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J. People Plants Environ > Volume 27(1); 2024 > Article
Woo and Park: The Effect of a Horticultural Therapy Program based on Cognitive-Behavioral Emotion Regulation Training on Improving the Emotional Intelligence, Emotion Regulation Ability, and Resilience of Children Eligible for Priority Support for Educational Welfare

ABSTRACT

Background and objective: This study sought to develop a horticultural therapy program (HTP) based on cognitive-behavioral emotion regulation training (CBERT) to improve the emotional intelligence, emotion regulation, and resilience of children eligible for priority support for educational welfare, and investigate its effects.
Methods: To conduct this study, an HTP based on CBERT was developed using indoor horticulture activities. The program was conducted on 42 children (21 in the experimental group and 21 in the control group) in grades 3 to 4 who were eligible for priority support for educational welfare and were attending D elementary school in Incheon metropolitan city. Emotional intelligence, emotion regulation, and resilience were measured using self-report questionnaires before and after participating in the HTP.
Results: The study found that the emotional intelligence (p < .01), emotion regulation (p < .01), and resilience (p <.01) of the children who participated in the experiment were significantly increased.
Conclusion: Through this study, it was confirmed that an HTP based on appropriate CBERT has a positive effect on improving children’s emotional intelligence, emotion regulation ability, and resilience. In future research, it will be necessary to expand its application to all grades and general children as well as children eligible for priority support for educational welfare.

Introduction

Recently, in South Korean society, polarization between social classes caused by income disparity has become a more prominent social issue than ever (Yeo, 2008). Economic crises have had the direct effect of increasing the breakdown of poor families, exacerbating the problems of children in poverty (Heo et al., 2005). Children in poverty not only have low self-efficacy and self-esteem, but also live with low motivation to learn, and an inferiority complex (Lee, 2005). In addition, they may feel psychologically discouraged and alienated due to their emotional anxiety (Lee, 2005). A lack of parental protection and support may cause them to become shy and passive children, or to exhibit more aggressive and destructive tendencies than their peers (Jung, 2008). Compared to other kids, they are more susceptible to social problems like bullying, depression, suicide, and school violence (Baek, 2015). To prevent such problems, the importance of developing emotional resilience, such as children’s emotional intelligence and resilience, has been emphasized (Baek, 2015).
It is crucial that children from poor families learn and develop emotion regulation skills and form good morals and character in order for them to lead healthy social lives (Kim, 2011). Cognitive-behavioral emotion regulation training (CBERT) is based on the premise that the stimuli that determine human behavior are not only those that can be physically and objectively observed (Kang, 2006). This is an approach that reduces inappropriate behavior, directly teaches children the cognitions or strategies needed to perform tasks, and actually trains the cognitive processes involved in problem behavior (Kang, 2006). Various approaches can be used to modify cognitive behavior, including speech therapy, intrinsic control, rational emotive behavior therapy (REBT), problem-solving training (PST), social cognition training (SCT), and self-instructional training (Meichen-baum, 1977).
Gardening involves a variety of plant-based activities and provides opportunities to interact with living organisms (Chen et al., 2013). Horticultural therapy is an activity that improves or maintains the functions of the human mind and body using plants or gardening activities. The systematic and specific experience of growing and caring for plants has a positive effect on the emotional intelligence, emotional purification, emotional development, social skills, and emotional regulation abilities of emotionally anxious children (Choi and Yoon, 2016, Kim et al., 2016; Yoon, 2001). In addition, the application of a horticultural therapy program (HTP) to children from low-income families, who had difficulty learning or relating to peers due to emotional anxiety, resulted in significant improvements in all aspects of their psychological, emotional, and social functioning (Im, 2010).
Therefore, in this study, we developed an HTP based on CBERT for children eligible for priority support for educational welfare, and aimed to verify its effects on improving their emotional intelligence, emotional regulation ability, and resilience.

Research Methods

Research subjects and implementation

This study was conducted on 42 3rd and 4th grade children eligible for priority support for educational welfare at D Elementary School located in N-gu, Incheon Metropolitan City. Schools willing to participate in this study were identified by sending recruitment notices to 10 elementary schools selected for the Educational Welfare Priority Support Project in the Incheon Metropolitan City. Of the schools willing to participate, D Elementary School, which best met the selection criteria, was finally chosen. The selection criteria for schools were whether they would allow us to hold classes indoors, allocate time for program activities, involve 40 or more students, and obtain their legal consent forms.
The program was conducted once a week from September 27 to November 29, 2022, with a total of 10 sessions of indoor horticulture activities. It ran for 60 minutes every Tuesday from 2:00 to 3:00 p.m. at the Educational Welfare Office of D Elementary School. A level 2 welfare horticulturist certified by the Korea Horticultural Therapy and Welfare Association (KHTA) conducted the program with the assistance of a school social worker in charge and a trainee.
Prior to conducting this study, we visited the elementary school and explained the purpose, schedule, and precautions of this study/program to the children who agreed to participate. We had the participating children fill out a demographic questionnaire. This study was approved by the Institutional Bioethics Committee of Konkuk University (7001355-202007-HR-393).

