Negotiating vulnerabilities : a constructivist grounded theory study of engagement in green spacesby community dwelling people living with dementia

Background
Dementia is an important public health challenge globally. Progressive cognitive impairment interferes with one’s ability to function socially and independently and can result in a diminished quality of life.
With no cure to this terminal condition, research efforts are increasingly being geared towards interventions that can improve the lives of people while living with dementia. Psychosocial supports are highly beneficial in this regard. The natural environment has been demonstrated to have a positive impact on quality of life in general, and so its role as an effective intervention in improving the health and wellbeing of people living with dementia is worthy of serious exploration. Most of the available evidence, however, has focussed on people without dementia, or when dementia is included, the focus is on people living with dementia in institutionalised settings rather than the community.
The focus of this PhD study is on the potential impacts of engagement in green space by community dwelling people living with dementia on the complex psychosocial processes associated with the dementia experience, and consequently improving quality of life. The study takes an embodied personhood approach, that is, the perspective that although dementia can disrupt the ability to recall explicit memories, the individual can retain their habits and experiences ingrained in their body memories which do not require executive functioning to be expressed.
Aim
The overall research aim of this qualitative, constructivist grounded theory study is to explore the impacts of engagement with green spaces on the psychosocial aspects of living with dementia. To achieve the aim, the research questions are: How do community dwelling people living with dementia interact with green spaces? What factors affect access and interactions with green spaces for community dwelling people living with dementia? and What are the impacts of green space engagement on psychosocial aspects of living with dementia and the effect of engagement on overall quality of life?
Design and method
Constructivist grounded theory, underpinned by the theoretical perspectives of symbolic interactionism and constructivism, is the methodological approach for this study. Participants were drawn from both urban and rural communities across Australian states, including NSW (3), Victoria (2), Queensland (2), and South Australia (1). Data was collected via 8 individual interviews, memo notes and participants’ photos, during December 2021–April 2022. Initial and focused coding, constant comparative analysis, theoretical memos and conceptual mapping supported the data analysis until theoretical saturation was achieved. Inter-related categories and key concepts were generated by the data analysis.
Findings
The study found the phenomenon to be ‘treading the path’ of limitations, vulnerabilities, and abilities, identified through the key concepts of ‘locating nature’ and ‘being engaged’. For familiarity and safety reasons, there was a preference for nearby nature and a propensity towards a personal competence led approach to engagement.
The contexts or conditions under which the participants interacted in green spaces were conceptualised as ‘setting the scene’. The physical and social environments in green spaces posed some challenges and constrained engagement, while some of the features of the environments were enabling.
The participants engaged in two processes as they recognised their abilities and negotiated their vulnerabilities in green spaces. The two processes identified from the data analysis are ‘tuning in’ and ‘being in charge’. The associated benefits of engagement in green spaces include improved emotional wellbeing, expressions of spirituality and aspects of selfhood, and social connections.
Discussion
The connections between and within the categories and concepts were analysed and developed into the substantive theory; that community dwelling people living with dementia negotiate vulnerabilities in response to their interaction in green spaces, and the affordances and hindrances they experience.
Familiarity mediated certain choices and experiences including nearby nature and sense of place. Familiarity is not solely dependent on cognition but also on the embodied experiences of the individual, highlighting the importance of the embodied personhood in dementia.
Engagement in green spaces mediated mental restoration and spiritual experiences which, in turn, had positive effects on mental wellbeing and the meaning making of the challenges of living with dementia. In the active process of reinforcing a sense of self and identity through opportunities for agency and autonomy in green spaces, the participants were not only negotiating vulnerabilities but also improving important aspects of their quality of life. For example, people living with dementia often feel lonely and socially isolated in their community, but green spaces appear to offer opportunities for meaningful interactions and social connections, and active citizenship.
The context of enabling conditions and constraints offered new insights into areas of dementia friendly design principles and positive risk taking.
Contrary to the narrative of decline often associated with dementia, people living with dementia in this study demonstrated evidence of retained abilities, resilience, and self-determination. The propensity to live well with dementia amongst the study participants reflects the enabling capacity of green spaces to help people successfully ‘tread the path’ toward an improved quality of life.
Conclusions
The study concludes that green space engagement is beneficial for: mental restoration; meeting spiritual needs; reinforcing identity; and various social aspects of living with dementia. The substantive theory generated by this research provides evidence for the need to support community dwelling people living with dementia to engage more in nature to promote emotional and psychological wellbeing, and provide opportunities of maintaining spirituality, selfhood and social connectedness. The study also highlights the complex physical and social factors that influence engagement, including constraints and enablers, with important real-life implications for families, dementia support organisations and local government and urban planners.
Further, this study provides new knowledge and extends previous research undertaken with people living with dementia. It contributes to and strengthens the application of constructivist grounded theory in dementia scholarship.