Street-Level Bureaucracy & Conflicting Rights in Long-Term Care Facilities

Background and Purpose: An abundance of long-term care regulations creates a bevy of rights for nursing facility residents, staff, and families relating to privacy, safety, confidentiality, dignity, and autonomy, among other issues. Front-line workers and managers have significant discretion and responsibilities for interpreting these rights, particularly when they conflict. Building on street-level-bureaucracy theory (Lipsky, 2010), which focuses on how front-line workers implement policy, this study asks the following research questions: (1) How do long-term care facility staff at various levels (direct care, mid-level professional, top management) resolve conflicting rights among residents, staff, and families; (2) How do processes and understandings for resolving conflicting rights differ between a religious and secular-based facility?

Methods: This study employs a novel advanced multi-method qualitative design with semi-structured staff interviews (n=90) (direct care, mid-level professional, top management), content analysis of long-term care facility policies (n=75), and participant observation of two facilities for a multi-layered cross-comparative in-depth case study to inform social work research at micro and organizational levels. Given different guiding principles, missions, and emerging research on secular and religious facilities, interview data (n=80), Medicaid data, participant observation, and facility policies provided in-depth case comparisons between a secular and religious-based facility. This study includes additional interviews (n=10) with top management at other facilities, given the sparse number of workers at this level at any facility. Data was analyzed with three rounds of coding in Dedoose for open, focused, and thematic coding. Extensive analytical memo writing enabled conceptual development, abstraction, and data interpretation.

Results: Data analysis revealed variations in staff responses to conflicting rights regarding autonomy and safety (e.g. fall prevention, dementia, coronavirus) and discrimination (i.e. sexual/racial harassment). While harassment was rampant, direct care workers responded more deferentially to residents and often justified harassment as part of a customer service job in one’s home. Staff at all levels relied on teams to develop creative problem-solving approaches, but team composition and discretion varied significantly between facilities and staff levels. While staff included few social workers, staff heavily relied on them to adjudicate conflicting rights. While religion framed organizational principles and goals at only the religious-based facility, front-line staff at both secular and religious-based facilities drew heavily on individual religious beliefs. Mid-level professionals and upper-level managers at the religious facility relied more on organizational religious principles than individual religious beliefs, whereas mid-level professionals and upper-level managers rarely invoked religion at the secular facility to resolve conflicting rights.

Conclusions and Implications: Conflicting rights impact resident care and relationships among residents, staff, and families. Varying levels of staff employment (front-line, mid-level/upper-level management) and facility religious-affiliation shaped how workers resolve conflicting rights. This research provides policymakers and practitioners with new data about how staff resolve conflicting rights, which can facilitate stronger policies to support an overburdened and underpaid long-term care workforce and their facilities. This research also expands street-level-bureaucracy theory to include managers and reveals how various team approaches can produce diverse solutions. These findings can guide social workers informing long-term care policy reform, particularly in the wake of COVID-19.