Horticultural therapy program development

In this study, an HTP was designed to allow participants to experience appropriate processing of emotions through indoor horticultural activities based on CBERT. The program was divided into four stages: relationship building, exploration, insight and alternative skill acquisition, and finishing, with a total of 10 sessions (once a week, 60 minutes per session; Table 1). In each stage, the main approaches of emotion regulation training were appropriately applied, including emotion recognition, emotion regulation, behavioral strategies, understanding other people’s emotions, identifying automatic thoughts, and cognitive strategies. The relationship-building stage aimed to build rapport among the children, ease tensions, and provide guidance on program goals, content, and schedule so that they could understand the program and increase their motivation to participate. The exploration stage allowed them to recognize their own emotions and learn strategies to regulate them. The insight and alternative skill acquisition stage involved understanding the emotions of others and learning behavioral strategies. The finishing stage was designed to help them understand automatic thoughts and learn cognitive strategies. In addition, each session activity included a detailed three-step process: opening their minds to remind them of what they learned in the previous session and to motivate them, horticulture activities to achieve the goals, and closing the session by sharing feelings.
Stage 1 (Session 1) is the relationship-building stage. This stage, which was the beginning of the program, consisted of an explanation of the norms to be followed and an introduction of the goals to be achieved. Through the activity of making name tags decorated with pressed flowers (Session 1), the children introduced themselves and built a therapeutic relationship between them to enable them to interact smoothly.
Stage 2 (Sessions 2–4) is the exploration stage. Through making grass head dolls (Session 2), participants learned about different words that express emotions and trained themselves to recognize emotions by expressing their own emotions on their doll’s face. Making colored sand terrariums (Session 3) was a process that helped participants distinguish and understand the emotions they wanted to use or discard through colors they liked and disliked. Notably, through the succulent planting activity (Session 4), participants learned about the types of emotion regulation strategies, including cognitive, behavioral, physiological, and experiential regulation, with a focus on identifying their own negative emotions while selecting succulents, planting them, and touching the soil. They were also introduced to methods of emotion regulation so that they could control the negative emotions they felt. The session was designed to help them acquire the skills needed to recognize and control such emotions by applying the methods in class.
Stage 3 (Sessions 5–9) is the insight and alternative skill acquisition stage, with an emphasis on positive emotions. In this stage, the activities were designed to allow participants to share their own experiences of feeling positive emotions, to notice positive emotions around them, and to fully accept and experience them. In making a flower basket (Session 5), participants used an umbrella to write positive situations and words on each umbrella panel and decorated it with the flower basket. The session was designed to help them learn behavioral strategies to shift into positive emotions, by having them open the umbrella and remember the positive words when they feel negative emotions.
In making a topiary (Session 6), participants performed the difficult process of wrapping sphagnum moss around a plant and holding it with rope. This session was designed to allow the children to learn strategies for seeking help from others when it is difficult to solve problems on their own. In decorating a canvas with dried flowers (Session 7), after listening to the story “Chansu, the Farter,” participants recognized the way Chansu expressed his feelings to his friends and learned ways to express their own feelings. Moreover, the session was designed to allow them to recall their own experiences similar to Chansu’s, write down words expressing their feelings on a canvas, and create and decorate a mini bouquet of encouraging thoughts. In smelling herbs (Session 8), participants were asked to select an emotion card that best expressed the emotion they felt when smelling an herb, and then to exchange the selected card with their friends. They played a “Guess Your Mind” game in which they had to guess what emotion their friend was feeling based on the picture of the emotion card their friend had chosen. Through this, they were trained to communicate with their friend so that when their friend understands their feelings, they can remember their feelings, and understand their friend’s feelings.
Making a wreath (Session 9) aimed to help participants understand automatic thoughts and identify the thoughts that come to their minds in certain situations. It was designed to enable them to understand automatic thoughts through the process of recalling the emotional changes they had recently experienced, finding the situation in which the changes occurred, and identifying and remembering the emotions they felt in that situation. Notably, the participants were encouraged to observe the given materials and be aware of any automatic thoughts that come to their mind while performing them, and to experience behavioral strategies, including “how to communicate their emotions,” “asking for help,” “knowing other people’s emotions” and “understanding automatic thoughts.”
Stage 4 (Session 10) was the finishing stage. It was designed to enable participants to learn cognitive strategies to modify and change their automatic thoughts, and to apply such strategies to real life. Preserving dried flowers (Session 10) was also designed to allow participants to recognize, remember, and preserve the positive aspects of themselves that changed as a result of their participation in the program.

