“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

Abstract

Background and Objectives

In conversations about expanding age-friendly ecosystems, the concept of “age-friendliness” has not been explored in relation to residential settings.

Research Design and Methods

This multiple-case study compared four residents’ perspectives on the age-friendliness of a retirement and assisted living community, combining individual semi-structured interviews with observational data and organizational document analyses in a contextualist thematic examination.

Results

Three themes depict (A) existing experiences of the setting as “age-friendly” and the tension of the built design vs. identity; (B) resident-to-resident microaggressions, delineated into 4 subthemes including identity-related, intergenerational, condition-related microaggressions, and their influence on social isolation; and (C) desired experiences of the setting as “age-friendly” reflecting the social design. In cases of visibly perceptible diversity (white cane, darker skin tone), residents fared worse in experiencing microaggressions stemming from ableism, racism, and age differences. Conversely, in cases of visibly imperceptible diversity, residents had more positive or entirely positive experiences. Although the setting met many environmental and healthcare needs, it lacked design factors prioritizing meaningful social relationships among residents, affecting social isolation.

Discussion and Implications

Resident-to-resident social relationships were key in the experience of a retirement and assisted living community as age-friendly. Resident-to-resident microaggressions undermined perceptions of the community as age-friendly, and influenced social isolation. We reflect on the organizational role in mitigating against negative social relationships and social isolation to maximize dignity.

Age-friendly ecosystems (Fulmer et al., 2020) are an outgrowth of the framework by the World Health Organization (2007) on age-friendly cities and communities. The core policy design is to respond to older adults’ needs across multiple sectors. To that end, the U.S. healthcare system is guided by the 4Ms in the age-friendly health systems (AFHS) framework, incorporating what matters, medication, mentation, and mobility, designed “to prevent harm to older adults” and address their “unique needs and wants” (Institute for Healthcare Improvement [IHI], 2019; John A. Hartford Foundation, n.d.).

Older people’s perspectives about what “age-friendly” means to them as residents in a housing and care setting are absent. A systematic review highlighted the need for input by older adults based on publication trends with a focus on age-friendly cities and communities, but not residential settings (Torku et al., 2021). Employing a sample of older adults, Dikken et al. (2020) developed a questionnaire on age-friendly cities and communities but not residential settings. Although these studies acknowledge input generated from older adults, they entail primarily a city- and community-wide focus.

Thought leaders have advocated for envisioning nursing homes, assisted living, and retirement communities as age-friendly by drawing on, and expanding the 4Ms framework, especially for spaces including care other than healthcare (Bonner et al., 2022). Congregate residential settings such as retirement and assisted living communities have long espoused principles of aging-in-place by offering colocated care levels, active lifestyle, and social engagement opportunities (Zarem, 2010). Many older people move to such settings to receive therapeutic and affirming services and supports as their healthcare needs increase (Krout et al., 2002). However, whether such settings are in fact experienced as “age-friendly” by residents has not been studied.

Social relationships, included in WHO’s (2007) framework among its eight themes, refer to social participation, respect, and social inclusion. The lifecourse concept of linked lives (Bengtson et al., 2012) helps to illustrate the centrality of social relationships among residents in a retirement and assisted living community as residents’ lives are intertwined in the same physical space over time. Studies of resident-to-resident aggression in congregate settings (Gimm et al., 2018, Rosen et al., 2008) are emblematic of linked lives and fraught relationships.

Social ties can affect how residents spend their time, can complicate residents’ lives, and affect “their personal troubles,” with positive resident-to-resident relationships such as cliques and friendships serving as sources of strength and connection among residents (Gubrium, 1997, pp. 83–84). Kilaberia and Ratner (2018) found residents supporting one another during times of worsened health, implementing informal agreements to check on one another to remain connected. Among negative social relationships are avoidance of engagement with other residents to prevent unwanted social exchanges (Gubrium, 1997); relational aggression and poorer mental health and quality of life (Trompetter et al., 2011); conflict between residents due to residents fulfilling unwanted caregiving roles for other residents, tensions between residents from differences in religion, and in intergenerational activities when older and younger adults’ pace or expectations differed (Kilaberia & Ratner, 2018). Eckert et al. (2009) noted “aggression and intolerable behavior” by residents resulting in being asked to leave the assisted living setting (p. 122). Kilaberia (2021) noted instances of English-speaking residents not wanting to share a room with residents they thought did not speak English.

