Introduction
As individuals age, they can face increasing barriers to meaningful participation and inclusion within their living environments. Much of the research on social inclusion among older adults to date has focused on community-dwelling persons who are ageing in place (e.g. Hale et al., Reference Hale, Gauld and Barrett2012; Buffel et al., Reference Buffel, Phillipson and Scharf2013; Scharlach and Lehning, Reference Scharlach and Lehning2013; Warburton et al., Reference Warburton, Scharf and Walsh2017). However, for some older adults – those who face financial challenges, significant physical and or cognitive limitations, or lack social support – remaining at home in the community may not be tenable or desirable.
Assisted living facilities (sometimes referred to as independent living) offer one alternative to ageing in place, providing minimal support in a congregate living environment. They function as an intermediate option for older adults who do not need the level of personal care provided in long-term care facilities. In Canada, where this study took place, most of these facilities consist of private suites in a managed building with some common spaces. There are government-subsidised and privately funded facilities across Canada and costs, as well as available services, vary considerably. Although these facilities provide an important alternative living environment for older adults, little is known about the extent to which these places actually address social exclusion, or what features might facilitate social inclusion within such settings.
There has been a growing focus on social relations and interactions more broadly within congregate living settings for older adults, including both assisted living and long-term care facilities or nursing homes (Bruce, Reference Bruce, Innes, Archibald and Murphy2004; Dobbs et al., Reference Dobbs, Eckert, Rubinstein, Keimig, Clark, Frankowski and Zimmerman2008; Casey et al., Reference Casey, Low, Jeon and Brodaty2016). Within the latter settings, most research has focused on the actions of people with dementia – referred to as responsive or aggressive behaviours (Dupuis et al., Reference Dupuis, Wiersma and Loiselle2012; McDonald et al., Reference McDonald, Hitzig, Pillemer, Lachs, Beaulieu, Brownell, Burnes, Caspi, Du Mont, Gadsby, Goergen, Gutman, Hirst, Holmes, Khattak, Lowenstein, Mirza, Mcneill, Moorhouse, Podnieks, Rideout, Robitaille, Rochon, Rosenberg, Sheppard, Tamblyn Watts and Thomas2015). A smaller body of literature is also emerging on negative social relations and relational aggression in assisted living (Trompetter et al., Reference Trompetter, Scholte and Westerhof2011; Kemp et al., Reference Kemp, Ball, Hollingsworth and Perkins2012). Recently, Goodridge et al. (Reference Goodridge, Heal-Salahub, Paus-Jenssen, James and Lidington2017) surveyed residents in two low-income communal living sites in Saskatoon, Canada and found that 39 per cent of residents had witnessed bullying and 29 per cent had experienced bullying, which resulted in feelings of exclusion and difficulties conducting everyday activities. This focus on ‘bullying’ frames a broad range of acts of exclusion as interpersonal issues without consideration of the multi-dimensional and multi-scalar factors influencing inclusion and exclusion (Walsh et al., Reference Walsh, O'Shea and Scharf2012). Even worse, this framing also seems to infantilise older adults and portray their behaviour as petty (Funk et al., Reference Funk, Herron, Spencer, Dansereau and Wrathall2019). A more complex interpretive approach to these interactions is needed.
The purpose of this article is to examine where, when and how older adults living in assisted living settings experience inclusion and exclusion. To do so, we compare and contrast the experiences of older adults in one low-income facility and one higher-end facility in a mid-sized Canadian city. In the sections that follow, we outline our conceptual approach, research design, and characteristics of the study sites and participants. Applying the concept of encounter as an analytic lens, we analyse the dynamic intersection of individual, interpersonal, environmental and macro-scale dimensions of social inclusion across both sites. In doing so, we broaden understandings of the range of conditions shaping actions that have been variously referred to as aggression and bullying in later life.
Social inclusion, ageing and the environment
Social inclusion refers to the ability to participate fully in relationships and activities within the context of a particular environment (Wilton et al., Reference Wilton, Fudge Schormans and Marquis2018). It involves both a process and an outcome of eliminating barriers to this participation such as lack of resources, rights, goods and services (Levitas et al., Reference Levitas, Pantazis, Fahmy, Gordon, Lloyd and Patsios2007). The concept recognises that participation is not just an individual choice; people and organisations can shape programmes, practices, policies and attitudes to support inclusion (Funk, Reference Funk2015). Exclusion itself can take many forms such as exclusion from work, resources, social activities and decision-making processes (Grenier and Guberman, Reference Grenier and Guberman2009). Ultimately, social exclusion provides a useful tool for conceptualising how multiple forms of disadvantage intersect, whereas social inclusion offers a multi-dimensional response to addressing such disadvantages.