Measurement tools

Emotional intelligence

To measure children’s emotional intelligence, the Emotional Intelligence Scale for Upper Elementary Schoolers (grades 3–6), developed by Moon (1996) based on the emotional intelligence model proposed by Salovey and Mayer (1990), was used. It consists of a total of 47 questions, and higher scores indicate higher emotional intelligence. The reliability coefficient of the scale for this study, Cronbach’s α, was 0.88.

Emotion regulation ability

The Emotion Control Checklist (ERC) developed by Shields and Cicchetti (1995), adapted by Park (2004), and modified by Lee (2008) was used to measure children’s emotion regulation. It consists of a total of 24 questions, and the maladaptive emotion regulation domain was measured by reverse scoring. Its reliability coefficient for this study, Cronbach’s α, was 0.89.

Resilience

The Resilience Quotient Test (RQT) for adults developed by Reivich and Shatte (2002) was adapted by Kwon (2010) and then reorganized for children by Lee (2013). This scale for children was used to measure children’s resilience. It consists of a total of 36 questions, and higher scores indicate greater resilience. Its reliability coefficient for this study, Cronbach’s α, was 0.75.

Analysis methods

In this study, changes in children’s emotional intelligence, emotional regulation, and resilience were analyzed using SPSS Statistics. The Shapiro-Wilk test was used to test the normality of the control and experimental groups. An independent t-test was used to compare the control and experimental groups. A paired t-test was used for the pre-and post-test before and after the program. The level of statistical significance was set at p < .05. Chi-squared test was used for demographic data.

Normality test

Before implementing the HTP, a homogeneity test was conducted between the experimental and control groups, and the two groups were found to be homogeneous (Table 2).

Results and Discussion

Demographic characteristics

Of the 42 children who participated in the study, the 21 in the experimental group had a mean age of 9.14 ± 7.82 years, and the 21 in the control group had a mean age of 9.19 ± 8.78 years. There were no differences between the groups in terms of the gender, age and grade of the participants (Table 3).

Emotional intelligence

Comparing participants’ emotional intelligence before and after the HTP, it was found that the emotional intelligence of the experimental group improved significantly (p < .01), and there were also significant effects in the sub-domains of emotional intelligence, including emotion recognition, emotion regulation, and emotion utilization (Table 4). These results are consistent with previous findings. HTPs have been reported to be effective on children’s social competence, as well as their emotional intelligence, including emotion recognition, emotion regulation, and emotion utilization (Kim 2014; Jeon, 2015). By participating in gardening activities and communicating with peers, children have the opportunity to recognize and express emotions, thereby improving their emotional intelligence (Oh, 2019). Such activities have a positive effect on reducing depression and anxiety in children, and are effective in alleviating their negative tendencies (Yoon, 2009). In addition, nature-based activities have a positive effect on emotional intelligence by purifying the emotions of elementary school students and helping them regain mental and physical health and stability (Jeong, 2007). This study implemented an HTP that included CBERT to help participants learn strategies for comforting themselves, asking for help, and shifting negative emotions into positive emotions. Horticultural activity programs help participating children train to recognize their own emotions and understand the minds of others by caring for and growing plants themselves, realizing the preciousness of life and communicating with other participants in the process. It seems that such training experiences have a positive effect on improving their emotional intelligence, including emotion recognition, emotion regulation, and emotion utilization (Kim, 2020).