Studies above show that social relationships and their quality can affect the experience of a congregate housing and care setting as age-friendly. Yet, studies to date have not addressed this. The AFHS framework (IHI, 2019) focuses on health, cognitive, and functional areas in its tenets of medication, mentation, and mobility. The “what matters” tenet broadly espouses person-centered care but does not explicitly incorporate social and relational aspects in conceptualizing “age-friendly” care, as does the broader city- and community-focused WHO’s (2007) framework. The goal of the present study is to provide first-hand perspectives from older adults about the extent to which a retirement and assisted living community was age-friendly in their experience. The following research questions were asked: (1) How do residents define the experience of a retirement and assisted living community as age-friendly? (2) Do residents describe social relationships as affecting the experience of the setting as age-friendly and, if so, how?

Method

The Setting

The study setting was an urban, nonprofit retirement and assisted living community with a resident census of 334 residents across independent living and assisted living in the United States Midwest (approximately 700 residents including in the skilled nursing facility [SNF], which is not a direct focus of this study). Fifty-four percent of residents were in independent living needing no services, and others received some care services or were in assisted living. According to the state’s regulatory body (Office of Ombudsman for Long-Term Care, n.d.), adults 55 and older were eligible to live there. Adults younger than 55 also lived in the setting due to medical or disability exceptions (Centers for Medicare and Medicaid Services [CMS], 2015). The setting employed 483 staff across all care levels and three shifts: nurses; social workers; certified nursing and medication assistants; chaplains; rehabilitation therapists; dietitians; maintenance, kitchen, security, and other staff.

Study Design

The study was guided by the collective case study framework in which a few cases represent the “quintain” or the “collective target” under study (Stake, 2006, p. 6), and informed by the intersectionality lens (Crenshaw, 2013) given the focus on social relationships.

Selection of cases

Four residents representing the four cases were recruited in person. The first author made an announcement about the study to a group of residents. Then, those who expressed interest were interviewed. Of those, four met the selection criteria as recommended by Stake (2006, p. 23):

1. Is the case relevant to the collective target? The collective target is represented by the same retirement and assisted living community in which the four residents lived. All drew support from the same care infrastructure embedded in the setting, were governed by the same organizational policies and expectations, and exposed to the same resident census and social environment. In this manner, all four cases were relevant in examining the experiences of age-friendliness in the same setting.

2. Do the cases provide diversity across contexts? The intersectionality lens (Crenshaw, 2013) posits that a social system (such as a retirement and assisted living community) can be experienced differently given multiple dimensions of social identity, and that inequities can be compounded due to these dimensions interacting within systems that contextualize the human experience. As described in Table 1, cases were selected to represent multiple social dimensions of identity such as age (ranging from 57 to 91 years old); race (three White and one Black residents); health and disability status (ranging from relatively healthy to invisible and visible limitations); and length of residence in the setting (ranging from 2 to 30 years).

3. Do the cases provide good opportunities to learn about complexity and contexts?

4. Commonalities among residents were that they were all female (compared to 68% in the resident census) and lived in the same setting. Differences were their identity and sociocultural makeup, as described in Table 1. Holding the setting constant and examining four different cases in it allows the discernment of between-resident complexities while at the same time illustrating the broader context of the environmental infrastructure (health and social services) in which all were immersed.

5. Table 1 (top portion) illustrates case characteristics.

All four residents that are part of this case study responded to the same interview questions: (1) What does “age-friendly” mean to you? (2) What do you think would be a good/better definition of “age-friendly?” What should it refer to/entail? (3) In this setting, there are younger residents and older residents living together. What do you think of this generation-mixing?

Types of Data

Types of data to examine the research questions included individual, semi-structured, in-depth interviews, general observational data of additional residents in the setting, and organizational documents to triangulate knowledge gained from the interviews. Data were collected for 3 years through September 2019. Table 2 describes types and volume of data.

Individual, semi-structured, in-depth interviews

Interviews were conducted with the four residents face-to-face (mean interview time was 57.5 min, range 44–84 min). Recordings were transcribed verbatim and deidentified.

General observational data

General observational data were collected as the first author interacted daily with residents. The majority of the observational data centered around the social activities calendar distributed in the setting. Residents came together to participate in mixers, educational, spectator, and faith-related activities in shared spaces such as the dining room, conference rooms, and auditorium. The first author also spent time with residents individually, one-on-one, or in small groups. Residents knew that they were being observed and had participated in various intergenerational learning opportunities over many years (Kilaberia & Ratner, 2018; Ratner et al., 2022).

Organizational documents

Five types of document data, available to all residents in the setting, were reviewed for statements that described the setting as age-friendly. These included policy statements about residents having input in decision-making about their life in the setting. Meeting minutes of the Resident Council (representing Residents’ Association) were examined for 3 months per year across 3 years, for a total of nine monthly meetings, varying time periods to account for a variety of issues across more than 1 year. The organization’s public-facing website delineated information for prospective residents and described the setting in terms of its attractive qualities.

