 2 daily sessions of physical therapy lasting 45 minutes each for 5 days a week. Every session lasted 60 minutes and included manual activities related to taking care of plants under the guide of a specialized therapist . The activities in the garden ranged from simple to heavier and complicated, and were adapted to the patients’ level of activity based on the judgement of the therapist who worked with the patients during the sessions. The activities performed were: planting herbs on an adapted cultivation table, sowing beetroot seeds on a cultivation bench, loosening soil in a flower bed, digging, harvesting tomatoes, collecting seeds, flower arranging for the lunch table, shaping bushes, and pruning trees. Whenever possible, the harvest of vegetables, seasonal fruits, flowers and herbs was provided.
Interviews and diaries.
After each gardening session, all the patients were asked to fill a diary about the activity just concluded, to assess their experience and to express their feelings. Furthermore, face-to-face semi-structured interviews lasting approximately 60 min were conducted individually by three researchers at the end of the therapeutic gardening intervention. Questions were developed in order to explore subjective representations and meanings associated with the contact with nature, the experience of being involved in the therapeutic gardening intervention, and its potential to foster patients’ engagement in care management (for a detailed overview of the interviews’ guide see Table 1). Interviews were audio-recorded and transcribed verbatim.
Thematic analysis of interviews and diary transcripts was performed using NVIVO10 analysis software  independently by three researchers.  An open coding approach informed by the research main aims was performed and categories (eg, “contact with nature”) and themes (eg, “self-efficacy feelings when in contact with nature”) were developed. Themes were detected according to two criteria (i) prevalence of descriptions during the interviews and (ii) the potential value of themes in explaining different participants’ perceptions.  The researchers participated in regular discussions during data collection, in order to cross-validate the interpretation and to ensure trustworthiness of data analysis. If there was disagreement, the researchers discussed their analysis until a collaborative meaning was reached.
This study included 22 Italian participants, all of whom had been patients who have been involved in therapeutic gardening activities. Their ages ranged from 60 to 88 years (45% male) and they were all married. Among them, 14 patients (63%) were diagnosed with ischemic stroke and 8 patients (37%) were diagnosed with hemorrhagic stroke. The time elapsed since diagnosis ranged between 2 months and 10 years.
Interviews and diaries unveiled five main themes related to patients’ experience of being involved in a therapeutic gardening intervention: 1) the restorative effect of nature, 2) therapeutic gardening as a protected self-expression space, 3) the plant as a catalyzer of patients-therapist relationship, 4) the contact with nature as a boost for self-efficacy, 5) therapeutic gardening as a bridge between the hospital environment and the outside world.
The Positive Experience of Nature
The sample as a whole showed a positive attitude towards nature during their rehabilitation program. Regardless of age, gender or severity of symptoms, patients found nature to be restorative, a setting that allows human beings to retreat when under stress.
“When you say green I suddenly think about grass and peaceful landscapes. This makes me feel relaxed.” (79-year old female patient)
“Thinking of green has a soothing effect on me.” (69-year old female patient)
In the patient view, nature also provided a great distraction when individuals were involved in fatiguing or overwhelming situations: patients described nature as engrossing, and natural scenes as occasions to focus away from pain and discomfort.
“Thinking about nature allows you not to be absorbed by your pain and problems.” (81-year old female patient)
“Experiencing nature and green landscapes takes me away from troubles and worries connected to my health.” (62-year old male patient)
Nature was also depicted as something fundamentally linked to human spirituality, thus allowing individuals to come in touch with their ‘genuine essence’. Nature was experienced by patients as a space in which human beings can connect spiritually both within themselves and outside themselves.
“I had seed flowers and vegetables: Delphinium, Zinnias, and salad. This activity [the gardening] impacted my mood: it kept me in touch with the power of the ground, with its smells and its strength.” (69-year old female patient)
“My tomatoes are growing, their growth reminds me of my daughter: she is so grown-up! Don’t you think that life is magic?” (64-year old female patient)
Patients perceived the growth of plants as steady and progressive, not erratic. Thus, when thinking about the contact with plants, patients associated feelings of consecutiveness and understood their interdependencies with other living beings. Nature also prompted patients to reflect on the ever-changing nature of existence and what might lie beyond it.