Emotion regulation ability

Comparing the participants’ emotion regulation ability before and after the HTP, it was found that the experimental group’s emotion regulation ability was significantly improved (p < .01), and there were significant effects on adaptive emotion regulation, a sub-domain (Table 5). This is consistent with previous findings that an HTP based on CBERT was effective in improving emotion control ability in children from low-income families (Jang, 2014). It is also in line with previous findings on the relationship between young children’s gardening activities and their emotion regulation and happiness: gardening activities provide them with diverse stimulation and objects of curiosity, and are effective in improving their emotion regulation (Kim, 2020). Lee (2008) argued that providing a program that helps people train in how to regulate their current emotions in order to identify and positively express their emotions will lead to more effective outcomes. In this study, participating children were taught about the types of emotion regulation and trained to understand each other’s emotion by comparing their own emotions felt through working with soil and plants with their friends’ emotions. In addition, the participants were encouraged to fully express the diverse emotions they felt during the activity, and to recognize that the emotions they expressed were their own sentiments.
It appears that the HTP based on CBERT had emotional effects on the participating children, resulting in positive outcomes in improving their emotion regulation; the program, which uses plants, helps them reduce tension and stress and increase psychological and physiological stability while learning emotion regulation strategies to turn their negative emotions into positive ones (Ulrich, 1981; Lee, 2006; Kim et al., 2012).

Resilience

Comparing the participants’ resilience before and after the HTP, the experimental group’s resilience was found to be significantly improved (p < .01), and there were significant effects on optimism and root cause analysis (RCA) skills, the sub-domains of emotion regulation (p < .05; Table 6). Optimism, a sub-domain of resilience, helps one overcome a difficult reality with a positive and hopeful attitude instead of destructive thoughts or words when experiencing failure or facing adversity (Shin et al., 2009). RCA skills reduce stress as much as possible by accurately identifying the cause of stressful situations, making sense of life, and coping effectively (Shin et al., 2009). It seems that during a CBERT-based HTP, training that helps participants improve their problem-solving skills can have significant effects on optimism and RCA skills, which are sub-domains of resilience. Such training enables them to accurately identify the cause of a problematic situation, to make sense of life by seeking help from others or encouraging and comforting themselves, and to cope effectively with difficulties (Shin et al., 2009). This is consistent with the findings of previous studies: that children’s ego-resilience was effectively improved by combining comprehensive and holistic horticultural therapy with various therapeutic activities (Park, 2010); and that children’s resilience improved when they were continuously exposed to a natural environment by teaching them how to plant and care for plants themselves in class and having them observe the plants with interest (Oh, 2019).

Conclusion

In this study, we developed a horticultural therapy program (HTP) based on cognitive-behavioral emotion regulation training (CBERT) for children eligible for priority support for educational welfare, and aimed to determine its effects on improving emotional intelligence, emotion regulation ability, and resilience in participants. The study’s results confirmed that the program had a positive effect on improving such children’s emotional intelligence, emotion regulation ability, and resilience. Specifically, significant differences were found in emotional intelligence, as well as in emotion regulation, which is a sub-domain of resilience.
The CBERT-based HTP developed in this study is significant in that it not only provides children who are at a critical stage of building their emotion regulation skills with an opportunity to think about their own minds, but also helps them to learn what emotions are, think about their easily overlooked emotions, and establish a framework for effectively dealing with the emotions they will experience in life (Jeon, 2020). Moreover, by participating in the program, the children were able to experience and learn the confidence, stability, satisfaction, creativity, concentration, joy, and more that plants provide in situations where diverse emotions can be felt (Kim, 1998; Son, 2016). The importance of this study was also shown in that an HTP that provides emotional effects and physiological stability through psychological stability (Ulrich, 1981; Lee, 2006; Kim et al., 2012) was developed based on CBERT, and its effectiveness was confirmed in the field. However, there are limitations when it comes to generalizing the effects of the horticultural therapy intervention in this study for the following reasons: the population size of the experimental group was small, with just 21 3rd and 4th grade students, and the temporal scope was limited to 60 minutes per session for a total of 10 sessions.
To generalize the findings and promote the broader application of such programs in the future, it seems necessary to conduct research by increasing the population size, and testing different types of subjects, including not only children from low-income families, but also general children and multicultural children. It also seems that further research should be conducted on the development and assessment approaches of HTPs that apply various psychological and emotional theories, and on the effects of HTPs that consider children’s emotional development. Furthermore, there will be a need to prove the effectiveness of HTPs for improving psychological/emotional well-being through a comparative study between simple horticultural activities of plant cultivation, an HTP that secures the three elements of plants, subjects, and therapists, and an HTP that applies CBERT.

