Street-Level Bureaucracy and Conflicting Rights in Nursing Homes: Safety versus Autonomy

• In Event: 40461 - Section on Sociology of Law Roundtables
  In Refereed Roundtable (60 minute): Table 1: Medical Ethics and Law

Abstract

Introduction:
Nursing home regulations create many rights for residents. Staff have significant discretion in and responsibilities for interpreting these rights. Building on street-level bureaucracy theory (Lipsky, 2010), which focuses on how front-line workers implement policy, this study examines how staff at various levels (floor staff, mid-managers, upper-management) exercise discretion to resolve conflicting rights regarding safety and autonomy.

Design and Methods:
This study employs a multi-method qualitative extended comparative case study of three levels of staff in two nursing homes (independent versus corporate structure) to examine how staff understand and respond to conflicting rights for residents involving safety and autonomy. Data includes in-depth semi-structured interviews (n=80) of three levels of staff (floor staff, mid-management, upper-management), observation (8 months), organizational policy review (n=376), and legal data review (i.e. laws/regulations).

Findings:
Autonomy and safety presented conflicting rights in three situations: fall prevention, food intake/refusal, and medication management. Staff at various levels employed unique tools to exercise discretion, including interpersonal conversations, documentation, and organizational lenses/resources. Staff understood and responded to conflicting rights by invoking interprofessional team approaches across staff hierarchies, especially among floor staff and mid-managers. Even when upper-managers sought external guidance (e.g. attorneys/risk managers) to resolve conflicting rights, they deferred to the discretion of floor staff and mid-managers to communicate and implement decisions on the ground, which still left room for discretion. Team approaches across staff hierarchy were less common when conflicting rights arose in medication management. Differences in organizational structure became relevant only in the context of food intake.

Discussion:
This study extends street-level bureaucracy theory to include managers—many of whom still engage in some formal caregiving tasks on the floor and work closely with front-line workers. It underscores the ubiquity and importance of team collaboration for resolving conflicting rights, particularly in a healthcare context where interprofessional teams are common.

Author

• Angela Perone, University of California-Berkeley