The multiple dimensions of social inclusion/exclusion have been conceptualised in various ways in both qualitative and quantitative research. At the individual level, researchers have examined how age, gender, marital status, health, household composition, education, employment status and other factors influence exclusion. For example, age has a significant effect on access to material resources, social relations and services (Van Regenmortel et al., Reference Van Regenmortel, De Donder, Dury, Smetcoren, De Witte and Verte2016). Most studies also examine environmental and structural determinants of exclusion, and generally demonstrate that access to services (Walsh et al., Reference Walsh, O'Shea, Scharf and Shucksmith2014), availability of information about services (Dwyer and Hardill, Reference Dwyer and Hardill2011), transportation and mobility (Engels and Liu, Reference Engels and Liu2011), safety and security, and opportunities to participate in decision-making or civic engagement have a significant impact on social inclusion (Walsh et al., Reference Walsh, O'Shea and Scharf2012; Hagan Hennessy et al., Reference Hagan Hennessy, Means and Burholt2014). However, all of these variables interact with one another in different ways and may have different effects on different older adults in different places and times.
Over the last two decades, there has been a growing interest in age-specific dimensions of social inclusion/exclusion including how lifecourse events such as exiting the labour force and widowhood, alongside declining physical and cognitive health, interact with other factors to produce exclusion (Warburton et al., Reference Warburton, Ng and Shardlow2013). Older adults may also accumulate disadvantage throughout their lives, resulting in pronounced disadvantage and precarity in later life (Grenier et al., Reference Grenier, Phillipson, Laliberte Rudman, Hatzifilalithis, Kobayashi and Marier2017). The spaces older adults move through in their daily lives are smaller relative to younger populations and, as such, these immediate or local spaces may play a larger role in their inclusion/exclusion (Scharf et al., Reference Scharf, Phillipson, Kingston and Smith2001; Buffel et al., Reference Buffel, Verté, De Donder, De Witte, Dury, Vanwing and Bolsenbroek2012). At the macro-scale, broader public, policy and consumer discourses shape inclusion and exclusion for older adults. For instance, ageist discourses can lead some older adults to feel their inclusion is a burden to others, leading to ‘altruistic’ self-exclusion (Du, Reference Du2013). Discourses around positive ageing, active ageing and ageing well can further exclude those who are not able to engage actively (McParland et al., Reference McParland, Kelly and Innes2017). Ultimately, there are some distinct aspects of social exclusion that older adults face within their local environments and from much broader national and international scales (Walsh et al., Reference Walsh, O'Shea and Scharf2012).
Addressing multiple dimensions of exclusion is complex, as experiences and feelings of inclusion do not automatically occur as a result of presence and participation in the same place as others (Hall and Wilton, Reference Hall, Wilton, Grover and Piggott2015). Indeed, co-presence and participation can also be marked by forms of aggression and territoriality (McDonald et al., Reference McDonald, Hitzig, Pillemer, Lachs, Beaulieu, Brownell, Burnes, Caspi, Du Mont, Gadsby, Goergen, Gutman, Hirst, Holmes, Khattak, Lowenstein, Mirza, Mcneill, Moorhouse, Podnieks, Rideout, Robitaille, Rochon, Rosenberg, Sheppard, Tamblyn Watts and Thomas2015; Casey et al., Reference Casey, Low, Jeon and Brodaty2016). For example, residents may strike out at one another while passing in the hallway or when negotiating a seat in the lounge (Herron and Wrathall, Reference Herron and Wrathall2018). Yet existing studies of social inclusion among older adults tend to focus on broader dimensions of inclusion and exclusion (such as programme availability, safety, security and community characteristics) and there are few situated studies of how these dynamics play out across specific types of settings, and especially in assisted living. Space is salient for understanding inclusion and exclusion, and can shape the social encounters that constitute inclusion or exclusion.
Within social geography and sociology, space has been understood as constitutive; in other words, space has constitutive power to bring everything into its ambit (Lefebvre, Reference Lefebvre1991). For Michel de Certeau (Reference de Certeau1984: 96), ‘spatial practices … structure the determining conditions of social life’. Space structures relationships of proximity and distance, and through its materiality and routine activities affects the character of social relations. Space can serve to both include specific populations and exclude others. Furthermore, Wiles (Reference Wiles2005) argues that spaces and places are processes involving ongoing negotiation, contested interpretations and relationships of power that shape and are expressed within them. The dynamic character of space and place is related to actions and interactions within them and larger-scale actions and policies around it (such as ageing-in-place policies and discourses of ageism). Given the constituitive and dynamic nature of space and place, we can understand assisted living settings as sites in which inclusion and exclusion are constantly being negotiated, contested and reshaped by daily encounters within it as well as larger-scale processes outside its walls.