“When I think about nature I suddenly remember my father when he taught me to grow our land, it was so satisfying!” (71-year old male patient)
“Nature reminds me of my tomatoes in my terrace, I really miss it and I miss eating something made with my own hands.” (81-year old female patient)
Therapeutic Gardening as a Protected Self-Expression Space
In the patients’ words, gardening provided a “purpose” and helped in giving sense to their daily life during the hospitalization period. The hospital settings was generally experienced by patients as a depriving place where several life choices were not allowed. In this framework, gardening is experienced as a “break” from the hospital environment and routine which, in itself, offers a sense of autonomy and agency, because patients were requested to make their choices (ie, in regards to which plants to garden, as to gardening activities and their patterns, etc). In other words, enacting gardening behaviors, although framed in the script of the healing protocol, offered patients some “degree of freedom” and the occasion to subjectively interpret the assigned task of caring for plants in their own way, by expressing their spontaneous attitudes and skills while interacting with nature.
“Taking care of plants gives you a daily purpose to achieve, making you feel useful and empowered.”
(83-year old female patient)
“When you are hospitalized you lose the control of your body, of your life, of your choices. Having the responsibility to take care of a plant helps you in regaining sense of power and self-esteem.” (70-year old female patient)
“If I learn to take care of my plants maybe I can learn to take care of me.” (85-year old male patient)
Contact with Nature as a Boost for Self-Efficacy
The hospitalization was experienced by patients as a loss of control on their life. Through working with plants, patients experience responsibility and caring for the plant’s life. In most of the cases, the responsibility of “taking care” of something alive (ie, plants) was experienced as close to having more control of their life and healing. Thus, patients reported an increased self-esteem and a better acceptance of their health condition. This also contributed to improved patients’ attitude towards self-care and to enhanced feeling of power and control.
“Before beginning this activity [the gardening] I thought I would have failed. But, when I see my flowers growing up, I am amazed and I realize that I can do something good.” (70-year old female patient)
“If you take responsibility to care for a plant, you should behave as a mother that takes care of her child.” (73-year old female patient)
“I know I’m very limited in what I can do, but I think getting the results gives you a boost … I am really proud of my results.” (64-year old female patient)
The Plant as a Catalyst for the Patient-Therapist Relationship
The contact with plants facilitated, in the patients’ perspective, the patient-therapist relationship by sustaining their communication exchanges. Interviews and diaries showed the crucial role of plants in orienting the communication and the interactions between patient and therapist thus facilitating the healing effect of the program. Furthermore, plants offered cues to legitimize exchanges related to the patients’ illness and health experience, thus triggering a deeper and more authentic patients’ contact with themselves.
“While I am working with my plants, me and my therapist often discuss about my progress in rehabilitation and it is useful for me.” (79-year old female patient)
Furthermore, when speaking about plants also discussion about future patients’ plans and strategies to manage health and care out of the hospital become possible.
“When I see my healthy plant and I feel it is alive, it gives me hope for my future.” (69-year old female patient)
Therapeutic Gardening as a Bridge Between the Hospital Environment and the Outside World
Moreover, patients described the healing gardening intervention as a “bridge” between the rehabilitation experience in the hospital facility and the daily life, thus favoring the transition of rules, strategies and skills for disease management acquired during the hospitalization to their usual life context. The focus on nature allowed a more positive attitude to life. Thus, patients felt more legitimized and able to plan new life trajectories and to include their health condition in life projects. As a consequence, the role of patients was perceived as only one of the individual’s multiple selves.
“I think it [gardening] is therapeutic. When I look at all these living things growing and talk to other people about it, I feel better when I come back home.” (83-year old male patient)
“I really love gardening activities. They allow me to feel ‘outside’ of the hospital walls and to feel, in a certain way, like being at home.” (69-year old female patient)
Discussion and Conclusions
This exploratory study was aimed to obtain a deeper understanding of post-stroke patients’ experience of performing part of their rehabilitation program in a therapeutic garden. The authors are unaware of any studies involving this clinical population in this activity in the scientific literature. For this reason, a qualitative phenomenological approach was chosen for this research.
According to the evidences gained from our study, post-stroke patients spontaneously defined therapeutic gardening as healing per sé. In the patients’ view, nature was perceived as a context in which health and wellbeing can be more easily achieved, thanks to its engaging power. Designing and implementing rehabilitative interventions featuring natural settings and/or contact with plants could help fulfill post-stroke patients’ care needs and expectations, and may also help them engage in the care process.