Data Analysis

A contextualist thematic analysis was conducted to compare “the ways individuals make meaning of their experience, and, in turn, the ways the broader social context impinges on those meanings” (Braun & Clarke, 2006, p. 81). The retirement and assisted living community as the broader care organization served as the social context reflected by observational and organizational document data and analyses. The four residents individually represent data items, and quotes below represent data extracts referring to social relationships in the experience of the setting as age-friendly.

Observational data analysis accounted for the experiences of additional residents in the setting. Observations were organized by types of social interactions (same generation resident-to-resident, intergenerational resident-to-resident, group, and one-on-one interactions). The focus on social relationships with students who were residents for learning rather than living purposes was excluded.

Document analysis accounted for the organizational context, which ordered life in the setting by outlining rules and expectations. The organization’s public-facing website information, compiled into a text document, was coded for repeated references to the care campus and the wider community, keeping in mind the overarching interest in the portrayal of the setting as age-friendly.

All data (four interviews, observations, and document data) were coded inductively at a semantic or explicit level, following systematic steps (Braun & Clarke, 2006, pp. 83–84). In phase 1, the first author noted unique and shared case factors based on repeated rereading of the interview data. In phase 2, the first author generated initial codes based on the interview data, collating them in phase 3 but keeping data sources (interviews, observations, and document data) separate: observational and document analyses substantiated the findings based on the interview data but did not primarily serve to develop themes. The focus was on aggression broadly, delineating themes as (a) ongoing and (b) suggested meaning of “age-friendly”; (b) social relationships in terms of (b1) generation-mixing and (b2) condition-mixing; (c) belonging and intersectionality; and (d) uncaring national culture toward older adults.

Subsequently, developing themes based on data integration occurred with the co-authors in phase 4, by checking if the themes related to the coded extracts (quotes presented below) and the entire data set including the interviews, observational, and document data. Integration and accounting for the entire analytic data set occurred at this stage, and amounts to saturation in Braun and Clarke’s (2006) thematic analysis. Themes and subthemes were delineated in two iterations, after six small- and large-group discussions among co-authors. As a result, “uncaring national culture toward older adults” as a developing theme was eliminated as it was thought to be unsupported in the context of the entire analytic data set. Microaggressions were specified from the broad focus on aggression. In phase 5, “the influence of microaggressions on social isolation” was delineated as a theme based on a discussion of the previous theme of “belonging and intersectionality.” Three themes and four subthemes were defined and named as presented in the results section below. All data except documents were coded utilizing NVivo Pro (Lumivero, 2022). Document data were organized and reviewed for content in a Microsoft Excel spreadsheet.

Rigor

Although prolonged engagement by the first author who lived in the setting is a strength of the study, years of immersion can result in the loss of objectivity (Padgett, 2016). Utilizing rigor criteria by Lincoln and Guba (1985), trustworthiness was established as follows: to ensure dependability, the first author utilized the inquiry audit technique by documenting the process and the product. The balance of emic (as participant) and etic (as researcher) perspectives was mitigated by keeping a reflection journal and then engaging in peer-debriefing sessions with a university mentor during data collection, to account for the process. Subsequently, to account for the dependability of the product, at the time of data analysis, the first author collected input from co-authors (E-S.C., D.K.P., M.L., and T.R.) on coding and converging interview, observational, and document analyses. In this manner, co-authors served as inquiry auditors who examined the data, findings, and inferences, also ensuring confirmability.

Reflexivity and Study Ethics

The study was aided due to the first author living in the setting as a resident while collecting data. The retirement and assisted living community had an established understanding with area universities and academic medical centers to allow students to engage in short- and long-term learning experiences. In its marketing materials, the organization referred to intergenerational activities with students as an attractive way to engage socially for older people considering moving to the setting. These types of learning opportunities are undergirded by the evidence of benefit to both older and young adults (Campbell et al., 2023; Ratner et al., 2022).

Based on the immersion in the setting, the first author conducted multiple studies from observational and staff perspectives (Kilaberia, 2020, 2021; Kilaberia & Merighi, 2023; Kilaberia & Ratner, 2018; Kilaberia et al., 2024), collecting data in addition from the perspective of residents at the center of exploration in this current study. This unique opportunity enabled access to residents, organizational documents, and observations across shared spaces in which residents mingled. The first author’s role was to help alleviate the social isolation of residents by participating in various social activities. As a participant observer, the first author interacted with 10–15 residents daily one-on-one, in dyads or groups.

At the time of data collection, the first author self-described as an immigrant almost three times younger than the majority of residents. At the time of drafting the manuscript, co-authors were from diverse ethnic backgrounds, and, on average, younger than the study participants. All co-authors were trained as academic faculty representing disciplines of social work, gerontology, public health, and medicine.