Building on the contact hypothesis developed in social psychology as well as the work of Goffman (Reference Goffman1961), geographers have become increasingly interested in the extent to which shared spaces such as the street, drop-in centres (Conradson, Reference Conradson2003), sports clubs (Amin, Reference Amin2002), various social enterprises (Wilton and Evans, Reference Wilton and Evans2016) and even the private sphere of the home (Schuermans, Reference Schuermans2013) can support ‘meaningful connections’ with others. Wilton and Evans (Reference Wilton and Evans2016) argue that social encounter – moments of contact, connection and exchange with others – is essential to understanding social inclusion as an uneven relational process that unfolds over time and across space. In a sense, encounter is an ingredient or starting point for understanding inclusion and exclusion. Encounters may be characterised by the deep joy of proxemics and belonging experienced through spaces of inclusion (Maffesoli, Reference Maffesoli1996; Walby and Spencer, Reference Walby and Spencer2018) and they can be constituted by exclusionary spaces that produce atmospheres of isolation, shame and rejection (Thrift, Reference Thrift2008; Ranasinghe, Reference Ranasinghe2017). As Hall and Wilton (Reference Hall, Wilton, Grover and Piggott2015) note, sometimes spaces and experiences of inclusion/exclusion are entangled with one another. Thus, a focus on encounter provides a way of understanding the contingency of social inclusion as a dynamic and relational process that is bound up in the dynamics of space and place. There is a dearth of research on assisted living facilities that highlights the salience of spaces of encounter in experiences of exclusion and inclusion; we seek to address this gap through a qualitative, comparative case study of encounters occurring at two different assisted living facilities.
Methods
The data for our situated analysis of the dynamics of inclusion and exclusion come from a larger project about older adults’ experiences of aggression. The project employed a case study comparison approach in which tenants (and managers) at two separate retirement communities were recruited for participation in semi-structured qualitative interviews. We were interested in how features of the two different congregate living settings might shape tenant experiences, interpretations and responses to aggression. In both settings, multi-dimensional processes of inclusion and exclusion were explored within participants’ accounts of relational aggression, as well as their descriptions of their living settings and broader environments.
Following institutional ethics approval, we first identified all independent and assisted living facilities in one central Canadian city from a list available through a local non-profit agency. Facilities that did not provide any social opportunity for residents were omitted. Then, we specifically identified two such facilities based on their considerable divergence in terms of rental cost and ownership structure.
The first of these (hereafter referred to as Pinecrest) is a long-operating residential complex incorporating independent and assisted living suites for older adults, and is attached to a full-service nursing home (only tenants in independent and assisted living were recruited). The complex is run by a not-for-profit charity with a volunteer board of directors. It has 100 tenants. Lunch and dinner are available at a self-serve, cafeteria-style dining room, and tenants may opt in and purchase meal plans for additional fees. Tenants can access a recreation room, coffee area, library, computer lab and outdoor group areas, as well as weekly shuttle transportation to shopping. If needed, support and personal care services must be provided by public home-care or by private hire. Social programmes and activities are run by tenants, and at the time of interviews, there were four weekly activities: bingo, shuffleboard and card game evenings, and a coffee get-together.
The second facility (hereafter referred to as Riverside), was a newer, large for-profit enterprise, owned by a national corporation. Rent subsidies are not available for tenants. Suites are smaller than those at Pinecrest, but the rent covers many more services, including three meals a day (two served in a formal dining room with full wait-service). Group spaces include outdoor party spaces, computer desks, games area and coffee bar, movie theatre, activity room with exercise equipment, a chapel and a tuck shop. Shuttles regularly take residents shopping, to church and on group outings, and transportation can also be booked for appointments. Care services are not explicitly provided, but there is a nurse on the staff and a small team of care aides provide overnight support for emergent needs. There are at least three organised activities daily, with options including cooking, art and exercise classes, competitive activities such as pool and carpet-bowling, evening movies and musical performances, and occasional social outings, concerts, parties and special events.
These two facilities were approached to solicit organisational support for the project and permission to distribute project information to tenants. Following this, tenants were invited through recruitment posters to participate in a study of ‘everyday resident interactions’. At Riverside, a research assistant also made a brief presentation to the tenants (only four tenants attended); and set up a ‘drop-in’ table in the lounge area to pass out study information. Eligible participants were required to have resided at one of the two selected facilities for a period of at least one year, and be 60 years of age or older.
A research assistant conducted all interviews with the tenants. Interviews ranged between 55 and 180 minutes, with an average time of approximately two hours. The interview guide opened with some brief contextual questions (e.g. age, place of birth, labour force participation, marital status and how long they had resided in the facility) and then elicited in-depth descriptions about the tenant's activities and interactions (e.g. Do you spend much time outside your apartment and in the building's common areas? Which activities, how much time; what time of day; specific areas?). We asked whether they find some people difficult to get along with or have had conflicts with, and to provide specific details. They were also asked to describe the people they have become friends with, and informal exchanges of support as well as what they liked and disliked about living in the building. In addition, the second author interviewed a manager at each location to explore how assisted living settings and their activities were organised and rationalised, as well as how conflict was interpreted and managed. Interview questions focused on managerial approaches to tenant-to-tenant and tenant–staff conflicts, and interpretations of the reasons for such conflict. These interviews also provided detailed information about leadership style and the organisational structure of each location. In total, we interviewed 13 tenants (seven at Pinecrest and six at Riverside) and two managers. Consistent with case study methodology (Baxter, Reference Baxter and Hay2016), carefully selecting contrasting case study sites and diverse participants (i.e. in terms of age, socio-economic status and role in the facility) provides a rich basis for exploring the contingencies of social inclusion through the lens of encounter in assisted living settings. Participants in the study ranged from 63 to 90 years of age (median age 83). They were predominantly female (11 women versus two men) and had resided in the facility for 1–13 years. Two tenants were married and lived with their spouses, two tenants at Pinecrest were married to spouses in the attached long-term care facility and nine tenants lived alone. On average, Pinecrest tenants were slightly younger and had lower educational attainment than those at Riverside. Pseudonyms have been assigned to all participants.
