Current State of the Horticultural Therapy recreation for all (wellness model) or 2) RT should focus on recreation for ther- Profession in the United States apy (clinical model) (Austin et al., 2015; Wozencroft and Griffiths, 2012).
1 2 1 These philosophical differences led to Derrick R. Stowell , J. Mark Fly , William E. Klingeman , two approaches, recreational therapy Caula A. Beyl3, Angela J. Wozencroft4, Douglas L. Airhart5, and and therapeutic recreation. Therapeutic recreation was developed to satisfy the P.J. Snodgrass1 therapy/clinical and recreation for all/ wellness viewpoints. However, profes- sionals who identified with the clinical ADDITIONAL INDEX WORDS. allied health, education, health care, professional development, therapeutic horticulture viewpoint did not embrace the term “therapeutic recreation” (Wozencroft SUMMARY. While horticultural therapy (HT) has a long history in the United States, and Griffiths, 2012). “Recreational the- fi the profession has not had the acceptance and growth that related elds, such as art, rapy” emerged as the clinical model and music, recreational, occupational, and physical therapies have experienced. The is more recognized in health care than is objective of this study was to identify the current challenges and opportunities of HT in the United States. Maximum variation sampling was used to select current HT (Shoemaker, 2002). and former members of the American Horticultural Therapy Association (AHTA) The profession of HT has had a for interviews. A total of 27 participants were interviewed between Nov. 2019 and similar debate based on philosophical Jan. 2020 using semi-structured qualitative interviews by Zoom. The interviews differences. The original name of revealed six themes: 1) current state of the profession, 2) AHTA operations/ AHTA, National Council for Therapy structure, 3) education/credentialing, 4) funding/job opportunities, 5) public and Rehabilitation through Horticul- awareness/networking, and 6) research. This paper will discuss the challenges and ture, reflected two main viewpoints: opportunities presented in the six themes and provide recommendations for the therapy and rehabilitation (Shoemaker, future growth of the HT profession. 2002). The council also included volun- teers from garden clubs, programs in human service, professionals in horticul- orticultural therapy (HT) is therapy in the United States since the ture, and individuals leading horticul- an allied health profession late 1700s (Davis, 1998), HT has not ture programs in a variety of treatment Hthat uses people–plant con- advanced as a recognized health care settings (Haller et al., 2019). Like RT, nections to enhance health care profession like other allied health pro- two terms began to develop to describe outcomes and improve well-being fessions. The profession of HT was different elements of the profession: (Ascencio, 2018; Haller et al., 2019; still considered an emerging profes- “therapeutic horticulture” emerged to Im et al., 2018). Other allied health sion in a report from just 11 years ago describe the use of horticulture in com- professions include art therapy (AT), (Shoemaker and Diehl, 2010). Haller munity settings to promote wellness, music therapy (MT), recreational th- and Malone (2019) also discussed the and “horticultural therapy” emerged to erapy (RT), occupational therapy continued challenges of HT as the describe the use of horticulture for treat- (OT), and physical therapy (PT). profession continues to emerge and ment in a clinical setting (Shoemaker, Despite horticulture being used as become more widely accepted. Mem- 2002). As the profession continued to bership numbers shown in Table 1 advance, the definition of horticultural may also help to illustrate the current therapy also changed to include a clini- Received for publication 30 Mar. 2021. Accepted for publication 14 May. 2021. professional status and awareness of cal focus to align with more health care HT compared with other allied health Published online 12 July 2021. professions and move the profession associations. The AHTA has 486 toward professional credentialing. Relf 1Department of Plant Sciences, University of Ten- nessee, University of Tennessee Gardens, 112 Plant members. RT is the next highest with (2006) stated that the AHTA definition Biotechnology Building, 2505 EJ Chapman Drive, 2200 members, and art and music in 2005 broadly defined horticultural Knoxville, TN 37996 therapies have more than 4000 mem- therapy to be a treatment for “all ages, 2Department of Forestry, Wildlife and Fisheries, bers each. ” University of Tennessee, 427 Plant Biotechnology backgrounds, and abilities. The cur- Building, 2505 E.J. Chapman Drive, Knoxville, TN AcomparisonofRTandHT rent AHTA definition now includes the 3799 may indicate challenges and potential concept of the participation of horticul- 3Herbert College of Agriculture, University of Ten- pathways forward for HT. Both RT ture in a “treatment, rehabilitation, or nessee, 2621 Morgan Circle, 126 Morgan Hall, ” “ ” Knoxville, TN 37996 and HT grew out of principles of OT vocational plan and HT is an active (Davis, 1998; Robertson and Long, part of treatment (AHTA, 2017). 