The study reflects the relationist ethics (Sherwin, 1989), acknowledging “the interdependent, [ … ] unequal relationships that shape our lives” (p. 62). In its justice orientation and acknowledgment of complex relationships, the relationist ethical perspective emphasizes the importance of the context, aligning with Braun and Clarke’s (2006) contextualist thematic analysis, the linked lives concept of the lifecourse perspective, and the intersectionality lens guiding this study. Power symmetry and interpretation of meaning are accounted for by referring to the immersion in the setting, rigor, and reflexivity.

Following the principlist approach of the Belmont report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979), ethics review approval and care organization’s permission were obtained prior to study initiation (approval number: STUDY00000905). Participants provided in-person verbal informed consent to the first author. They received no compensation for participating in the study.

Results

Three themes were identified: (A) existing experiences of “age-friendly”: built design versus identity; (B) resident-to-resident microaggressions delineated into four subthemes: (B1) identity-related microaggressions, (B2) intergenerational microaggressions, (B3) condition-related microaggressions, and (B4) the influence of microaggressions on social isolation; and (C) desired experience of the setting as “age-friendly.” For each theme and subtheme, Table 3 provides illustrative quotes in addition to those presented below (with the age of residents in parentheses).

Theme A. Existing Experience of “Age-Friendly”: Built Design Versus Identity

The setting offered on-site: a health clinic, rehabilitation clinic, memory care in an adjacent SNF, palliative and hospice care, and pharmacy. On-site amenities included a library, exercise room, chapel, café, grocery store, etc., such that residents could meet their health, social, spiritual, and other needs within the setting without leaving it. Daily, many professionals and paraprofessionals mingled with residents, bringing them to or from care services, and reminding them of appointments or home visits. The organization’s website marketed as attractive the availability of the care infrastructure, promising older adults peace of mind, choice, multiple care levels, and freedom from home maintenance. It emphasized safety, security, affordability, and wellness-based living, including social opportunities both on the care campus and in the surrounding city.

Observational data showed that residents felt secure thinking that beds would likely be available to them in the adjacent SNF, if needed. Residents were often observed as they transitioned between their apartments in the independent living part of the campus and SNF, where they stayed temporarily for wound healing, medication and nutrition regimen, and therapeutic treatments after surgical interventions at area hospitals. Many residents appraised hopefully the availability of the rehabilitation clinic right on-site that helped them with mobility, balance, muscle strength, or mastery of assistive devices. The availability of these therapeutic supports gave residents confidence in meeting their needs.

Residents 1, 3, and 4 referred to this deliberate design embedded in the setting through infrastructure and services as “age-friendly.” Resident 1 (91) described the setting as “built for us.” Resident 3 (71) referred to the setting as responsive to her needs as a person with disabilities: “space that is not confined to one level and then another level [i.e., no stairs to navigate], if one needs a wheelchair or a walker, having adequate space to put them.” For Resident 4 (70), reflecting her social identity was part of her understanding of “age-friendly,” aside from the built environment: “For me, personally, age-friendly means knowledge and talking to my grandparents and my father [ … ] they told me things about my culture [ … ] how we were treated as African-Americans [ … ] bigotry and those things were going on.” Although Resident 2 (57) did not explicitly refer to the built design as disadvantageous to her, she referred to the gap between the eligibility criteria for residing in the setting (starting at 55 years of age) and the design built for residents decades older: “[younger adults are] still interested in things that are age appropriate to them. [ … ] And it’s going to be quite different than an 81-year-old.”

Observational data showed that some residents voiced concerns that the setting used to be “mostly church [Christian and homogenous] people, and now it’s all kinds of people.” During the annual review of the census with residents, no information was presented on the racial or ethnic makeup.

Theme B. Resident-to-Resident Microaggressions

Resident-to-resident microaggressions reflected identity-related, intergenerational, and condition-related microaggressions, which influenced social isolation.

Subtheme B1. Identity-related microaggressions

Identity-related microaggressions pertained to micro-indignities experienced due to who the residents were. Whereas Residents 2 and 3 experienced ableist microaggressions, Resident 4 experienced racist microaggressions.

Resident 2 (57) perceived being “picked at” due to her disability that was invisible outwardly, and, for that reason, surveilled. As a result, she experienced having to legitimize her disability to be believed: “most people don’t think I’m disabled [ … ] I tell them that I’ve had some head injuries and a lot of times I have to tell them about my shoulders because I can’t do certain things with my shoulders.”

Resident 3 (71) experienced being attributed additional disabilities because she utilized a white cane: “many people think you’re deaf too and they have to shout at you.” Although she attempted to convey that she was not deaf, “they just don’t understand [being blind]. I just feel sometimes that it’s like my mother used to say, pulling hen’s teeth, to get people to understand. [ … ] It’s just very frustrating.” Resident 3 experienced direct insults: “I came home from somewhere one day [ … ] I managed to get around all the people [sitting in the lobby] and this one guy blurted right out loud, ‘You’re not as dumb as you look!’”