Interviews were digitally recorded and transcribed verbatim (with participant consent) to enhance the credibility and confirmability of the data analysis. NVivo 11 software was used to organise the transcripts, which were then coded using a constant comparison approach (Charmaz, Reference Charmaz2014). Three research team members reviewed a transcript and discussed initial codes collectively to begin developing a code book. The first and fourth authors then continued initial coding, followed by more focused coding examining individual experiences and site-specific dynamics of exclusion and inclusion. The findings that follow are organised so as to (a) examine how lifecourse histories and individual characteristics shaped experiences of social encounters and potential inclusion/exclusion; (b) examine how time and the specific organisation of spaces shaped experiences of social encounters and potential inclusion/exclusion within assisted living facilities; and (c) examine how spaces and discourses beyond the walls of assisted living shaped tenants’ social encounters.
Individual experiences and lifecourse dimensions shaping social encounters
Although participants often had close and frequent encounters with one another (especially during mealtimes or social activities), their descriptions of their encounters with their neighbours also illustrated clear private boundaries and distance. Rosa, a tenant of Pinecrest, explained that she seldom had other tenants into her suite:
No, you go to the door, you stand at the door and talk. Very seldom, unless it's a friend at the corner, like you've been friends since god knows when. But on the whole, there's not very many that do that.
Spatial practices (respecting the boundaries of tenants’ private rooms) and temporal aspects (how long have you known someone) reinforced a sense of distance among tenants in their daily encounters. Although we heard of close long-term friendships in some interviews, tenants generally agreed that developing these friendships in assisted living was challenging. Kay corroborated that she very rarely received invitations to other tenant's apartments and when she did she was unsure whether they were genuine: ‘I know one [tenant] on second floor said, “Come up and have tea with me.” Well that's too casual and vague an invitation to take her up on it.’ She inferred that a serious invitation needed a specific time and place. Respecting the boundaries of the facility, Willow invited neighbours to coffee-time outside the apartment. She said,
there's a lady on the first floor … and I had invited her to come for coffee and said, ‘Then you're not sitting by yourself, why don't you come and join us?’ And I invite all the time but they don't come.
She believed some individuals simply prefer solitude.
Some tenants confirmed that they try to avoid or limit their encounters with others in the facility. Louise explained that at a previous residence she had befriended a couple and became very involved in their lives (which included a family break down and a ‘physical fight’ between the couple she befriended). Her son advised her not to get too involved with ‘people like that’ and as a consequence she stated ‘I kind of said to myself when I came here, “I want to be friendly but I'm not going to get buddy-buddy with anybody.”’ Similarly, Kay commented, ‘I'm not the kind of person that would draw that kind of thing. I keep to myself, I'm quiet, mind my own business.’ She later commented, ‘I didn't have time or energy for neighbours, you know.’ Tenants in both facilities suggested that they tried to avoid getting involved in conflicts in particular. For several tenants at Pinecrest this was motivated by past histories of victimisation, highlighting specific lifecourse and gendered dimensions of exclusion.
Kay explained that she felt out of place during discussions about the city in the old days, having migrated from elsewhere; she admitted, ‘You sort of feel left out sometimes, that's what I get. But they're not unpleasant. But nothing is a serious, uh, it doesn't mean a lot.’ Although she suggested this was insignificant, she later commented, ‘it's hard to make friends when you come from another community. Even though I've been here 12 years it's very difficult to get close’. Her reflection illustrates how lifecourse and place-based factors intersect to produce a strong sense of place for some tenants while making other tenants feel out of place. In this example, a sense of place history allows tenants to engage with comfort in conversation with others. Indeed, place and the organisation of space has a significant influence on tenant encounters and their experiences of inclusion and exclusion.
Local sites of encounter: the implications of space and time for inclusion/exclusion
In both facilities, congregate dining rooms provided regular opportunities for encounters with other tenants. Such encounters were, however, constrained by the specific organisation of and temporal accessibility to these spaces. When asked about her interactions with other tenants in the Pinecrest dining room, Willow said: ‘No there's not much there, you just sit at your table and, because you can go there for 4:30 but you have to leave at 5:30.’ Pinecrest tenants also did not have a formally assigned seating plan in the dining room and some tenants had difficulty finding a place to sit. The following quote from Rosa expresses the awkwardness involved:
you usually sit in that chair there and that's my chair, you know? But I didn't find it because … it works out that it opens and then home-care has to take some meals to some people … But most [tenants], they know where they are supposed to sit, so yeah.
She explained further that this informal seat-claiming sometimes caused problems for new tenants. Indeed, attempts to sit in the ‘wrong place’ could lead to encounters of exclusion, as Louise recalled:
I kind of went along with my tray and there was an empty spot and she said to me, I guess she looked like I was coming there and she said, ‘Oh no this table is full.’ So I said, ‘Oh that's okay, no problem I'll just go over here.’