4Department of Kinesiology, Recreation and Sport Studies, University of Tennessee, 322 HPER Build- 2020). Beginning in 1919, the Men- Both RT and HT saw the need for ing, 1914 Andy Holt Avenue, Knoxville, TN 37996 ninger Clinic in Topeka, KS, was one developing professional standards to 5School of Agriculture, TN Tech University, Box of the first institutions in the nation to grow the profession. RT developed a 5034, 715 Quadrangle, Cookeville, TN 38505 use RT and HT for mental health professional credentialing process in D.R.S. is the corresponding author. E-mail: treatment (Davis, 1998; Robertson 1981 managed by the National Council [email protected]. and Long, 2020). Philosophical dif- for Therapeutic Recreation Certifica- This is an open access article distributed under the CC BY-NC-ND license (https://creativecommons. ferences developed within RT as the tion that requires college coursework, a org/licenses/by-nc-nd/4.0/). profession progressed based on two supervised internship, and a creden- https://doi.org/10.21273/HORTTECH04792-21 viewpoints: 1) RT should focus on tialing examination. The professional
330 August 2021 31(4) Table 1. Professional organizations associated with allied health and their year a summary of the results to help validate of founding. the study (Castillo-Montoya, 2016). Yr Members The pilot interviews were not included Profession Professional organization founded (no.) in the final results. z SAMPLING AND THE STUDY Occupational American Occupational Therapy 1917 65,000 therapy Association POPULATION. Maximum variation sam- Physical therapy American Physical Therapy Association 1921 100,000y pling (Patton, 1990) was used to Music therapy American Music Therapy Association 1950 4,000x select 27 individuals to be interviewed Art therapy American Art Therapy Association 1969 4,247x with characteristics that vary in the Horticultural American Horticultural Therapy 1973 486w study population and with knowledge fi therapy Association of the speci c subjects being studied Recreational American Therapeutic Recreation 1984 2,200v (Palinkas et al., 2015). Those charac- therapy Association teristics consisted of current (n = 23) z and former members of AHTA (n = American Occupational Therapy Association (n.d.). yAmerican Physical Therapy Association (n.d.). 4): horticultural therapy educators at xJ.M. Fly, unpublished data. colleges or universities (n = 4), horti- wAmerican Horticultural Therapy Association (2020b). cultural therapy educators who teach v American Therapeutic Recreation Association (n.d.). at AHTA Accredited Certificate Pro- grams (n = 7), professional-level credential is “Certified Therapeutic Rec- and 4) What steps are needed for HT members (n = 6), associate-level me- reation Specialist” (CTRS). Currently, to advance as a profession? mbers of AHTA (n = 6), and former AHTA has a professional registration members of AHTA (n = 4). This process for the designation of “Horticu- Materials and methods study included professionally regis- tered individuals who have their HTR ltural Therapist—Registered” (HTR). INSTRUMENTATION AND STUDY (n = 17; 63%) and nonregistered indi- This includes college-level coursework DESIGN. Basic qualitative research helps and a supervised internship, but no ’ viduals (n = 10; 37%). Study partici- to understand participants points of pants represented each of the regions credentialing exam. According to Shoe- view and identify recurring patterns and maker (2003), a voluntary registration across the United States (Fig. 1). Prof- themes in the topic being studied (Ary essional-level and associate-level mem- system is not sufficient for the profession et al., 2012). For this study, a semistruc- bers were recruited through AHTA. to gain more acceptance within health tured qualitative interview was devel- Educators and former members of care. Some members of AHTA believe a ’ oped using Castillo-Montoya s (2016) AHTA were recruited through per- credentialing exam is as an important interview protocol refinement process, sonal contacts of the lead researcher. step to advance the profession (Starling which resulted in nine questions for DATA COLLECTION AND ANALYSIS. et al., 2014). The desire for professional noneducators and 11 questions for HT The 27 interviews were conducted credentialing has been supported by educators (Table 2). The interview pro- and recorded between Nov. 2019 and past studies of HT professionals (Shoe- tocol was piloted with three HT profes- Jan. 2020 using Voice Over Internet maker, 2003; Stober and Mattson, sionals recruited through personal Protocol; they were then transcribed, 1993). A 2017 survey of AHTA mem- contacts of the lead researcher. These and uploaded into qualitative data bers found 85% of 171 respondents sup- pilot reviewers, who mirrored the study analysis software (NVivo 12; QSR ported supporting credentialing efforts population, also assisted with reviewing International, Burlington, MA) for (Cassidy, 2017). A 2020 survey of AHTA members illustrated that 87% of 218 respondents supported credential- Table 2. Interview questions for a qualitative study on the current state of horti- ing efforts (AHTA, 2020a). cultural therapy (HT) in the United States. Debate among HT professionals Questions asked for educators about the future of HT, professional 1a. If educator: How long have you been educating/training people in HT? credentialing, and whether to focus on 1b. If educator: How many people apply to your program each year? How many are a clinical model or a wellness model, accepted? How many people complete