As a Black woman, Resident 4 (70) felt that some of the interactions in the social environment were hostile, discriminatory, and overtly exclusionary:

She [a fellow resident] was saying every Black person she knows is a junkie, or sells dope, or is a dope man. [ … ] I had several people say, “Why don’t you go where your kind is wanted?” Those are the things that bother me. [ … ] I try to keep as sane as I possibly can without getting really angry, but for me, at 70, to see that this is still happening … is crazy to me.

Subtheme B2. Intergenerational microaggressions

Intergenerational relationships were experienced as age-related microaggressions (73% of residents were 80 and older, comprising the greater proportion in the setting). All residents except Resident 1 reported intergenerational microaggressions.

Resident 1 (91) reported positive social relationships with younger adults, referring to them as “an asset”: “I like to hear their ideas, and I like to share mine with them.” Resident 4 (70) relied on younger residents for affirming experiences, and described “a group of people that I hang around with that [ … ] make it very pleasant for me to be here. They’re all younger than me.” At the same time, Resident 4 did not appreciate individuals generations younger living in the setting because she perceived it as disorienting to them and to older residents:

There’s [sic] people here in their 30s and 40s, and they’ve got to be bored. It’s a whole culture shock because you’ve got people who are 100, and you’re 30 or 40 [ … ] It’s [eligibility criteria to move into the setting] advertised as 55 and over; why is somebody who could be as old as my grandchildren living here?

Residents 2 and 3 reported negative intergenerational experiences, referring to the vastly divergent interests: “I feel like I have a lot to talk about, but it’s stuff that if I talked about it, [ … ] they wouldn’t identify with it or they wouldn’t understand it” (Resident 2, 57). Resident 3 (71) referred to older adults growing up in a different historical time when persons with disabilities were invisible in community life (were institutionalized or hidden from public view), which resulted in the lack of tolerance: “a lot of people, especially the older ones, didn’t grow up with children in wheelchairs or people using white canes [ … ] it’s difficult for them to have a clue about what’s correct and what isn’t.”

Observational data showed that some older residents in their 80s and 90s perceived younger residents in their 40s as unyielding, fast, and unaccommodating, referring to their experience as “it irked me,” or “it drives me crazy,” opting out of attending social activities entirely due to the younger residents participating also.

Subtheme B3. Condition-related microaggressions

Condition-related microaggressions referred to life stage (pregnancy or child-rearing), medical conditions (dementia), or socioeconomic status that could be hard to reconcile. Sharing the setting with child-bearing younger women who for life stage (pregnancy) and social (unhoused) reasons had to reside there was distressing for Resident 4 (70): “It’s the ones with the babies or who are pregnant, who kind of boggle my mind; why are they here? Why would they want to be here?!” Resident 3 (71) referred to cognitive challenges playing a part in not remembering repeated requests: “They have some sort of memory issues and can’t remember from one time to the next.”

Observational analysis of additional residents in the setting showed that poverty was a condition noted by residents. Some could not afford to pay for periodic social outings (bus fare or a theater ticket). One resident, under medical advisement to gain weight, could not afford to eat in the dining room (residents either utilized meal plans or paid cash). She was sometimes observed sitting by the dining room exit, stating she “will go upstairs [to her apartment] and eat a frozen dinner.” In another instance, in a group setting, two residents argued about being able to shop at less and more expensive grocery stores because they each had economic circumstances reflective of their shopping decisions. As a male resident explained, if he shopped at a budget store, this did not mean that he did not support workers underpaid and overworked by the store; rather, it meant that he could not afford to shop at a more expensive store frequented by the female resident who collected social security and a pension in addition, whereas the company he had worked for “went under,” resulting in a smaller income.

Subtheme B4. Influence of microaggressions on social isolation

Noteworthy is the social isolation accompanying experiences of microaggressions as residents referred to feeling unsupported, separated, or isolated: “nobody said a word to him about [insulting me]. There must have been five or six people there with him” (Resident 3, 71). Or, “I don’t have a lot in common with anybody here” (Resident 2, 57). Resident 4 (70) expressed hopelessness at perceiving the environment as one in which

You [residents] assume because someone is this way [Black] that this is how they are [referring to stereotypes and prejudicial beliefs]. I would like to see it be just that we all get together and live in harmony. I don’t think in my lifetime that’s ever going to be and that’s sad.

Observational data showed that although the setting offered a robust calendar of activities through its two departments of recreational activities (in independent living and SNF), many were spectator activities (watching, listening). Those that were participatory (singing along, playing a game) typically did not include relationship-making between residents. Residents aside from the four included in this study were observed actively seeking personal and social connections: one resident repeatedly verbalized that older residents housed a wealth of information on various topics and asked whether her own and other residents’ personal stories could be recorded by someone to leave behind as archival information. Another resident wondered whether there could be an activity in which they could get to know residents on a personal level. Some residents wandered the hallways alone and were rarely seen in community with others.

