Safety, Autonomy, Discrimination, and Religious Exemptions: Three Papers on How Long-Term Care Facility Staff Navigate Conflicting Rights

Abstract

Individual rights are revered in the United States. As political polarization has grown, media attention has increasingly focused on how this polarization presents conflicting rights between liberals and conservatives. However, this dichotomy may be overstated and more nuanced on the ground, particularly in healthcare, given the centrality of patient care. Long-term care facilities present an ideal case for studying conflicting rights in healthcare as spaces where residents receive 24-hour residential care in an increasingly patient-centered workplace. This dissertation examines how long-term care healthcare staff navigate three areas of conflicting rights: (1) safety and autonomy rights among residents; (2) staff rights to a workplace free of discrimination and resident rights to autonomy and decision-making; and (3) staff rights to religious freedom and resident rights to quality care. This three-paper dissertation employs a multi-method qualitative comparative case study of three levels of staff in long-term care facilities to examine how staff understand and respond to conflicting rights. Data includes in-depth semi-structured interviews (n = 90) of three levels of staff (floor staff, mid-management, upper-level management), observation of staff meetings (n = 30), review of facility policy documents (n = 376), and review of federal and state laws on fall prevention, food intake, and medication management. The first empirical study (Chapter 2) incorporates all four types of data to include an in-depth case comparison between two facilities and three levels of staff, whereas the other two empirical studies (Chapters 3 and 4) incorporate only the semi-structured interviews to compare three levels of staff. Data from these three empirical studies reveal several key findings. First, staff at all three levels relied on interprofessional teams across staff hierarchy to navigate conflicting rights, particularly regarding residents’ rights to safety and autonomy (i.e., fall prevention, food intake, and medication management). Second, while sex and race-based discrimination from residents was common, staff rarely reported discrimination. Staff often framed discrimination experiences as a condition of employment or attributed discrimination to residents’ health or cognitive status, which precluded staff from naming experiences as discrimination, blaming residents, and claiming their rights and reporting discrimination. Third, when confronted with religious exemptions, staff moved beyond dominant juxtapositions of religious liberty and equality to center patient care. By foregrounding patient care, staff reconciled cultural discord (competing cultural frames) and achieved social coherence (a justifiable conclusion after harmonizing conflicting principles) in ways that still permitted some staff to support both nondiscrimination principles for LGBTQ residents and religious exemptions by staff (exclusions to providing care based on religious or moral reasons). While team approaches, understandings of discrimination, and approaches to social coherence varied among staff level, all staff experienced conflicting rights while working at a long-term care facility. This dissertation examines the complexities and nuances of their understandings and responses to conflicting rights and presents implications for theory, social work practice, and social policy.