your program each year? continues to challenge the profession Survey questions for all interviews (Shoemaker, 2002). Therefore, the 1. First, tell me what you like most and least about the practice of HT in America purpose of this study was to interview right now? current and past members of AHTA 2. What challenges do you think HT currently faces? and assess the perceived current state 3. It is the year 2030. What pleases you the most about the practice of HT in the of HT in the United States and iden- United States? What is your vision for HT in the future? tify future directions for the profes- 4. What has to happen for us to achieve your vision? sion. The research questions were as 5. What are the constraints and barriers to achieving this vision, if any? follows: 1) What is the current status 6. What are the supports, opportunities, or resources that could help us achieve this of HT in the United States? 2) What vision, if any? should the profession of HT look like 7. What role should HT education have in achieving this vision, if any? in the future? 3) What role does HT 8. What role should a professional organization have in achieving this vision, if any? education play in the future of HT? 9. Is there anything else you would like to say about the future of HT in America?
August 2021 31(4) 331 well-being of everyone. Although they may have different opinions about the future direction of HT, they all care deeply about the profession. After completing content analysis of the interviews, six themes (Table 4) were identified: 1) current state of the profession, 2) AHTA operations/struc- ture, 3) education/credentialing, 4) funding/job opportunities, 5) public awareness/networking, and 6) research. CURRENT STATE OF THE PROFESSION. During the interviews, 11 (41%) of participants reported that the profession was “growing,” 3 (11%) said it was “shrinking,” and 3 (11%) Fig. 1. Study participants and American Horticultural Therapy Association said “staying the same.” Actually, (AHTA) membership by U.S. region. membership in AHTA has declined by almost 40% since 2009 from more than 800 members to 486 in 2020 (AHTA, codebook development and content notations do not mean any one topic 2020b; Larson et al., 2010). One par- analysis. The codebook was created is more important than another. ticipant stated, “We lose members. We based on methodology developed by Results are losing credibility because there’s Guba and Lincoln (1985). Interviews hardly any of us out there anymore and were coded using Tesch’s(1990) Study participants discussed what most of us are older and will eventually eight-step coding process (Table 3). they like about the HT profession. retire.” Some participants do not see The interviews were coded by the lead They talked about the ability to use the benefit of membership in AHTA. researcher and a second coder to plants to make a positive change in peo- “A lot of people got lost along the way establish interrater reliability (O’Con- ple’s lives. One said, “The people–plant and did not feel included.” Some par- nor and Joffe, 2020). When coding connection is very important.” Eleven ticipants attribute this downward trend was complete, discrepancies between (41%) said horticulture therapy is uni- to not accommodating practitioners the two coders were analyzed and dis- que in how it improves people’shealth who are not professionally registered, cussed until consensus was achieved. and well-being using the people–plant changes in the professional registration The codebook was revised and inter- connection, and 15 (56%) said the con- requirements, and AHTA’s focus on views were recoded (Zade et al., nection to nature fosters growth in credentialing. One stated, “If they 2018). A 97.23% agreement between people. One indicated they value HT don’t get them to become profession- coders was achieved with an average because, “They see the benefits of gar- ally registered within 5 years, they don’t unweighted Cohen’s kappa of 0.62, dening or working with natural materi- stay members anymore because there is which falls in the substantial agree- al.” What is clear from the interviews is just nothing there for them.” Asecond “ ment category (Landis and Koch, horticultural therapists are passionate participant stated, Do not make it so 1977). The results section includes about their work and feel strongly hard to be registered and furthermore … notations of both the number and about the ability of plants and the care do away with registration. To be of plants to make a significant differ- registered means nothing to anyone percentage of study participants who ” “ mentioned a specific topic. Because ence in the lives of people with physical except AHTA. Another stated, My this is a qualitative study, these and/or mental health issues and the vision would include that the national organization would become more inclu- sive and find ways to get back people Table 3. Tesch’s (1990) eight-step coding process. that were active before.” Step no. Description Study participants also discussed a perceived difference between the 1 Read through transcriptions and get a sense of the whole. clinical side and the wellness side of “ ” 2 Pick one interview and read through it. Ask, What is this about? HT. One participant discussed why fi Write topics you nd in the interviews. their membership lapsed: “If you are “ 3 After reading