Across the three documents given to all residents—Resident Handbook, residency agreement, and by-laws of the residents’ association—resident-to-resident relationships were not addressed. The grievances section of the Resident Handbook outlined “ways to share concerns” and steps to take. The residency agreement between the organization and tenants noted the same, and was explicit in shirking responsibility that was not related to standards of care: in a statement of no liability, the document described the organization as a party who is “not an insurer of Tenant’s safety,” not responsible for “inconvenience of any kind,” nor for “any damage arising from acts of negligence of other tenants,” nor for “harm caused by third parties (such as other tenants) [ … ] who are not under the control and direction of Management.”

Of seven designated committees in the by-laws of the residents’ association (crafts, food, social mixer, spiritual life, resident spotlight, bingo, and library committees), none was tasked with addressing resident-to-resident relationships. These committees served the purpose of engaging residents and making life fun in the wider campus, but no committee was appointed to address social isolation stemming from resident-to-resident tensions.

Resident Council meetings served as a dialogue between residents and management. In the meeting notes for 9 months, resident-to-resident issues raised pertained to pet and smoking lease violations. A resident comment is recorded in year 3, stating that “we need to be more attentive to our own behavior.” No other statements explicitly addressed resident relationships or social isolation.

Observational data of additional residents showed that alienation could be experienced in the environment even in the absence of resident-inflicted microaggressions. An African American resident perceived that the Black history month was not being celebrated—she had asked for a table to be arranged with some information about African American history and did not feel that her request was honored. During the month, the setting offered weekly screening of films with race as the central theme. Given this context, some residents experienced not being able to see in the environment the kind of material culture (objects, décor) that would resonate with their identity.

Theme C. Desired Experience of the Setting as “Age-Friendly”

Residents’ outlook on what would comprise the optimal experiences reflected person-specific contexts. Resident 2 (57) referred to “a broad spectrum of ages [ … ] ‘individual friendly’ is all I can think of because I’m disabled. But I’m not disabled like someone in an electric power chair.” Residents 2, 3, and 4 advised broadening the meaning of “age-friendly,” suspending assumptions in cases of prejudice, investing in education (of fellow residents), and building a sense of community.

We have a lot to teach each other. [ … ] a lot of education about people from different countries that I’ve never been in. [ … ] Or people who were in different fields than I was. I really like that kind of knowledge. That, to me, makes it home, makes it comfortable. (Resident 4, 70)

Whereas three residents’ optimal definitions of “age-friendly” above suggested the desired experience—treatment in a different way, community education—Resident 1 (91) reflected on individual efficacy in which changing one’s attitude could contribute: “I think a lot of times your attitude is absolutely imperative for setting the tone of how you are accepted.” Resident 4 (70) offered a similar perspective in how she had mitigated racial microaggressions: “It’s who you talk to and how you talk to people that makes you feel comfortable. [ … ] I have chosen decent enough friends that it’s not uncomfortable. When I first came, it was uncomfortable.”

Synthesis of the Analysis Across the Four Cases

Cross-case analysis is part of a multiple-case study (Stake, 2006). Figure 1 depicts the cross-case comparison. Reflecting different experiences of a social system given multiple (and compounding) dimensions of social identity (Crenshaw, 2013), residents fared worse in experiencing inequitable treatment in cases of visibly perceptible diversity (white cane, darker skin tone). They had negative experiences or experienced exclusions outright (Residents 3 and 4). Conversely, in cases of visibly imperceptible diversity, residents had more positive or entirely positive experiences (Residents 1 and 2).

Uniquely, Resident 1 (91) reported entirely positive relationships and reciprocity across all themes: “My friends are everybody. [ … ] I’ve had good luck, maybe.” Or, “I am living a good life.” This resident underscored the role of self-efficacy, attitude, and personal responsibility in self-presentation across all themes and did not report being socially isolated (Table 3). Of note here is residents’ intersectionality with the organization as a social system, in addition to among-resident intersectionalities within the setting. Unless a specific set of attributes aligned with the setting, as was the case with Resident 1 (homogenous background, long residence in the setting, relatively good health), Residents 2, 3, and 4 struggled to maintain personal integrity, noted interpersonal injustices and lack of belonging, were isolated to varying degrees, and found comfort in individually seeking out small groups of residents who could be supportive.