She was excluded from sitting with others for a week until someone was absent and she was invited to sit at a table. She described the social order and routine as strange and initially difficult to navigate. Alternatively, some other residents explained that they returned to their rooms with their food and eat there.
At Riverside, the staff tried to place tenants ‘with people who might be compatible with them’ (manager) in the dining room. Despite this, the dining room was a site of exclusion for some tenants. Some tenants framed disengagement at the table as an individual choice (‘they don't seem to want to [talk]’) and one that was appropriate for the context (Victoria: ‘…you're eating, you know’). Other justifications for disengagement and more hostile forms of exclusion were also discovered: in particular, several tenants justified ignoring others, openly dismissing others or reducing their opportunities to express their opinions (particularly any negative opinions or complaints). For example, Amelia justified her response to tenants that complain about their food:
We've got to say to them, if they start talking, ‘I'm sorry, I don't want to hear it. I like my food’ … I say, ‘Well, if it's cold, I call someone from the kitchen and I go up to the kitchen and ask them to heat my food up for me.’
Similarly, Gerry explained how he used to say hello to a man who sat outside but after an encounter where the man began complaining about the cheap food that was being served, he no longer talks with him.
Similar complaints, however, garnered some legitimacy in monthly town hall meetings at Riverside. Amelia described the function of the meetings: ‘The thing is they're trying to do things to suit you. If you don't like it, don't complain to your neighbour, they won't get anything done. You have to complain to management.’ Other tenants condoned speaking up and even expressing anger about issues at these forums. Moreover, there was a right time and place for complaining at Riverside; tenants were expected to engage as assertive consumer citizens and express concerns in town hall meetings and through a complaints box. Notably, this is in contrast to a complete lack of mechanisms for involving tenants in decision-making at Pinecrest.
Outside the dining room, tenants of both facilities had some other opportunities for encounters with fellow tenants, although this varied significantly between the two sites. Congregate spaces and activities at Pinecrest were few in number and had limited hours of operation. Catherine (age 88) invited a new tenant to a coffee group, who responded: ‘you've just finished your lunch now what you want to go have coffee and cookies for at that time?’ Kay also suggested there was a lack of activities in the evening: ‘they seem to close up the drawbridge after seven’. Both examples illustrate the limited range of opportunities for well-timed, meaningful and positive encounters outside tenants’ apartments in common spaces. Formally organised opportunities were structured around limited staff availability while other activities were tenant-driven.
Many residents spoke of a tenant-driven Senior's Club that once existed at Pinecrest (for more details, see Funk et al., Reference Funk, Herron, Spencer, Dansereau and Wrathall2019). The club provided a degree of inclusion for some tenants, particularly for organisers who expressed a sense of pride, purpose and ownership in the club. The club required members to pay Can $10 for monthly meals organised by tenants. Nancy volunteered to sing for entertainment, and other tenants expressed their enjoyment of the meals. There were conflicting stories about the club's demise. Some suggested it was because newer members were not interested in helping out with the tasks involved. Others such as Willow suggested that some of the members ‘cause[ed] problems’, and tenants’ narratives indicate that there was conflict over leadership, membership, ownership and the nature of activities more broadly (including the Meal Club: Funk et al., Reference Funk, Herron, Spencer, Dansereau and Wrathall2019). Their narratives also raise questions about the sustainability of tenant-driven programmes in assisted living.
As noted above, Riverside tenants had many more opportunities for formally organised social encounters with other tenants as well as people from the broader community. Gerry commented, ‘it's nice to be in here. I know my neighbours.’ He also described participation days, which involved team-based activities (sometimes with local schoolchildren) and provided a shared common purpose between tenants and contributed to familiarity and connection to others outside the facility. Amelia suggested that she did not always like these kinds of activities, but they at least got her out of her room to assess whether she did like them. Evelynn described herself as having ‘fell into those activities’ that were regularly occurring around her. The structure and variety of staff-run activities at Riverside prompted tenants to get out of their rooms and become involved with others. There was also a sense among some tenants at Riverside that they should try to extract value from what they have paid for in rent, particularly in relation to food. Such consumerist discourses may also have motivated at least some involvement in activities more broadly.
Seeking inclusion beyond assisted living
Tenants of both facilities made trips outside the facility to socialise. However, transportation and mobility made it difficult for some tenants to continue participating and engaging with others outside the facility. At Riverview, Evelynn explained:
I have a car; I don't like to drive in the dark. And I like to socialise. To categorise old people, they don't like to go out in the evening. And to not be alone, you have to go out, go to places that old people gather. And I don't like to go out across the city.