through several interviews and asking, What is this not an HTR and don’t fitwithina ” about?, begin to list topics and group similar topics. certain cookie-cutterness, you are not 4 Take your list of topics and go through the interviews. Organize a legitimate practitioner and there’sa topics to begin to determine where codes emerge. lot of judgments and negativity put 5 Turn descriptive words for topics and condense into categories. on people who don’t fitwithinthe Reduce total list by groping topics. Identify any interrelationships. ” fi mold. Another stated that horticul- 6 Make a nal decision for categories. tural therapy practitioners “need to 7 Assemble data into categories to perform preliminary analysis. decide if we want to be in the medical 8 Recode data as necessary. arena or in the health and well-being
332 August 2021 31(4) Table 4. Summary of findings from a qualitative study of the current state of the jobs on top of doing this.” Although horticultural therapy (HT) profession in the United States. AHTA uses a paid association manage- Current state of the profession ment company to run daily operations, American Horticultural Therapy Association (AHTA) is losing members such as membership and conferences, AHTA is not accommodating of nonregistered practitioners the company does not engage in any Members disagree about the need for credentialing policy or decision-making regarding the The profession has a divide between clinical side and wellness side of HT current status or future direction of HT There is a lack of diversity in the profession of HT (AHTA, 2019). Those responsibilities AHTA operations/structure remain with the volunteer board. Other There is not enough happening at the national level to move the profession of HT allied health associations have a full- forward time executive director to manage con- The AHTA Volunteer Board is a limitation to the growth of the organization ferences, workshops, and daily opera- The lack of preapproval for coursework for professional registration is a frustration tions and provide support to their Education/credentialing boards. One participant stated, “We Students perceive a challenge in finding courses for professional registration need to put a lot of pressure on our There is a need to standardize HT degree programs national organization as it exists now, Universities are not initiating new majors or as it needs to exist, to serve the needs There is a need to identify and train future HT educators at universities of those in the field. … I think things Providing HT education for allied professionals could help grow the profession aren’t happening enough at the nati- Funding/job opportunities onal organization level.” There is no insurance or third-party reimbursement for HT EDUCATION/CREDENTIALING. The There is no way to track use of HT in the United States education/credentialing theme was fi There is no current U.S. Bureau of Labor Statistics job classi cation for HT discussed by 25 (93%) of study partici- Many HT practitioners have to create their own business or position pants. Coursework selected for profes- Public awareness/networking sional registration requirements was There is a lack of awareness of HT by public developed by AHTA using a job anal- There is a lack of awareness of HT by health care professions ysis. The last job analysis in 2014 Marketing of HT is a priority to help grow the profession fi identi ed therapeutic and horticulture Increase networking within HT and regional groups is critical for the profession knowledge, skills, and abilities needed Research for horticultural therapists (Starling There is a lack of robust, evidence-based research of HT in the United States et al., 2014). To qualify as a registered There is a need for metrics for assessment/documentation of HT outcomes horticultural therapist, students must There is a need for clinical practice guidelines for HT take 9 h of HT courses, 12 h of plant There is a need for multidisciplinary research collaboration of HT programs science courses, 12 h of human sci- There is a need for research grants to document benefits of HT ence courses, and complete a supervi- sed internship. Currently, individuals may take coursework to qualify for arena … because that is one of the of review of proposed coursework for HTR from more than one university tensions. It would help clarify what professional registration. Although or site. This can illustrate the flexibil- the curriculum and the research sho- the association does have a list of ity to create a program of coursework uld be.” One participant wanted HT coursework needed to qualify for to meet the unique needs of students. to become “well integrated into not HTR (AHTA, n.d.), there is no pre- One study participant discussed their only health care, but a whole wide approval process for specific courses. personal challenge of obtaining the range of human services, including AHTA does not review and approve needed coursework for professional wellness programs.” courses until a student submits a reg- registration, “No one seems to know Another concern with the current istration application. One participant what is going on. … There is always a state of the profession is the lack of mentioned how this affects students: lot of dialogue going on about where diversity within the HT profession. “They [students] will call AHTA and to get classes and who needs to do “When you go to AHTA conferences say, ‘Does this class work?’