Adjudicating Conflicting Rights: The Invisible Role of Social Workers in Nursing Homes

Background and Purpose: Nursing homes are one of the most heavily regulated industries in the United States and present a unique space where the rights of residents and staff intersect—and sometimes conflict—to present complex problems. Healthcare regulations and person-centered care foreground residents’ rights (e.g. quality care, safety, autonomy) while employment-related policies foreground staff rights (e.g. workplace safety, pay, nondiscrimination). Recent concerns about quality care, workforce shortage, and equity have renewed conversations about additional policy and regulatory reform to address the rights of residents and workers. Nursing home social workers sit at a unique nexus of these rights, given their macro, mezzo, and micro-level training. Building on street-level-bureaucracy theory (Lipsky, 2010), which focuses on how front-line workers implement policy, this study asks: How do nursing home staff understand and resolve conflicting rights among residents, staff, and family?

Methods: This study employs a 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=376), and ethnographic observation of two facilities (n=8 months) for a multi-layered cross-comparative in-depth case study. 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: While social workers represented only a very small number of the overall nursing home workforce, data revealed the overwhelming reliance on social workers to resolve conflicting rights that arose among residents, staff, and family. Certified nursing assistants, nurses, directors, and administrators regularly deferred to social workers via written policies and unwritten practices to resolve a variety of issues, including discrimination concerns by staff, residents, or family, concerns about quality of care and workforce shortage, and concerns about conflicting rights to resident autonomy, dignity, medical decision-making, and safety (e.g. bed rails). Staff at all levels and professions described the emotional labor and unique professional experience that these conflicts required and felt ill-equipped to resolve these issues. While social workers ultimately resolved most of these conflicts, they, too, reported feeling ill-prepared for this role but ultimately relied on their social work training in systems-level change, case management, and interpersonal communication to resolve conflicting rights.

Conclusions and Implications: The nursing profession dominates the nursing home workforce, and many nursing homes hire only a handful–if any–social workers. Social work’s contributions are often rendered invisible in this space in larger policy conversations about nursing home reform. However, this research underscores the important role that social workers play in resolving conflicts, particularly amidst growing attention to nursing home resident and workforce concerns. A 2022 report by the National Academies of Sciences, Engineering, and Medicine underscored the need to address nursing home quality, in part, by increasing staff support and overall staff, including social workers. While social workers reported the need for more targeted training to help them resolve conflicting rights, the profession is uniquely positioned to provide this service, given its focus on social justice and foundational micro, mezzo, and macro-level training.