Race and Sex Discrimination By Residents in Long-Term Care Facilities: Underreporting and Legal Consciousness Among Three Levels of Staff

Background and Purpose

Despite increased attention on racial and gender justice in workplaces, discrimination complaints remain vastly underreported. Building on legal consciousness theory–which explains how individuals invoke (or do not invoke) legal principles to define everyday experiences–this study examines how long-term care facility staff understand discrimination by residents and why staff fail to report discrimination. Long-term care provides an ideal case study for examining discrimination underreporting because it presents an extreme case of conflicting rights that may shape reporting in other healthcare spaces. Healthcare regulations and person-centered care foreground residents’ rights (e.g. quality care, safety, autonomy) while employment-related policies foreground staff rights (e.g. nondiscrimination). Over half of direct care workers in long-term care facilities are women of color. When floor staff experience race/sex discrimination by residents, staff at all levels may struggle resolving these conflicting rights, including social workers, who often mediate these conflicts.

Methods

Recent research suggests that staff level may shape experiences of discrimination (Allen, 2020; Roscigno, 2019). This study, thus, employs a qualitative comparative case study design that compares three levels of staff in long-term care facilities to answer the following research questions: (1) How do long-term care facility staff from three occupational levels understand experiences of discrimination by residents?; and (2) Why do long-term care facility staff underreport experiences of discrimination by residents? Data includes in-depth semi-structured interviews (n=80) of three levels of staff (floor staff, mid-management, and upper-management). This study used a combination of selective and snowball sampling procedures to recruit facility staff. All professionally transcribed interviews were coded and analyzed in the software program Dedoose through four rounds of coding, memo-writing, and regular meetings with five coders that achieved inter-reliability scores of 0.83 and 0.84 (very high agreement).

Findings

Findings reveal rampant unreported instances of race and sex discrimination by residents. Staff at all levels rarely invoked discrimination to describe interactions with residents. Floor staff framed discrimination as a condition of employment or attributed discrimination to resident health or cognition. Mid-management framed experiences around staff safety. Upper-management acknowledged staff rights without invoking discrimination rhetoric. By avoiding naming experiences as discrimination or blaming residents, floor staff never reached the claiming process that would result in a report or complaint of discrimination. Managers’ framings also shaped how staff named, blamed, and claimed experiences of discrimination and help explain why staff may be hesitant to report discrimination by residents.

Conclusions and Implications

This research extends legal consciousness theory to examine how workers understand their rights when they conflict with patient rights. It also provides new data about an understudied but timely topic: discrimination by residents/patients and persistence of underreporting. As nursing home reform evolves in the wake of COVID-19, new practices and policies can better support staff experiencing discrimination by residents. Institutions are grappling with the consequences of centuries of racism, and many workplaces have begun making efforts to improve their workplace culture to better support staff of color. This research provides important empirical evidence supporting these efforts, particularly for long-term care staff.