Effect of Horticultural Therapy Program on Psychological Wellbeing, Hope, and Social Adjustment Among Patients With Psychotic Disorders
Phase: NA
Conditions: Psychotic Disorders
Sponsor: Alexandria University

  
  
   
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Cover letter   
Mohamed Hussein Ramadan Atta   
faculty of nursing, Alexandria University, Egypt   
Alexandria governorate, Smouha area, Egypt  
Dear Editor: Clinical trial   
Date: 3-10-2023  
We confirm that this work is original title: Effect of Horticultural Nursing Program 
on psychological wellbeing, Hope, and Social Adjustment among patients with 
psychotic disorders.  
  
In this study, we show that.   
  
Introduction  
  The World Health Organization (WHO) stated that the worldwide prevalence of psychotic 
disorders is estimated to be around 3 in 1000 individuals with 3.5% of the general population 
(WHO, 2019). Psychotic disorders affect a person's thoughts, behavior, and emotions which are 
characterized by symptoms such as delusions, hallucinations, disorganized speech, and behavior. 
These disorders are linked to a significant loss of psychological wellbeing, which can lead to 
feelings of hopelessness, helplessness, and despair (Heinze et al., 2018; de Winter et al., 2022).   
Patients with psychotic disorders often experience poor psychological wellbeing, which 
encompasses negative emotions such as anxiety, depression, fear, hopelessness, and despair. The 
factors contributing to this poor wellbeing are complex and can include biological, environmental, 
and social causes (Fornells-Ambrojo et al., 2016). Furthermore, symptoms of psychotic disorders, 
such as delusions, hallucinations, depressed and shifted mood can contribute to negative emotions, 
which can impact the overall psychological wellbeing of the patient. The prevalence of poor 
psychological wellbeing among psychotic patients is high, and it can significantly reduce their 
quality of life, impair their daily functioning, and increase their risk of self-harm and suicide. 
Adding, psychotic patients often experience a loss of hope, which refers to a state of pessimism 
and despair where individuals feel their situation is unlikely to improve.  
(Heinze et al., 2018; Shenoy & Praharaj 2023).   

  
  
   
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Poor social adjustment is a common challenge experienced by individuals with psychotic 
disorders. It refers to difficulties in adapting to and functioning in social situations and 
relationships (Smart et al., 2020). Furthermore, Tee et al., 2020 highlighted the importance of 
social support and social networks in promoting social functioning and reducing social isolation 
among individuals with psychotic disorders. Poor social adjustment can significantly impact the 
lives of individuals with psychotic disorders, reducing their quality of life, impairing their ability 
to function in daily life, and increasing their risk of relapse and hospitalization (Couture et al., 
2019). Therefore, providing complementary interventions to routine care aimed at improving 
social adjustments and improving levels of hope which enhance psychological wellbeing are 
essential for the well-being of individuals with psychotic disorders (Kontos et al., 2021).  
Complementary interventions, also commonly referred to as complementary and alternative 
medicine or integrative approaches, can offer several potential benefits for individuals with 
psychotic disorders. It's important to note that while some complementary interventions may be 
helpful, they should not be used as a substitute for evidence-based medical treatment. Horticulture 
therapy as one of complementary therapy is an effective and promising intervention for individuals 
with psychotic disorders, providing a range of benefits for their physical and mental well-being 
(Patricia et al., 2017; González et al., 2011; Siu et al., 2020)    
Horticulture therapy involves gardening and plant-related activities as a form of therapeutic 
intervention, enhance patient to be mindful to current environment and promote relaxation which 
can reduce symptoms such as anxiety, depression, and social isolation, improve cognitive function, 
and promote overall well-being .With this respect, there is an urgent need to find a sustainable and 
eco-friendly solution for this complex issue by returned to nature and utilizing the low cost and 
current resources at the same time to make a signification reduction in the psychotic disorder’s 
symptoms (Gorman, & Anwar, 2022; González et al., 2011; Kontos et al., 2021).  
 For instance, a systematic review by Van den Berg et al. (2015) found that horticulture therapy 
had positive effects on social functioning and quality of life in individuals with various mental 
health conditions. Horticulture therapy is promising therapy in promoting hope, the well-being of 
individuals with psychotic disorders, providing a low-cost, non-invasive, and engaging therapeutic 
option (Hernandez, & Garcia, 2022; Lu et al., 2021; Siu et al., 2020).  
Horticulture therapy has been found to have positive effects on individuals with psychotic 
disorders, promoting social interaction, reducing social isolation, and improving cognitive function 
(González et al., 2011; Hemmati-Sadeghi et al., 2021; Siu et al., 2020; Van den Berg et al., 2015). 
Effectiveness of horticulture therapy in enhancing well-being, reducing symptoms, and facilitating 
social adjustment in this population, is (González et al., 2011; Siu et al., 2020; Van den Berg et al., 
2015).  
The research on horticulture therapy's impact on psychological well-being, hope, and social 
adjustment among patients with psychotic disorders holds significant importance for both patients 
and nursing professionals. It suggests that horticulture therapy programs can be a valuable 
therapeutic option, offering a non-invasive and engaging approach to promoting psychological 
well-being and social adjustment (González et al., 2011; Siu et al., 2020; Van den Berg et al., 
2015). Additionally, by fostering social interaction and reducing isolation, horticulture therapy 