… and what.” It is important to note that … it’sallwhitewomen.” One rec- AHTA will not comment on that. … this is one personal experience of a ommendation was to create opportu- So, they have it all ready and they feel study participant that may or may not nities for diverse groups of individuals like they have got it all in line, but be reflective of all students studying to learn about HT and provide schol- then AHTA may come back and say, HT in the United States. A few study arships for HT training. A need was ‘Your plant propagation class and participants felt some of the non-HT also expressed to develop programs in your group therapy skills class does course work, such as plant propaga- the United States that reach a diverse not count’ and they are pretty angry tion using tissue culture or pest man- clientele. about that.” agement, may not be applicable to AHTA OPERATIONS/STRUCTURE. Participants(n=16;59%)exp- practice HT. One participant stated, Study participants (n = 25; 93%) dis- ressed concern that having a volunteer “I wonder if we could not streamline cussed concerns or frustrations with board posed challenges, such as time to the horticultural sciences to include AHTA operations/structure. One devote to AHTA work. One participant things that people are going to use in frustration discussed was AHTA’slack stated, “They volunteer, and they have practice.”
August 2021 31(4) 333 Standardization of education is level when they retire. One educator even get a slice of that piece of the pie.” also needed to ensure practitioners are stated, “It’s going to be a problem This participant discussed how rehab implementing HT in a safe and effec- because if I were to leave, I have no hospitals in their area have greenhouses tive manner. One participant stated, clue who they could hire to come and used by OTs and PTs in their therapy “There is too much disparity among teach.” The guidelines set by AHTA programs, but they don’t have horticul- the quality of [educational] pro- require that individuals teaching HT tural therapists on staff to run HT gramming.” This does not mean all courses must have at least 3 years of programs. educational programs need to be the experience as a practicing HTR. This Understanding the extent HT is same. For example, one study partici- may limit the number of qualified used is compounded by the fact there is pant stated that other professions have people teaching HT courses required no way to track who uses horticulture educational programs with different for registration and to maintain edu- as therapy besides surveying AHTA foci, such as landscape architecture, cational programs in the future. membership and members of regional which has programs that are design- Finding ways to connect HT edu- HT groups. Currently, there is no hor- oriented and other programs that are cation opportunities to other allied ticultural therapist job classification construction-oriented. “It would be health professions may be another way listed by the U.S. Bureau of Labor Sta- kind of cool to have horticultural ther- to move the profession forward. “We tistics, which tracks employment infor- apy educational programs like that.” can have OTs, Rec therapists, PTs, and mation in the United States and An example would be one HT pro- social workers add to their own cre- publishes the Occupational Outlook gram may focus on working with older dentials, experience, and competency Handbook online. This information adult populations and another may in HT. I think that’s our inroad.” gives basic job outlook, education, pay, focus on school-age populations. FUNDING/JOB OPPORTUNITIES. and numbers of people employed in a Study participants (22; 81%) dis- Funding was expressed as a need to specific job (U.S. Bureau of Labor Sta- cussed the need for more educational support jobs; HT research; outreach; tistics, n.d.). In 2014, the AHTA sub- opportunities; however, colleges and public awareness and professional mitted a proposal, during the public universities are hesitant to add new organizations, such as AHTA; and comment time, to include the career of programs that do not lead to employ- regional networking groups. Partici- horticultural therapist into the Stan- ment. Participants (n = 16; 59%) men- pants felt the future of the profession dard Occupational Classification for tioned the lack of job opportunities as rests on being able to create a market the 2018 revision. However, the pro- a major issue: “They [universities] for HT job growth. Without adequate posal was denied based on “Classi- want to launch programs that provide funding, organizations cannot employ fication Principle 9 on collectability” students with direct routes to careers horticultural therapists. One participant (U.S. Bureau of Labor Statistics, and that path is not clear [for HT].” stated, “People don’twanttopayforit 2017). Classification Principle 9 states Until a clear path to professional [horticultural therapy]. I don’t know if that for an occupation to be included, employment in HT is defined, univer- that is because so many people do gar- theremustbeawaytocollectand sities may be reluctant to add new den and so many people have access to report data on the specific occupation courses and HT degree programs. nature. Nature’sfreeandmaybethat’s (U.S. Bureau of Labor Statistics, Educators were asked about enro- part of the expectation.” One partici- 2010). This further shows HT is not llment in HT courses. Some programs pant stated frustration with the “lack of organized in a way to know who is are not currently enrolling new stu- jobs and lack of accreditation or recog- practicing in the profession. dents in HT courses due to faculty nition, nobody has ever heard of horti- Study participants (n = 10; 37%) retirement or programmatic changes. cultural therapy.” One educator discussedhowtheyoftenhavetorely Although one certificate program had mentioned, “When students ask me, on their own initiative to create a the ability to accept 20 to 25 students am I going to get a job? I have to be business or position within an organi- each year and regularly had a waiting honest and tell them there is not a lot zation. For a profession to grow, partic- list of 60 students, other programs did of jobs out there. They do come up. ipants expressed the need to move from not have a waiting list, with class num- Do not get discouraged.” creating their own job to more sustain- bers ranging from 4 to 35 students. In The fact that HT is not reimburs- able job growth. “You are going to many cases, students only take the able by insurance was the main issue have to work very hard to get and retain introduction to HT course and not discussed as to why it is not more jobs, to run your own business or talk the remaining HT courses. Another prominent in the allied health field and yourself into jobs.” Another participant challenge is finding facilities offering why there are not more jobs. One par- stated, “Youarelikelytomakeitmore quality HT internships required for ticipant stated, “We need to get hor- on your own if you are a self-starter and professional registration. One partici- ticultural therapy established with you want to begin a business.” How- pant stated, “The internship also needs Medicare/Medicaid so that it is re- ever, as one educator recognized, “Not to get standardized a little bit more cognized, and practitioners can be everyone is equipped to have their own than what it looks like now.” reimbursed.” Another participant ack- business.” Finally, one concern voiced by 10 nowledged the importance of insur- PUBLIC AWARENESS AND (37%) participants was the need for ance reimbursement that pays for other NETWORKING. All 27 (100%) of partic- future educators (who may also be areas of allied health: “That [insurance ipants discussed the public aware- research scientists). Current educators reimbursement] keeps OTs and PTs ness/networking theme. They felt the expressed concerns about who will be employed, and we [horticultural thera- majority of the general public is not qualified to teach HT at the college pists] are not a part of that. We don’t familiar with HT nor its medical use
334 August 2021 31(4) and benefits and applications in differ- robust research needed to have clearly participants discussed the need for “big ent settings. They also felt the lack of defined procedures for assessment, picture grants or funding sources that awareness of HT within health care is a treatment protocols, and benchmarks will help us do more research and per- major challenge for the future of the for positive outcomes to promote the haps even more work to help define the profession. One stated, “Marketing is benefits of HT and meet requirements profession at this stage in the game.” really big, I think we are not, as an HT for insurance reimbursement. There One participant stated, “The best cha- community, doing a very good job of needs to be large randomized con- nce of us getting that research done is marketing the practice.” Participants trolled studies to document the bene- over a national research study that mul- felt increased recognition of the profes- fit of HT programs. Increasing the tiple HTs participate in because … I sion, including acknowledgment by the amount of research on HT will then don’t really see any one person having health care community, doctors pre- lead to increased evidence-based prac- the resources to do the kind of re- scribing HT, and health care facilities tice of the profession. One study par- search.” It was suggested that collabo- incorporating gardens and offering HT ticipant stated, “I want to see it [HT] rating with other allied health care programming are all important for the continue, but I do hope we can just researchers could help increase the future growth of HT. One participant get more evidence-based research on number and quality of HT research stated, “I would like it to be recognized how horticultural therapy helps differ- projects. Publishing more research on as it is a legitimate, billable activities ent populations.” HT would “help secure more grant therapy.” Another participant stated More HT clinical practice guide- opportunities and could secure donors they would like to see HT be “much lines are needed to help increase stan- and money.” more visible to people as a complemen- dardization and ensure patient safety. Recommendations tary or alternative therapy.” Participants One participant discussed the need for mentioned public and health care pro- clinical practice guidelines to ensure A list of recommendations based fessionals are receptive and interested in there are, “Certain metrics that every on the six themes discussed in this