Overall, based on the integrated interview, observational, and document analysis, the understanding of the setting as age-friendly referred to the built environment (embedded health and therapeutic supports). Social design was a desired (and lacking) trait of the optimal experience of “age-friendly.” For Resident 2, both the built environment and social inclusion were part of the desired experience of “age-friendly.” Except for Resident 1, improved social relationships were part of the desired experience of “age-friendly” for all others. Figure 1 succinctly depicts these findings.

Discussion

This collective case study examined experiences of a retirement and assisted living community as age-friendly, comparing four residents’ perspectives and utilizing observational and organizational document analysis for an in-depth portrayal. Two contributions of this study are: (a) the inclusion of the perspectives of older persons directly from them to reflect their voices as direct stakeholders in giving input on their experience and understanding of a retirement and assisted living community as age-friendly; and (b) reflecting resident-to-resident microaggressions as a form of mistreatment in the same community.

The main finding is that resident-to-resident social relationships are a key component in the experience of a residential care setting as age-friendly. As a negative form of relating, resident-to-resident microaggressions undermined perceptions of the setting as age-friendly. Additionally, microaggressions played a role in social isolation. These findings are reflected below in terms of the lifecourse perspective and the organizational role in addressing social isolation.

Dignity in Linked Lives

For many older adults, transitioning to retirement communities can be involuntary or compelled by lifecourse factors such as changes in marital status or retirement (Bengtson et al., 2012; Robison & Moen, 2000). These changes can be life-altering, even traumatic, to older people. Additionally, sharing a congregate setting forces residents to interact with one another daily, and often closely, yet such sharing is not always voluntary. Possibly, the involuntary or acquired nature of social relationships contributes to microaggressions. As Ayalon and Green (2013) found, residents derived greater meaning from past social relationships and valued those as deep and intimate, in contrast to relationships with residents within their continuing care retirement community, which they deemed as being “of convenience,” developed only because of living in the same setting and lacking history. The combination of a congregate housing and care setting and replaced social relationships results in conditions likely to produce varied social responses when older adults comingle. More importantly, identity intersections among residents inevitably create room for positive experiences but also for relational inequities, as this study found.

Such relational inequities manifested as microaggressions in this study. Pierce (1970) initially coined the term when describing covert insults towards Black Americans as microaggressions. Sue et al. (2007) emphasized their invisible dynamic. Microaggressions assail identity based on differences, with examples such as: racial microaggressions based on “assumptions about intelligence, competence” as well as “education, income, or social status derived from racial stereotypes” (Williams et al., 2021, pp. 999–1000); ableist microaggressions based on “valuing of certain types of abilities over others” (Kattari, 2020, p. 1171).

In studies of social relationships in congregate housing, microaggressions stemming from intersecting background, health and disability status, or life stage differences have not been examined. Cliques and avoidances noted by Gubrium (1997) are suggestive of boundary-demarcation among residents. Though Ayalon and Green (2013) found that socioeconomic status, cohort/generational and functional status differences interfered in friendship-making, they did not examine or find microaggressions specifically. Gietzen et al. (2023) examined microaggressions encountered by older adults mostly in community settings such as stores or restaurants (in some cases, within families), not residential settings. The present study highlights microaggressions as a form of relational inequity in a residential setting and the resulting social isolation in the experience of the setting as age-friendly.

Our study found that reverse ageism—exclusion of a younger resident—was a distinct form of microagressions in the setting. This may reflect youthism, or ageism directed toward younger persons (de la Fuente-Núñez et al., 2021) as part of the experience of microaggressions. Commonly, it is thought that older adults are vulnerable to ageism as a discriminatory form of treatment. This study showed that younger adults in a residential setting can also experience the reverse of ageism directed at them by older adults. Residents 18 years of age and older are increasingly admitted to live in congregate housing for older adults (CMS, 2015). This is a broader issue related to healthcare in the United States and likely due to various medical and disability exceptions, including the inability to divert young adults from institutional care. Generally, young adults find living in congregate residential settings for older people undesirable (Shieu et al., 2021). Intergenerational microaggressions may in part be due to larger systemic factors that then play out among residents in a setting such as that under study in this article. As Ne’eman et al. (2022) recommend, targeted policy may remedy the housing of young adults in congregate settings for older people, and alleviate some social tensions.

Studies of resident-to-resident aggression (Rosen et al., 2008), a more extreme form of violence, have suggested examining pathways leading to it (Caspi, 2015), or escalation points in the processes (Burnes et al., 2021). Similarly, future studies could examine pathways leading to microaggressions, or microaggressions as a component in such pathways. Especially interesting might be studies that examine residents on both sides of microaggressions, as suggested by the fact that in this study, Resident 4 experienced racist microaggressions, and, at the same time, directed intergenerational microaggressions at the young women residents in the setting. Similarly, Resident 3 experienced youthism and referred to older residents as undesirable to share the setting with.