  
  
   
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provides opportunities for individuals with psychotic disorders to connect with others and establish 
supportive relationships (González et al., 2011; Siu et al., 2020).  
Nurses have a crucial role in implementing and advocating for horticulture therapy programs, 
facilitating patient engagement, and providing ongoing support throughout the therapeutic process. 
The research underscores the potential of innovative and effective therapeutic interventions, such 
as horticulture therapy, to improve patient outcomes and enhance nursing practice (González et 
al., 2011; Siu et al., 2020; Van den Berg et al., 2015).  
The present study aimed to:  
Assess the impact of Horticultural Therapy Program on Psychological wellbeing, Hope, and Social 
Adjustment among patients with psychotic disorders.  
Research Hypothesis:  
Patients with psychotic disorders who received Horticultural Therapy exhibited higher 
psychological wellbeing, Hope, and Social Adjustment than those who didn’t receive it.    
Study method& Procedure  
Research Design:  
  
A quasi- experimental research design will be followed.  
  
  
Setting:  
The research took place at El-Maamoura Hospital for Psychiatric Medicine, which is affiliated 
with the Ministry of Health and Population. This hospital serves three governorates: Alexandria, 
Matrouh, and El-Beheira. It consists of a total of 21 wards, providing a combined capacity of 948 
beds. Among these wards, 14 are dedicated to psychiatric care, catering to approximately 880 
patients with psychotic disorders. Within the psychiatric wards, there are six free wards and four 
private wards, with two private wards for males and two for females. The private wards 
accommodate around 130 patients with psychotic disorders at any given time.  
In addition to the general wards, the hospital includes specialized units, such as male and female 
intensive psychiatric care wards, adolescent wards, a psycho-geriatric ward, an addiction center, 
and an outpatient clinic for psychiatric and substance-dependent patients.   
Administrative steps  

  
  
   
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Official written permission from General Secretariat of Mental Health and El-Maamoura Hospital 
for Psychiatric Medicine will be obtained for conducting the study after taking the ethical approval.   
Ethical Considerations:  
The necessary formal approval and permission to conduct the study will be obtained from the 
Research Ethics Committee of the Faculty of Nursing, Alexandria University, Egypt. Patients will 
be informed about the purpose of the study and an informed written consent will be obtained. Also, 
they will tell that they have the right to refuse to participate in the study and that their decision will 
not affect their care. In addition, they will also say that they have the right to withdraw from the 
study at any time even after starting and that their privacy and confidentiality will be maintained.   
Participants:  
 The G* Power windows 3.1.9.7 program will be used to estimate the sample size using the 
following parameters: total sample size around 880, effect size = 0. 5, α err prob=0.05, Power 
(1-β err prob) =0.95, Number of groups=2, Number of measurements=3, Corr among rep 
measures=0.5.  The program estimates a minimum sample size of 54 patients, the researchers 
decided to recruit 60 patients for the control group and 60 patients for the study group. To be 
eligible in the study, patients diagnosed with schizophrenia and bipolar disorder with no 
comorbidity, not in the acute stage, absence of any allergy toward plants, their duration of illness 
not exceeding 10 years and able to communicate coherently and relevantly as well as can read 
and write.  
 A proportionate stratified randomization sample technique from each unit will be obtained using 
the following formula: Total sample size/ size of the entire population × the expected population 
size of each unit. The required sample size will be selected randomly. Patients of the study group 
will be randomly subdivided into six groups with ten patients in each group and will receive 8 
one-hour group sessions of interventions, in addition to the routine hospital care. The control 
group will receive routine hospital care only (psychiatric examination, diagnosis, and 
pharmacotherapy).   
A total of 850 participants will be approached, 120 patients will select randomly, 60 for control 
and study group equal. To ensure that all hospital wards that serve adult patients with psychotic 
disorders will properly be represented in the study sample, the stratified sampling technique will 
used through applying the following steps:  
a. The 14 of psychiatric wards will be divided into two strata based on male: female  
proportion; (8 adult male and 6 adult female wards for psychotic patients).  
b. Considering the male to female wards ratio around (3: 2), random selection of adult 
psychotic wards will do using simple randomization technique to pick up 50% of these wards (7 
wards).  
c. On each randomly selected ward, all patients' medical charts will be screened to identify  