study HT when they are made aware of the horticultural therapist incorporates into are provided in Table 5. The following ” profession: “Everybody thinks it is a the work that they do. Having metrics narrative provides additional details fabulous idea when they hear it in the form of reporting, assessment, relatedtoeachrecommendation. [HT] … . If they [HT professionals] and documentation of HT program 1) Current state of the profes- want this profession to grow, which we outcomes is critical for the profession to sion. For the profession to move for- fi all do, then we, the community, we communicate HT bene ts to hospitals ward, HT professionals, AHTA, and have got to come up with a strategy.” and medical doctors, psychiatrists, regional networking groups need a Networking with allied health pro- therapists, and insurance providers. shared vision and a new model of HT fessionals was discussed as one strategy Researchers focusing on HT should also practice. Participants suggested a by 25 (93%) of participants as a way to seek out research grants through collab- shared vision should include increased advanceHT.Theimportanceandvalue orating with other horticultural thera- recognition within health care and the of regional groups was mentioned as a pists and allied professionals. Study general population, job and funding way to network and promote the pro- fession of HT at a local and regional Table 5. List of recommendations for advancing the profession of horticultural level. “Regional groups are actually the therapy (HT). workhorses;theyarethepeopleIfeel 1. Current state of the profession that are getting HT out into the public Further develop collaborations with HT professionals, American Horticultural eye.” Regional groups could “help our Therapy Association, and regional networks national organization be more respon- Explore shared vision and new model of HT practice sive across the country.” One way sug- 2. AHTA operations/structure gested to create more public awareness Find ways to for both nonregistered members feel valued within the organization was through social media. Participants Increase membership also mentioned the need for more net- Increase number of professionally registered members working within the HT profession. Develop ways to increase diversity of professionals and clients served through HT Increasing networking among practi- 3. Education/credentialing tioners and programs can provide Create horticultural therapy education task force opportunities to learn how programs Explore need for preapproval of coursework required for professional registration are being successful. One suggestion Continue to develop virtual workshops and continuing education opportunities was to have more local and regional 4. Funding/job opportunities events for networking, especially for Increase funding for professional associations (national and regional) therapistswhodonothavefundsto Explore funding mechanisms for providing HT in health care and community travel to the national conference. Net- settings working could also help grow the pro- 5. Public awareness/networking fession by creating more HT internship Continue developing collaborations with HT-focused organizations to increase opportunities. public awareness 6. Research RESEARCH. The research theme Collaborate with professionals to develop HT-related research was discussed by 14 (52%) of study participants. Unlike the other allied Conduct a comprehensive study of who is using horticulture as therapy across the professions, HT has not had the United States
August 2021 31(4) 335 opportunities, educational opportuni- funding to pay for HT programming. HT (Relf, 2006). This type of compre- ties, and research to develop evidence- Health care organizations are not able hensive study would provide a valuable based practice. to add new positions without a fund- update to previous studies including 2) AHTA operations/structure. ing structure in place through third- the landmark survey of hospitals in Membership growth will be vital for party reimbursement. It is important 1968 (Haller et al., 2019) and a similar the future of AHTA and the HT pro- for HT professionals to work toward study of HT in Tennessee in 2009 fession. New ways to ensure nonregis- finding grants, private pay, and other (Pfeffer et al., 2009). tered members feel valued and funding mechanisms to encourage included by AHTA must be found. To health care organizations to create Discussion gain recognition in health care, how- HT jobs. The HT profession has a long his- ever, it will be important to increase 5) Public awareness/networking. tory within the United States, but the number of registered members. Connecting with local organizations despite many accomplishments, the Members of AHTA and regional andschoolscouldbedonebydevel- profession has struggled to move networks need to increase the diversity oping more community-based pro- beyond the emerging stage. It is con- of professionals and clients served grams that have a wellness focus. cerning that several participants sug- through HT programming. This could Collaborating with public schools and gested the profession is not reaching its be achieved through the creation of nonprofits working with underserved potential, and opinions differed on scholarships for individuals from unrep- populations may not only increase which HT model the