Inside and Outside the For-Profit Nursing Home: Some External Determinants of Inside Power Relations

This paper offers a conceptual model for understanding how and in what ways externally determined factors affect power arrangements within a for-profit nursing home setting. Specifically, this paper links the activities of nursing homes as profit seekers to federal legislation and the activities of strategically structured interests which seek to socialize their costs. Additionally, it shows how social distinctions and other factors which have their origins external to the nursing home setting have consequences for what takes place inside. The model posits that it is those people who are members of society's more privileged groups (professional white males) who will get access to positions of power in part because members must go outside the organization into the greater society to obtain the certification which will allow them to occupy powerful positions. Consequently, those who have power inside the organization (professional white males) are very similar to those who have power in the greater society. Moreover, observational data indicate that those statuses which members of the nursing home enter with are associated with patterns of interaction and levels of control and authority. Finally, there is an attempt to spell out the implications of such findings and an attempt to show how government and community (non) involvement (could) affect relationships internal to the nursing home. As Jansson (1979:362) suggests, "a crucial policy choice that must be made by public agencies and officials is whether . . . to provide publicly funded services themselves or to utilize nonprofit or profit-oriented organizations in the private sector." More and more often, policy makers are depending on the profit oriented, private sector to provide social services; however, the costs of providing such social services continue to be met by the state (O'Connor, 1973). Recently, theorists have attempted to outline the consequences of capitalists' attempts to socialize their production costs and expenses while keeping profits in their own hands (e.g., O'Connor, 1973; Braverman, 1974). For example, Braverman (1974:271) argues that to the extent that capitalists are successful in passing their costs on to the state while reaping profits "the capitalist mode of production takes over the totality of individual, family, social needs, and in subordinating them to the market, also reshapes them to serve the needs of capital." He argues that with the transformation of the society into a giant market which benefits state-subsidized capitalists, the population no longer relies upon social organization in the forms of family, friends, neighbors, community, elders, children, but with few exceptions must go to market and only to market, not only for food, clothing, and shelter, but also for recreation, amusement, security, for the care of the young, the old, the sick, the handicapped (Braverman, 1974:276). Braverman goes on to argue that "since no care [for the young, the old, the sick, and the handicapped] is forthcoming from the community, and since the family cannot bear all such encumbrances. . . the care of all these layers become institutionalized" (p. 280). Presumably, because these changes in the care of humans are more often to meet the needs of capital than to benefit those who make use of the services, the care for humans becomes more profitoriented and more removed from humanistic concerns. The care for the young, the old, the sick, and the handicapped becomes more and more the responsibility of total (care) institutions which seek profit. But to see precisely what consequences this drive for profit has, one must look inside the walls of those total institutions which are profit-oriented. While he is not specifically concerned with profit-oriented total institutions, Goffman (1961) does look inside the walls of