  
  
   
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patients who met the predetermined inclusion criteria.  
d. From all patients who met the predetermined inclusion criteria in the selected ward, one 
third of them will be picked using simple randomization technique (almost the same proportion 
used in the decided upon number of subjects. Steps will repeat until the number of decided upon 
subjects will reached for control and study group 60 patients each.  
Tools:   
The following four tools will used to collect data:  
Tool I: social and health profile form:  
This form divided into two parts:  
• 
Part I is concerned with patients’ socio-demographic data such as sex, age, marital status, 
educational level, working status, and place of residence.   
• 
Part II aimed to elicit data related to patient's health such as duration of illness, presence of 
plant allergy, previous psychiatric treatment, and medications currently prescribed.  
  
Tool II: The Herth Hope Index (HHI)  
This scale is a self-reported tool designed to measure an individual's sense of hope and optimism 
(Herth, 1991). It consists of twelve items that are rated on a four-point Likert scale, ranging from 
"strongly disagree" to "strongly agree,". The HHI has been used in research studies, including those 
involving individuals with psychotic disorders, such as schizophrenia, to measure hopefulness, 
reported to be valid and high internal consistency (coefficient (> 0.90) (Mahmoud, Ali, & Hafez, 
2021).   
The reliability of the HHI has been demonstrated in various studies, including those involving 
individuals with psychotic disorders. Similarly, a study published in the International Journal of 
Mental Health Nursing in 2019, which evaluated the effectiveness of therapeutic horticulture for 
individuals with clinical depression, reported high internal consistency for the HHI (González et 
al., 2011).   
Tool III : Ryff psychological wellbeing scale (PWBS):   
The Psychological Wellbeing Scale (PWBS) was developed by Ryff in 1989 and modified to 18 
items. The PWBS consists of seven-point Likert scales for each of its six subscales, which include 
autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, 
and self-acceptance. The scores for each subscale are averaged, with higher mean scores indicating 
greater psychological wellbeing. Studies of psychotic patients have shown that the PWBS has high 
internal consistency, with alpha coefficients ranging from 0.78 to 0.88 (Mahmud, Islam, & Sharif, 
2022).   
Tool IV: Social Adjustment Scale Self-Report (SAS-SR):   
The Psychological & Social Adjustment Scale is a measure of psychological and social adjustment 
that will originally be modified by Weissman in 1999. is a paper-and-pencil selfreport scale that 
measures instrumental and expressive role performance over the past 2 weeks in adults. The 54-

  
  
   
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item assessment covers six areas of functioning, including work (either as a paid worker, unpaid 
homemaker, or student), social and leisure activities, relationships with extended family, role as a 
marital partner (if applicable), parental role (if applicable), and role within the family unit 
(including perceptions of economic functioning). The scores for each domain are calculated as 
averages, with higher mean scores indicating better psychological and social adjustment. The scale 
has been found to have high internal consistency with alpha coefficients ranging from 0.78 to 0.89 
(Gameroff, Wickramaratne & Weissman, 2012).   
The Preparation Phase  
Pilot study  
To assess the transparency, objectivity, viability, relevancy, and applicability of the research tools, 
a pilot study will perform on 20 patients who met the inclusion criteria .The patients in this group 
will not be included in the study sample.  Study tools will test-retest reliability will do for the study 
tools; The Herth Hope Index (HHI), Psychological &Social Adjustment Scale and Ryff 
psychological wellbeing scale (PWBS).   
  