Table 1
Goals and contents of each session of the horticultural therapy program applying cognitive-behavioral emotion regulation training
Stage Composition element Target Gardening activity topic Horticultural therapy approach based on emotional regulation training Benefit
1 Relationship formation Relationship formation About Me Program goals Content introduction Relationship formation I am this kind of person Pressed flower name tag How the program progresses, description of contents Build relationships by introducing yourself, creating nicknames, and decorating name tags.
  • Relationship formation

  • Yourself and others

  • Understanding emotions

2 Exploration Emotion recognition Know what words express emotions and recognize your own emotions Emotional Making grass dolls Learn words that express emotions, Know what you normally feel Making a lawn doll by recognizing your emotions
  • Awareness of one’s own emotions

  • Emotional expression

  • Language expressiveness

3 Emotion recognition Understanding the need for emotions, positive emotions and negative emotions know The emotion want to use Emotions that I want to throw away colored sand terrarium Using sand of various colors find the colors you like and dislike
Decorate with colored sand and plant plants while learning about positive and negative emotions
  • Emotion recognition

  • Understanding positivity and negativity

4 Emotion control Emotional regulation and understanding strategy What is emotional regulation?
Succulent gardening
Find the emotions felt through activities such as touching the soil and learning about succulents, Understanding the concept of emotion regulation and examining cognitive, behavioral, and physiological emotion regulation strategies
  • Emotion regulation concept

  • Emotion regulation strategies

  • Emotional expression

5 Insight and acquire alternative skills Behavioral strategy Understand and practice behavioral strategies Find positive language Making a flower basket Find experiences and words that make you feel good, write them down on an umbrella, and then decorate it in a basket with flowers. Practice opening an umbrella while looking at flowers when you are in a bad mood.
  • Recognize positive words

  • Positive environmental awareness

  • Acquiring behavioral strategies

6 Behavioral strategy Knowing how to seek help from others or comfort yourself Knowing how to ask for help Topiary making Try the difficult activity of wrapping sphagnum moss and wrapping it with rope and learn how to ask for help and comfort others when you have trouble doing it on your own
  • Ask for help comfort yourself

  • Behavioral strategy

7 Understanding other people’s emotions Expressing one’s feelings Hagi and friend empathize with each other, Understanding experiential strategies Dried flower canvas frame that expresses my heart Practice how to express your feelings and empathize and express responses to understand your friends’ feelings through stories about situations that occurred in the classroom. Express what you want to say to your friend in a canvas frame
  • Understanding other people’s emotions express your feelings

  • I learned how to communicate

  • Empathic response experience

  • Expressive reaction experience

8 Behavioral strategy Other people’s feelings notice Recognizing your friend’s feelings Planting Herb Plants Expressing emotions felt through herb plant selection process and scent and learning strategies to recognize and understand a friend’s emotions felt during the selection process
  • Know your friend’s feelings

  • Behavioral strategy

9 Understand automatic thoughts Understanding and recognizing the existence of automatic thoughts Find your thoughts in the moment Making a wreath Understand and recognize the existence of automatic thoughts that arise momentarily while examining materials and understand irrational beliefs.
  • Understanding automatic thoughts

  • Finding Automatic thoughts

  • Understanding irrational beliefs

10 Finishing Cognitive strategy Regulating emotions learning cognitive strategies Changing irrational beliefs Making herbarium Understanding irrational and rational beliefs and applying cognitive strategies for emotion regulation.
We pledge to preserve, remember, and apply the meaning of changed rational beliefs to Herbarium in our daily lives.
  • Finding irrational beliefs

  • Understanding rational beliefs

  • Negative cognitive strategy

  • Positive Cognitive Strategies

  • Cognitive strategy

Table 2
Homogeneity test of experimental group and control group before implementation of horticultural therapy program
Variables Experimental group (n = 21) Control group (n = 21) p-value

Mean ± SD
Emotional Intelligence 95.83 ± 9.67 96.71 ± 11.32 0.561NS
Emotional Regulation 77.79 ± 13.21 77.71 ± 13.30 0.973NS
Resilience 114.10 ± 11.82 116.38 ± 11.65 0.214NS

NS non-significant; by Shapiro-Wilk test, respectively.