Her comments illustrate a need for inclusion outside the facility but also a gap in meaningful activities within the facility during the evening. In addition, her words illustrate the challenges of driving across the city and how automobility spatially and temporally delimits and contributes to the exclusion of ageing persons (Urry, Reference Urry2004). It is also noteworthy that Evelynn believes that ‘old people’ are a homogenous group and that they need to hang out together. The homogenisation of old people contributed to different forms of self-exclusion as well as exclusion of others within the facility and in relation to outside communities. For example, Theresa expresses a loss of her cultural community because she was unable to drive to her friends’ houses to play mahjong [which she described as a game Jewish women play]. She said, ‘I've tried to teach it to some people here, I volunteered to teach mahjong. You need four people to play. So we can only play when there's four … quite often we don't play just from lack of people.’ Management had helped to advertise the game, but she believed that others in the facility were ‘afraid of it’. Throughout her interview, she described her sense of cultural exclusion and subsequent loneliness that arose from not only this but other encounters in the building.
The organisational representative at Riverside as well as some tenants commented on the value of bringing community into the facility. For example, Brian said, ‘they had the Chief of Police and they had [official's name] from the government … All taking part in the festivities and the entertainment. It really was something, you feel as though you belong.’ Riverside tenants described management efforts to create a sense of civic and community belonging. However, although welcoming community leaders into Riverside resonated with some tenants (e.g. middle-class males), tenants from non-dominant cultural groups may have felt excluded, as Theresa did.
At Pinecrest, the onus was on tenants to organise and facilitate any desired involvement with broader communities outside the facility and those with disabled bodies noted that this was a particular struggle. Kay explained that local store closures and her frailty made it difficult for her to leave the facility; she previously rode the facility van once a week but no longer feels ‘steady’ enough to do so (although her neighbour takes her out to get medication now once a month). In addition, Nancy spoke of going to the store and the library for her neighbours. Some tenants developed and drew on social support within the facility to access community resources. However, participation in social activities outside the facilities was somewhat constrained by the location of the facility and lack of social and material resources within and around it.
Macro-level dimensions of exclusion – ageism and ‘dementiaism’
Tenants internalised and enacted ageism and ‘dementiaism’ in their talk about their encounters with other tenants, and such beliefs appeared to inform their own experience of encounters as well as, in some cases, their actions towards others. Willow commented that she sought recreational opportunities in the broader community because ‘people here are old, don't have hobbies, don't really do things. So I don't associate with the people here’. Another tenant at Pinecrest explained that she felt isolated because she was somewhat younger than other tenants. She said: ‘It's worse than a retirement home here, they just got them so old putting them in here. The majority of them are in their eighties. They're just stuffing them in really old’ (Nancy). These participants defined themselves as ‘not old’ and avoided encounters with ‘old’ tenants unless they were helping.
Moreover, in negative descriptions of encounters with others, some tenants explained that they did not like interacting with tenants who had dementia. For example, Catherine stated:
you don't even want to talk to them because it's the same thing every day. This woman I talked about who went outside without her clothes, I used to sit and have meals with her, but she used to start telling me about when she lived in Saskatchewan, the same story every day, if you sat there three times a day you'd get the same story.
Having lost one of her regular table-mates, this tenant now frequently brings her food back to her room to eat alone. Interestingly, however, she does appear to engage in an altruistically motivated way with tenants living with dementia in the attached nursing home (e.g. helping them out with prompting and conversation). She said, ‘They need me to talk to them more than these people do [in assisted living].’ Her comments and actions suggest that she, like some other tenants, would prefer that people living with dementia be segregated in a separate location (e.g. removed from encounters) and that she interact with them on her own terms and in a way that affirms her values. The manager at Riverside observed similar ‘helping’ orientations among tenants whom she described as having ‘that care-giving type of personality’; they ‘adopt’ tenants with dementia, helping them out in various ways and seeking encounters: ‘they'll go and pick them up for dinner because they know they can't find their way or things like that’. Further reflecting this more paternalistic orientation, Kay excused tenants with strong opinions who might appear loud and pushy, invoking both age and dementia in her explanation: ‘if it's a venerable older person you sort of excuse it because they may be not “all there” so to speak. They're old and they have a reason to be the way they are. You sort of excuse it’. In other words, tenants felt some compulsion to help people living with dementia and invoked some compassion for them; however, this did not necessarily translate to more inclusive encounters. In several of these instances, this simply justified tenants’ control over and, in some cases, denigration of people with dementia.
In fact, Louise indicated that people living with dementia were the most frequent subjects of gossip at Pinecrest because they ‘do silly things’. For example, she described one tenant who kept wandering out and missing her scheduled appointments with home-care workers; other tenants warned Louise that encounters with this tenant were risky because inevitably the woman would repeat the same stories. Perhaps the most extreme example of ‘dementiaism’ was found in the account of Rosa who referred to a woman with dementia as ‘a real ding-a-ling … she called me and [manager] a jerk! We're those jerks (laughs) … She's dementia. Dementia plus (laughs)’.
Louise also described another tenant upstairs that frequently burned toast, filling the hall with smoke and triggering the alarm. Like others in this study, she drew on othering techniques in her talk to distance herself from those with dementia while trying to portray compassion: ‘those kind, you know, but it's not their fault, they need to be, there's, oh gosh I don't know, three or four or five of them, should not be living alone’. Similarly, Willow suggested that several tenants were actually so impaired that they should be in the nursing home, including one tenant that she is afraid will forget to return when she goes out for a walk. She also added, ‘you just often have to treat them like a child’.
