Coping with the Obligation Dilemma: Prototypes of Social Workers in the Nursing Home.

We examined the ways in which the social worker is coping with obligation dilemma in an Israeli nursing home. The research was conducted using semi-structured, in-depth interviews carried out with fifteen social workers employed in nursing homes. The interviews were analysed thematically, using constant comparisons. The three themes were concerned with the social worker's place in the nursing home, her relationship with the management and staff, and her coping with the obligation dilemma. These themes highlighted the difference between the interviewees. On the background of this difference, four prototypes of nursing home's social workers were defined: the managerial, the contented, the fighter and the frustrated. From analysing the findings, the significant place of the personal and environmental factors that influence the ways in which the social worker deals with these four themes emerges. Our findings suggest that the strengthening, empowerment and support of social workers in institutions can directly enhance the health, security, emotional well-being and quality of life of nursing home residents.

Introduction

The primary obligation of the social worker in a nursing home is to the residents themselves. This includes accompanying the new resident through the adjustment process to the nursing home (Beaulieu, 2012; NASW, 2003) and providing individual and group therapy (NASW, 2003). Contemporary literature devotes a great deal of attention to the role of the social worker in empowering residents, representing their interests, protecting their rights and dignity, and enhancing their coping skills and their decision-making abilities (Beaulieu, 2012; Kelchner, 2002; NASW, 2003; Nelson, 2000; Nelson ).

The social worker is also required to maintain contact with the resident's family. This involves providing emotional and administrative support and helping to resolve interpersonal problems (Beaulieu, 2012) and conflicts with the institution staff (Kelchner, 2002). There is a strong emphasis on the involvement of the social worker with the multidisciplinary professional team of the nursing home, including active participation in its deliberations and in interdisciplinary development and staff training (NASW, 2003).

The relationships in the nursing home can be examined according to the exchange theory of structural power (Blau, 1964). Reciprocity is the basic principle in this theory, and does not exist in this context due to the imbalance of power between the staff and the residents, who suffer from functional and cognitive decline (Nelson, 2000). Additionally, the ‘total’ nature of the institution further reduces the residents' ability for resistance (Nelson, 2000; Thomas, 2004). These features hamper the ability of social workers to act in accordance with their obligation to their clients (Allen ; Fogler, 2009; Nelson ).

The obligation dilemma of the social worker refers to a situation in which the fundamental obligation to the client might conflict with obligations to the employer or the client's family (Levy, 1976; Linzer, 1999; Lowenberg and Dolgoff, 1996). The social workers' obligation dilemma is intensified in organisations with a multidisciplinary staff that follows a different set of values (Levy, 1976; Reamer, 1982) and in organisations that are motivated by commercial interests (Lowenberg and Dolgoff, 1996).

The obligation dilemma emerged as the central theme of a qualitative study conducted in Israeli nursing homes, in which the social worker was torn between several obligations: to the resident, to the institution and to the resident's family (Lev and Ayalon, 2015). The current article focuses on the second part of the study, addressing the characteristics of social workers, their relationships with management and the multidisciplinary staff, and the ways in which they deal with the obligation dilemma.

Studies on the coping of social workers who faced an ethical dilemma, in which their obligation to their clients was challenged by institutional constraints and restrictions, have stressed the social workers' difficulties in acting in accordance with their obligation to the residents. Social workers acted in diverse ways, ranging between respecting their obligation to the organisation and respecting their obligation to their clients (Lev and Ayalon, 2015; Hyde, 2012; Fine and Teram, 2013; Papadaki and Papadaki, 2008).

Quantitative studies have pointed to a positive correlation between the difficulties of the social workers to act in ways that they perceived as moral or ethical and their stress levels (Di Franks, 2008; O'Donnell ). Studies also indicated a negative correlation between the ethical climate of the organisation and the levels of stress reported by social workers (O'Donnell ; Ulrich ).