profession should resented backgrounds to study HT and networking opportunities for HT but focus—a clinical model, a wellness recruitment of diverse groups of indi- also lead to opportunities for research model, or both. For a clinical model to viduals to serve in AHTA leadership and grant funding. achieve third-party reimbursement, positions. Research on understanding In 2020, AHTA hosted a web credentialing is key, but some question the types of programs and clients being meeting with 12 regional HT group whether credentialing is needed or real- served could identify ways to increase representatives from six regional istic. With these uncertainties, the next client diversity. groups (Jarslow, 2020). Future meet- few years are a critical time for HT. Pro- 3) Education/credentialing. A ings and collaborations between fessionals, AHTA, regional groups, and horticultural therapy education task AHTA and the regional networks can allied health professionals will need to force, composed of educators and HT further strengthen public awareness/ network to develop a shared vision for professionals, should be created to networking. To further heighten HT the future of HT. Understanding our develop more standardized courses, visibility, it is recommended HT pro- history and the challenges we face can increase the number of degree pro- fessionals make posters and do presen- help us chart a path forward. Regional grams, and promote graduate training tations at meetings of other allied networking groups will play a vital role in to address retirement of HT educa- health organizations. this effort. Increasing membership in tors. This task force should also find 6) Research. Increasing the AHTAwillprovidemorepeopleand ways to engage other allied health amount and visibility of quality research financial resources to achieve their goals. professionals in HT education. onthepracticeofHTisvitaltodevel- Study participants liked the fact Currently, AHTA only accredits 9 oping evidence-based standards. Creat- the profession is focused on nature— h of HT coursework. There is a need ing an HT research consortium and growing and caring for plants—as the for a preapproval process for 12 h of collaborating with allied health profes- therapeutic element. As society’s plant science and 12 h of human science sionals to conduct interdisciplinary knowledge of the benefits of nature coursework. The AHTA should also research is important because of the grows, HT should capitalize on this provide online internship supervisor limited number of HT scientists. Repli- trend to recruit, train, and advocate for training and work with institutions to cated, unbiased, and peer-reviewed HT jobs with adequate pay and insur- create more internship opportunities. research will help in developing evi- ance reimbursement. Working toge- During 2020, the COVID-19 dence-based practices. Many of the ther, we can all communicate the value pandemic pushed AHTA and regional larger federal research grants (U.S. of HT, promote the education of groups to develop virtual workshops. Department of Agriculture, National future HT practitioners, and train This could provide continuing educa- Science Foundation, National Insti- future professors and research scientists tion for allied health professions, build tutes of Health), as well as foundations, in HT. This can only be done if more networks to advocate for HT, and such as the Robert Woods Johnson HT practitioners take an active role in conduct HT research. For HT to be Foundation, encourage multiuniversity the growth of the profession and pro- on par with other allied health profes- interdisciplinary research projects. mote research on the benefits of HT. sions, the move toward professional More research is also needed on who is LIMITATIONS. This study only credentialing needs to continue, start- using HT programming in the United looked at current and former members ing with an updated job analysis. The States, its effectiveness, and how to of AHTA. The responses of the study AHTA will be working toward an expand job opportunities. A survey of participants may be biased toward spe- updated job analysis in 2021 (AHTA, hospitals and other health care facilities cific viewpoints. One example of a 2020b). that use horticulture or gardens as part potential bias is the professional regis- 4) Funding/job opportunities. of their ongoing treatment program, tration status of study participants. Professionals who practice HT need whether or not they have HTRs on This study included HTRs, which to focus on increasing funding for staff, may also help provide information accounted for 63% of study participants. AHTA and regional groups, as well as to further enhance the profession of The higher percentage of HTRs in the
336 August 2021 31(4) study sample could bias the results American Horticultural Therapy Associa- Haller, R.L., K.L. Kennedy, and C.L. relatedtoprofessionalregistrationand tion. 2017. Definitions and positions Capra (eds.). 2019. The profession and the development of a credentialing sys- paper. 30 Mar. 2021.
August 2021 31(4) 337 Shoemaker, C.A. 2003. An analysis of Stowell, D.S., M. Fly, and P.J. Snodgrass. bls.gov/soc/2018/soc_responses_May_ registered horticultural therapists. J. Ther- 2021. The horticultural therapy profession 2014.htm>. apeutic Hort. 14:51–55. in the United States. 5 May 2021. 338 August 2021 31(4)