Examples of dementia-related exclusion were less overt at Riverside, but like at Pinecrest, similarly reflected tenants’ struggles sharing space and communicating with people believed to have dementia. Evelynn (age 85) was asked to describe the ‘worst part’ about living in the facility and referred to dining room encounters with a table-mate suspected of having dementia:
Worst part is accepting somebody who's um (pause) I sit at a table with somebody who's not able to (pause) it seems like she's losing her brain. It's almost like she's got schizophrenia. That's the hardest part because I sympathised with her at first, but I don't understand her really. She says her son put her in a nursing home. And then after three years she ended up being here. She had to go to court against her son. She has an only son and she says her son put her in a nursing home and moved into her house. And to listen to that, I sympathised with her at first. But thinking about it, it's not possible to accept that. No, she's lost all her brains, and she's not able to cope with anything. And that's very hard for all of us sitting at that table. To accept her as (pause) I don't know, she's a mystery this woman. Because it seems like she has Alzheimer's, but at the same time she's (pause) I, we can't understand this woman.
Evelynn believed her table-mate sometimes did not come to lunch because she was avoiding them. She repeated that she did not understand her and that she was difficult to accept, but ‘she's still part of us, because she sits at the table with us’. She conceded that her table-mate wants to relate to everyone at the table but she felt she could not reciprocate. However, she later emphasised the importance of people with dementia being able to participate in social activities in the building. Although she knew she should accept and try to understand her table-mate, her narrative reflects the stigma and anxiety associated with living with dementia and highlights the exclusion of those believed to have dementia.
The managers of both facilities also implicitly or explicitly conveyed stigmatising and patronising views of dementia in their interviews. When asked about conflict between tenants, the Pinecrest manager referred to how poorly ‘adjusted’ tenants tend to ‘nitpick’ about ‘little annoyances’ (see also Funk et al., Reference Funk, Herron, Spencer, Dansereau and Wrathall2019). He ventured the following explanation for nitpicking, as well as gossiping and cliques:
it's always, the frontal lobe is the last thing to actually come and grow and it's the first thing to leave us, you know? I don't know if you've ever experienced somebody looking at you going, ‘What's wrong with your face?’ I've got one guy, ‘You're looking fat.’ Thanks dude. ‘Yeah you're really looking fat? Are you tired? Are you sick?’ It's like, ugh.
When prompted by the interviewer, he added: ‘basically the monitor in the brain leaves very soon’.
Although not explicitly invoking ageism or ‘dementiaism’, the Riverside manager cited differences in cognitive capacities between tenants (and a misunderstanding of dementia among tenants) as, to some extent, a causal explanation for conflicts that arise between tenants:
Because you're dealing with different levels of cognition I think that's the biggest thing. Because you expect people to be like you are, you know? And they're no different. I mean when you meet somebody you're thinking they're going to be the same as you. You know pretty quickly if they aren't but they don't always recognise that, they just think they're either dumb or not wanting to interact with them. That's probably the biggest problematic area is the cognition levels.
In contrast to the manager at Pinecrest, this participant tended to portray people with dementia and cognitive impairment as victims of other intolerant older adults and stigma towards dementia. Her comments reflect the somewhat contradictory nature of ‘dementiaism’ in both assisted living sites where caring for others was seen as a meaningful social encounter but living alongside difference was experienced as uncomfortable and sometimes associated with gossip, name calling and a desire to segregate ‘those people’ elsewhere. Both managers’ narratives are also noteworthy since these participants are socialising other staff and tenants, potentially shaping the way they act towards tenants living with dementia. At best, although managers and tenants alike tried at times to speak inclusively about people living with dementia, our data indicate that many struggled to act inclusively in encounters with them.
Discussion: towards more inclusive assisted living spaces
In this paper, we explored when, where and in what ways older adults in assisted living experience social inclusion and exclusion, guided by the concept of encounter (Valentine, Reference Valentine2008) to the moments and processes leading to inclusion or exclusion within specific sites. Viewing assisted living as a site of encounter illuminates how the organisation of space and time constrains routine encounters. For example, norms around privacy and respecting the boundaries of tenants’ apartments reinforced distance, and the structure and function of the dining room presented barriers to spontaneous encounter: tenants felt pressured to get in, get a seat and get out at Pinecrest, or at Riverside they were simply assigned to one grouping. Such examples illustrate how some routines and structures in assisted living do more to discourage moments of connection than foster them. For instance, at Riverside tenants competed for dining room seating space within an hour period, which seemed to exacerbate territoriality and frustration towards newcomers and people who needed assistance from home-care, as the former did not know where to go and the latter were perceived as taking up too much space for too long a period of time. As such, inclusion is more than just a function of co-presence, but also a function of timings and spacings that orient older people to share space co-operatively, rather than compete.