Based on our results, therapeutic gardening can be considered a virtuous example of inclusive care practice, where a general sense of belonging reduces the barriers that prevent post-stroke patients from participation in rebuilding their health and well-being. In our study, being engaged in this kind of activity appeared to foster a sense of belonging and self-worth in post-stroke patients. Generally, engaging post-stroke patients in proactive activities, such as therapeutic gardening, could help clinicians in actively assisting patients in cognitive reappraisal of their health and life circumstances and in mobilizing their bodies in an innovative way. This kind of occupation may be provided in addition to cognitive and motor skills programs more traditionally associated with traditional rehabilitation.
Customizing care interventions based on the patients’ needs and experiences is crucial to obtain positive health results and to improve post-stroke patients’ engagement.  With this perspective in mind, the potential offered by person-centered therapeutic gardening in terms of addressing the patients’ needs at different levels (ie, emotional, cognitive and behavioral)  makes it a valuable activity in promoting the active engagement of patients in their rehabilitation process.. First of all, therapeutic gardening may foster post-stroke patients’ acceptance and re-elaboration of their illness condition as it seems to allow them to overcome the emotional barriers such as fear, anxiety or wrong illness believes. Previous studies have shown how overcoming negative emotional barriers due to illness and being gradually able to experience a positive attitude toward the health care pathway with more positive feelings, is crucial to sustain the patient evolution along their health engagement process.  Furthermore, therapeutic gardening seemed to enable individuals to re-imagine their new identity within a safe environment. This activity may also allow patients to make the first steps in incorporating their disease condition in context of a positive life project.  It provides a training ground where one can express ones’ own identity in a framework that is in line with the outside environment, thus sustaining the integration of their “new patient’s identity”. Thus, therapeutic gardening appears to be particularly valuable for patients in helping to gain a “new normality” and to project satisfactory life trajectories for their future. This is in line with other studies which demonstrate how comprehensive interventions able to act on cognitive, behavioral and emotional components are more effective than single-focus interventions in engaging patients in care practices.  This feature of therapeutic gardening also might contribute to the greatest benefits from the rehabilitative program in terms of post-stroke patient’s health, wellbeing, and sustainable lifestyles after the discharge.
Patients also reported that contact with plants was valuable in improving self-efficacy and control over health. Working with plants, from the patients’ perspective, fostered self-awareness about health and illness and supported the development of a more proactive attitude towards disease management. As a consequence, patients experiencing this kind of activity can better become managers of their own care. 
Our results also showed how the interaction with plants facilitates the patient-therapist relationship fostering a democratic environment in which power dynamics are more balanced, thus promoting the healing process according to a participatory model of care.  It is interesting to note that during therapeutic gardening sessions, post-stroke patients experienced a safe setting where they could discuss the care process with their therapist, thus promoting self-disclosure and open communication about health concerns. This aspect makes therapeutic gardening a person-centered activity which establishes patients’ attitudes toward, perspectives on, and concerns about their health and health care as a priority to orient clinical interventions.
Although promising, this exploratory research presented some limitations. Although qualitative research methods may be the most appropriate tools to identify and address the patients’ priorities, thus enabling clinicians to explore the complexities of clinical practice and to inform a more client-centered, evidence-based practice , further quantitative studies on a larger sample would be useful to extend the preliminary results obtained with this study to a wider population of post-stroke patients and to verify their transferability to other clinical settings. Moreover, further research is warranted to identify patient-centered measures to assess the benefits of these interventions on the patients’ well-being and quality of life. For instance, measures of patient engagement  in the rehabilitation process or of psychological adjustment to illness  might be valuable indexes to assess the clinical and psychosocial effectiveness of therapeutic gardening.
Moreover, the findings from the present study, although preliminary, may be useful in clinical practice with post-stroke patients and may offer some useful insight for implementing therapeutic gardening activities within rehabilitation programs. These results may be also discussed in educational contexts to increase scholars’ and clinicians’ understanding of the strengthening effects of nature in care settings. Although potentially valuable, the evidence we have warrants continuing efforts to implement healing gardens in health care settings so that patients may benefit and researchers have more real-life settings in which to assess their effects. At this time, it is of vital importance that therapeutic gardening interventions are appropriately evaluated in order to develop the existing evidence base.
Conflict of interest
The authors declare that there is no conflict of interest
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Copyright: © 2016 Serena Barello, Guendalina Graffigna, Julia Menichetti, Matteo Sozzi, Mariarosaria Savarese, A. Claudio Bosio, and Massimo Corbo. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.