Organizational Role in Social Isolation

This study found reluctance on the part of the care organization to interfere in residents’ social relationships. Whereas interviews and observational data reflected microaggressions, document analysis showed the absence of investment in resident relationships other than through recreational activities. Specific policy statements invited residents to raise concerns, but social relationships, and especially resident-to-resident (mis)treatment, were not described as concerns.

“Age-friendly” has commonly referred to the physical plant and the organized care in it. This study showed that residents think of their social identity and its relationship to other residents as part of the setting’s age-friendliness. This very important aspect of residents’ interrelationships was not reflected explicitly in organizational documents. The vulnerability conveyed by residents, including their social isolation, suggests the lack of organizational supports, which curtails residents’ agency in being able to affect outcomes they desired—positive social relationships, freedom from indignities, and social inclusion, reflecting WHO’s (2007) tenets of age-friendly communities.

Although the organization ran a monthly activities calendar, it appears that social interaction (participation in activities) is not the same as social relationships. Residential settings may bolster relationship-making by listening to residents who request desired types of social experiences (knowing fellow residents on a personal level, having their knowledge and experience shared and recorded). Attending to such requests may encourage positive exchange and relationship quality among residents, which may mitigate against relational inequities.

Limitations

This study examined perceptions about a retirement and assisted living community’s age-friendliness by synthesizing interview, observational, and document analyses in a contextualist thematic study of a single nonprofit multilevel retirement and assisted living community. Grounds for transferability (external validity) were maximized by accumulating empirical evidence through multiple data sources (interviews, observations, and documents) as well as integrated analysis methods (contextualist thematic analysis of interview, observational, and document data). Thick descriptions resulting from this work aid in establishing contextual similarity for those seeking to make an application elsewhere. Because no criteria for rigor are unassailable in any open-ended qualitative inquiry, the goal is to persuade (Lincoln & Guba, 1985).

The setting did not have many racial/ethnic minority residents. The first author encountered approximately 11 such residents over the course of the study in the housing and assisted living care level (more such residents lived in SNF, which was not a direct focus of the present study). This study does not include men (represented by 32% in the resident census) due to pursuing shared (holding constant female gender and same setting) and differentiating (age, health and disability status, length of residence in the setting) attributes (Stake, 2006). Future studies including men and members of various gender identity and sexual orientation communities would likely illustrate different intersectionality-related findings.

Implications

The study findings show that AFHS’s 4Ms (IHI, 2019) may be broadened to reflect elements of a setting that is not exclusively about health. Bonner et al. (2022) referred to the “‘Age-Friendly’ rollout” that should account for the environment’s unique characteristics (p. 194). This study showed that social relationships affect perceptions of age-friendliness in a retirement and assisted living community. Similar settings may be well served by reflecting and expanding this social dimension in the 4Ms. Currently, the 4Ms reflect health-focused needs of older adults in at least three areas of medication, mentation, and mobility (IHI, 2019). The “what matters” tenet evokes person-relevant values but does not refer to the socioenvironmental and relationship aspects that can directly affect quality of life in residential settings. As this study showed, social relationships play a substantial role in finding belonging and community in the setting. Specifically, poor social relationships, and especially resident-to-resident microaggressions, detract from the perception of the setting as age-friendly.

This study showed the importance of considering intersectionality in residential settings. Accounting for race, class, and cultural differences in the relational aspect of the residential experience is important because positive relationships among residents can be compensatory for losses and transitions (Perkins et al., 2012). In this study, intersectionality contributed to resident-to-resident microaggressions, resulting in varying experiences of social isolation and social exclusion, influencing perceptions of the setting as age-friendly.

The retirement and assisted living community was primarily a health-focused setting with little room to engage effectively in terms of interpersonal injustices that could diminish both residents’ quality of life and social ties among residents. The broader WHO’s (2007) framework reflects the importance of social participation, respect, and inclusion. The AFHS framework parallels this goal in its aims to prevent harm and address the needs and preferences of older adults (IHI, 2019; John A. Hartford Foundation, n.d.). Residential care administrators, policy planners, and health and social service researchers and practitioners invested in developing “age-friendly” congregate ecosystems should account for—and reflect in policies—relational inequities among residents because they can directly affect residents’ perceptions of such settings as age-friendly.

Funding

None.

Conflict of Interest

None.

Data Availability

Data sharing is limited due to the qualitative nature of the study and associated ethical restrictions. This study was not preregistered.

Acknowledgments

Dr. Edward Ratner at the University of Minnesota Department of Medicine, and the retirement and assisted living community leadership are gratefully acknowledged for the learning opportunities afforded by the student program. This work was inspired by the National Collaboratory to Address Elder Mistreatment, which provided a community of practice of peers and mentors.

Ethics Committee

University of Minnesota IRB human subjects approval number: STUDY00000905.

References