Table 3
Verification of the demographic characteristics of the experimental group and the control group
Variable Experimental group (n = 21) Control group (n = 21) Total (N = 42) χ2 p-value

Mean ± SDZ
Age 9.14 ± 7.82 9.19 ± 8.78 9.16 ± 5.82 0.171 0.679NS

N (%)

9 Age 18 (85.7) 17 (80.9) 35 (83.3)
10 Age 3 (14.2) 4 (19.1) 7 (16.7)

N (%)

Male 10 (47.6) 8 (38.1) 18 (42.85) 0.3890. 533NS
Female 11 (52.4) 13 (61.9) 24 (57.15)

Z Mean±standard deviation

NS Non-significant

Table 4
Comparison of emotional intelligence results before and after implementing a horticultural therapy program
Variables Group Pre-HTPz Post-HTP t p-value

Mean±SD
Emotion Recognition Exp. 18.43 ± 3.80 21.33 ± 8.10 −2.0690. 031*
Cont. 18.33 ± 3.08 18.67 ± 3.02 −0.546 0.515NS

Emotional Expression Exp. 14.95 ± 3.47 15.19 ± 2.99 −0.354 0.374NS
Cont. 15.52 ± 3.17 15.52 ± 4.02 0.744 0.466NS

Empathy Exp. 13.29 ± 3.58 14.33 ± 3.94 −1.413 0.264NS
Cont. 13.95 ± 2.85 15.00 ± 3.77 −1.952 0.052NS

Emotion Regulation Exp. 30.24 ± 7.97 31.62 ± 7.89 −1.444 0.021*
Cont. 31.05 ± 3.65 31.33 ± 5.38 −0.270 0.756NS

Emotional Utilization Exp. 16.33 ± 1.67 16.81 ± 1.91 −0.960 0.046*
Cont. 16.10 ± 2.63 16.10 ± 1.99 −0.218 0.829NS

Total Emotional Intelligence Exp. 96.71 ± 11.33 107.57 ± 7.00 −4.303 0.003**
Cont. 94.95 ± 7.85 96.62 ± 9.39 −1.221 0.338NS

Z Horticultural therapy program

NS non-significant;

*, ** significant at p < .05, and .01, and by Paired t-test, respectively.

Table 5
Comparison of emotional regulation ability results before and after implementing a horticultural therapy program
Variables Group Pre-HTPz Post-HTP t p-value

Mean±SD
Maladaptive Emotion regulation Exp. 51.62 ± 11.06 53.57 ± 10.47 −1.071 0.297NS
Cont. 48.76 ± 9.71 47.95 ± 10.41 0.396 0.410NS

Adaptive Emotion Regulation Exp. 26.24 ± 7.08 32.38 ± 7.24 −3.737 0.001**
Cont. 28.95 ± 4.88 27.05 ± 6.78 1.638 0.120NS

Total Emotion Regulation Ability Exp. 77.86 ± 13.43 85.95 ± 15.08 −4.292 0.001**
Cont. 77.71 ± 13.30 75.00 ± 15.64 0.783 0.159NS

Z Horticultural therapy program

NS non-significant;

*, ** significant at p < .05, and .01, and by Paired t-test, respectively.

Table 6
Comparison of resilience results before and after implementing a horticultural therapy program
Variables Group Pre-HTPz Post-HTP t p-value

Mean±SD
Emotional Regulation Ability Exp. 18.24 ± 3.60 19.75 ± 3.54 −2.492 0.006**
Cont. 19.43 ± 3.34 17.95 ± 4.36 1.354 0.191NS

Impulse control Exp. 16.55 ± 3.26 16.43 ± 3,61 0.126 0.900NS
Cont. 15.76 ± 3.13 16.71 ± 3.76 −1.208 0.241NS

Optimism Exp. 14.90 ± 3.01 17.48 ± 3.45 −3.064 0.004**
Cont. 15.65 ± 3.06 15.15 ± 3.77 0.210 0.836NS

Root Cause Analysis (RCA) Skills Exp. 11.38 ± 2.41 13.10 ± 2.54 −1.985 0.031*
Cont. 12.43 ± 1.78 12.81 ± 2.80 −0.565 0.578NS

Empathy Exp. 17.81 ± 3.41 19.95 ± 4.08 −1.929 0.073NS
Cont. 20.30 ± 2.97 19.85 ± 3.34 0.561 0.581NS

Self-efficacy Exp. 16.14 ± 2.59 17.52 ± 2.58 −1.816 0.085NS
Cont. 15.55 ± 2.95 15.10 ± 3.30 0.814 0.4258NS

Positive Challenge Exp. 16.71 ± 3.13 17.90 ± 3.91 −1.357 0.190NS
Cont. 17.38 ± 3.49 17.14 ± 3.61 0.283 0.780NS

Total Resilience Exp. 111.81 ± 11.81 122.29 ± 17.06 −3.107 0.009**
Cont. 116.98 ± 11.65 114.45 ± 14.54 0.807 0.429NS

Z Horticultural therapy program

NS non-significant;

*, ** significant at p < .05, and .01, and by Paired t-test, respectively.

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