Comparatively, Riverside provided tenants with more opportunities than Pinecrest to engage in group activities focused on collective goals and interests. Team-based activity days fostered a common purpose and intent, and contributed to familiarity with neighbours. However, tenants were excluded from conversations and interactions when they threatened other tenants’ sense of place and ageing well in the facility. Specifically, complaints about aspects of facility life such as the food symbolically threaten tenants’ beliefs that they are getting their value for money and/or that they have chosen a good place within which to age. This recurring pattern illustrates the entanglement of inclusion and exclusion at Riverside as tenants sought to construct a positive environment and in doing so excluded those who threatened their contruction of the assisted living space as a good place to grow old. Such exclusion was reinforced by institutional structures (e.g. town hall meetings and suggestion boxes) that emphasised consumer citizenship and constructed a right time and space for complaints. This structure seemed to reinforce further tenants’ tendencies to justify exclusionary actions such as ignoring others, openly dismissing others or reducing their opportunities to express their opinion.
In contrast to Riverside, activities at Pinecrest were tenant-driven, resulting in a sense of ownership and purpose for some tenants who led activities but also conflicts over leadership, membership, ownership and the nature of activities. There was also concern about the ability and/or willingness of some tenants to sustain the activities needed to keep social groups running (Funk et al., Reference Funk, Herron, Spencer, Dansereau and Wrathall2019). These findings speak to the need to fund activities in assisted living sites which support the needs and capacities of all tenants. It also highlights the complex challenges of designing programmes and places that can support positive encounters. Indeed, a single club may not serve the diverse needs of all tenants nor will it necessarily offer all tenants opportunities to take on different roles and responsibilities. Ultimately, Pinecrest tenants had no formal structure to participate in decision-making, and this could also exacerbate forms of relational aggression such as gossiping and name calling, as well as reinforce a sense of territoriality.
Evidence from Riverside corroborates existing research about the importance of civic engagement for older adults and the value of bringing community leaders into assisted living to maintain a sense of connection and belonging (Hagan Hennessy et al., Reference Hagan Hennessy, Means and Burholt2014). At the same time, tenants’ narratives raised important questions about whose community leaders and decision-making processes are valued and integrated into assisted living. In both sites, tenants struggled to maintain connections with their diverse communities. Of critical importance in these accounts were issues of exclusion related to mobility and culture. Some tenants found themselves cut off from cultural activities and unsupported to continue valued activities and maintain their cultural identities. In other instances, tenants felt too unsteady or unsafe to continue going out into the community, despite available transportation. Here exclusion is directly linked with mobility across spaces delimited by automobility, safety and infrastructure, which prescribe certain forms of corporeality and proscribe others due to disability (Beckmann, Reference Beckmann2004; Cass et al., Reference Cass, Shove and Urry2005; Preston and Rajé, Reference Preston and Rajé2007). Our findings highlight the critical role of assisted living settings in creating opportunities for social encounters by bringing people into the facility or supporting tenants to connect with others through transportation.
Perhaps the most important role that facilities can play in addressing exclusion involves addressing talk and actions that perpetuate ageism and ‘dementiaism’. Consistent with Dobbs et al. (Reference Dobbs, Eckert, Rubinstein, Keimig, Clark, Frankowski and Zimmerman2008), tenants reported distancing themselves from other tenants who they perceived as older and disabled. They were particularly uncomfortable sharing space with people with dementia, although they acknowledged caring for these tenants as a meaningful and important social act. Consistent with the work on ‘dementiaism’ by McParland et al. (Reference McParland, Kelly and Innes2017), tenants expressed fear and anxiety towards the other with dementia and a desire to segregate those people. Some tenants were even warned not to engage with tenants with dementia. Manager's accounts suggest that these views were reinforced at a more structural level.
Conclusion
Assisted living site designers, managers and staff can build more inclusive environments by creating time and space for positive social encounters among tenants, as well as with community members and cultural groups beyond assisted living. Whereas other studies have pointed to the need for education among tenants and staff to address ‘bullying’ in assisted living (Goodridge et al., Reference Goodridge, Heal-Salahub, Paus-Jenssen, James and Lidington2017), we suggest that such education must address everyday spatial practices as well as macro-level discourses (i.e. ageism and ‘dementiasm’) that underpin exclusion and are often embedded in ageing-in-place policies. At the local level, this means attending to and reconstituting the way that particular spaces and routines constrain tenant interactions and reinforce boundaries and a sense of territoriality at specific times and places, as well as providing education that conveys the importance of encounters and place-making for older adults. At the macro-level, governments must support the creation of spaces of encounter across the continuum of care in diverse community settings, assisted living sites and long-term care. Moreover, research and policy on social inclusion must move beyond a focus on just community-dwelling persons or just those living in assisted living to address both the site-specific and interconnected nature of social inclusion and exclusion for older adults across different settings.
Acknowledgements
The research was made possible through the generous participation of older people in two assisted living sites as well as the work of Research Assistant Lisette Dansereau.
Financial support
This work was supported by the Social Sciences and Humanities Research Council of Canada (grant number 430-2016-00414).
Conflict of interest
The authors declare no conflicts of interest.
Ethical standards
This research received ethics approval from the University of Manitoba.