Implementation of the Horticultural Therapy Program   
On each recruited ward patients will interview individually to establish rapport and to apply tool I 
(A Socio-demographic and Clinical data Structured Interview Schedule) to elicit their 
sociodemographic and clinical characteristics. Each patient gets detailed explanations in relation 
to the aim of the study and objectives of the training and tool  I, II, III, and IV.  The latter two steps 
will do for the control group to take base line data and cross matching with study group will be 
applied.   
Egyptian Horticultural Therapy Program will develop by researcher in psychiatric nursing and 
botanist (reference) that included planting, watering, follow up, and harvesting plants. It consisted 
of eight group sessions; a 30-minute session will be conducted once a week for eight weeks. The 
first introductory session will concern participants sharing their interest in and experiences with 
plants, defining the goals of HT about their past horticulture experiences. At the end of the first 
session, a written plan for every session (time, duration, and setting) will be scheduled individually 
with each patient. Session conduct by two general group as female group and male group.  
 The therapist emphasized the use of two plants, one that produces a crop (Cloves) and the other 
one aromatic and floral plant (Levander).  Insert Table 1  
Session   
 General objective:  
Steps   
Opening session  
Emphasizing the general aim of 
General  
information  
about

  
  
   
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I-  
- 
- 
planting  
Empowering self-competency to 
take care of plant   
 
 
- 
- 
- 
- 
- 
- 
  
psychosocial benefit of planting. 
Name 
the 
plants 
with
presentable product of Cloves
and Levander.  
Asking about feeling toward 
plants and process of planting  
Give detailed brochure about 
steps of planting.   
Providing  tool  of  planting
(seeds, seedlings, soil, pots…..)  
Give note of schedule about 
daily expression of emotion  
  
 
 
 
 
 
II-  Beginning of Hope  
- 
- 
Learning 
and 
practicing 
planting 
 
- ???????  
Assuring the understanding  
III- It grows green  
-  
-  
Learning  
and  
practicing  
 
 
-  Expression of patients note  
propagation skills.  
Reflecting 
on 
and 
sharing 
thoughts about the vitality of 
plants.  
IV- Attention and fo llow  
-  
-  
Focusing  
on  
patients’  
-  
-  
Debriefing and expression  
 
up   
emotions  
Practice the emergency care 
of patient’s emotion  
Write note about current 
of planting  
state. 

  
  
   
8  
  
-  
-  about 
 
 
n to the complain 
planting.  
V-  Mindfulness:  
tasting 
ing the  
-  
-  
Experiencing  mindfulness  
 
 
-  
-  
-  
Present moment awillness  
 
 
 
 
watching,
and smell 
plants  
techniques  
during  the 
activities.  
sharing 
thoughts 
about 
using this experience in 
mindful eating, and its 
potential use as a relaxation 
activity.  
of watching, tasting and 
smelling.  
Describe the current view, 
smell, and taste in a 
nonjudgment attitude.  
Correct 
the 
patient’s 
description as focus on 
past/ future or previous 
judgmental talks.  
 
VI- Exhibition  Garden: 
collective view  
-  learning to design a pot 
garden using various plants 
and decorations. 
-   
 
-  
-  
Present every patient plant.  
share thoughts about the 
feeling of appreciation.  
VII-  Time  
of 
harvesting   
-  
  
Practicing harvesting.  
-  share  the  
symbolic 
meaning of harvesting. To 
share  overall 
feedback about the 
HT sessions.  
VIII- Ending session   
-  
Describing overall feedback 
about the HT sessions.  
 
-  Ask about meaning of 
growing.   
-  Describe  
benefits  
and 

  
  
   
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hazards of planting  
  
Evaluation or Follow-up Phase  
The evaluation phase encompassed a post-test assessment after one month and a 3-month followup 
assessment using the outcome measures administered at baseline that will conducted for both 
groups (study and control groups) through interviewing the participants individually to ensure the 
effectiveness of the HT.   
Give the detailed session and material for control group if needed.  
  
Statistical analysis plan  
Quantitative data will be analyzed and presented using various statistical measures. To assess the 
normality of distribution, the Kolmogorov-Smirnov test will be performed. Descriptive statistics 
such as range (minimum and maximum values), mean, standard deviation, and median will be used 
to summarize and describe the quantitative data. The significance of the results obtained from 
statistical tests will be evaluated at the 5% level.  
For qualitative data, numbers and percentages will be used to describe and summarize the findings. 
On the other hand, quantitative data will be summarized using the minimum and maximum values 
to reflect the range of the data. The mean will be employed as a measure of central tendency in 
statistical significance testing, while the standard deviation provides information about the 
variability of the scores in the dataset.  
Chi- square test, Monte Carlo test:  used to test the significance of result of qualitative variable.         
In addition, paired t-test will used test the significance of result of normal quantitative variables. 
Marginal Homogeneity Test Non-parametric significance tests will used for two dependent 
samples and McNemar test significance with two dependent sample studies.   
  
  
  

  
  
   
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Thank you so much.  
Thank you for your consideration of this research.   
Sincerely,  
[Mohamed Hussein Ramadan Atta]