The dilemma of obligation to the resident versus the institution

The needs of the nursing home residents and of the institution itself are not necessarily identical. In fact, the lack of congruence sometimes intensifies to a conflict of interests, when the policy of the institution is driven by financial and efficiency considerations, rather than a client-centred approach that respects the residents' privacy, autonomy and individuality (Angelelli, 2006; Harnett, 2010; Thomas, 2004). Furthermore, the very definition of the social worker's role as an advocate of the vulnerable resident is inherently limited due to her status as an employee of the institution (Allen , 2007).

This tension highlights the dual loyalty of the social worker, who is sometimes caught between conflicting obligations to residents and management, and must favour one or the other or find a balance between the two. The conflict can surface with respect to suspected cases of elder abuse (Lev and Ayalon, 2015), unnecessary admission of residents whose needs could have been met outside of the institution (Lev and Ayalon, 2015) and delayed release of residents whose rehabilitation is complete (Fogler, 2009).

The dilemma of obligation to the resident versus his or her family

The literature that deals with the social worker's dilemma of obligation to the resident versus his or her family has tended to focus on the process of transition to residency in the institution and the primary issues that arise during that period (Lowenberg and Dolgoff, 1996). These issues could present the social worker accompanying the family during the transition process with the dilemma of determining who the client is: the elderly person or the family? The dilemma might be exacerbated if the elderly person and his or her family have different expectations and needs and the social worker is torn between respect for the autonomy of the elderly person, who wishes to remain in his or her home, and concern for the welfare of the family, which can no longer bear the burden of home care (Monk and Abramson, 1982).

The dilemma of obligation to the family versus the institution

Although the professional literature does not contain much about the social worker's dilemma of obligation to the family versus the nursing home (Allen ; Lev and Ayalon, 2015), theoretical and field studies relate extensively to the potential conflict between the resident's family and the staff of the institution and suggest ways of dealing with it. Families that have difficulty accepting the authority of staff members, or have different expectations of the treatment their relative receives, tend to clash with the staff (Abrahamson ; Bauer, 2006). Furthermore, the limited authority of the junior staff and their only partial control of what goes on in the institution make it difficult for them to find satisfactory solutions to the family's demands, thus increasing the family's frustration and anger towards them (McGilton ). Conflict between the staff and the family may be influenced by a variety of other factors as well: individual characteristics and cultural background, the nature and severity of the illness and the resident's degree of disability, inappropriate behaviour of the staff, the type of institution and its policies, dissatisfaction with the treatment being given and unsolvable family tensions (Iecovich, 2000). The conflict can arise from or be exacerbated by psychological factors, like the guilt feelings of the family over having placed their relative in an institution (Allen ; Iecovich, 2000).

The present study

The literature relates to the possible occurrence of conflicts and obligation dilemmas in the social worker's nursing home environment (Allen , 2007; Lev and Ayalon, 2015; Fogler, 2009; Monk and Abramson, 1982) and suggests models, coping strategies and resolutions of such conflicts and dilemmas (Iecovich, 2000; Monk and Abramson, 1982; Nelson ). However, little research has been done on the ways the nursing home social worker deals with obligation dilemmas.

The current study is designed to contribute to the understanding of the ways in which social workers in nursing homes deal with the obligation dilemma, taking into account the broad context of their work environment, which includes their position in the nursing home and their relationship with management and other staff.

Methods

Sample

The study population included fifteen social workers, employed in nursing homes in Israel. The participants were located through the Israeli Ministry of Health website, which lists all the nursing homes under its jurisdiction throughout the country. For reasons of accessibility, the interviewees in the study were selected entirely from the Tel Aviv metropolitan area and the Sharon region north of it. The identification of the study population was based on maximum variation sampling (Patton, 1990). The heterogeneity of the study was evident in a number of areas, as detailed in Table 1.

Table 1

Characteristics of the participants

Seniority	Less than one year of experience	3 interviewees
	Between 1 and 10 years of experience	10 interviewees
	Over 20 years of experience	2 interviewees
Nursing home's ownership	Private ownership	8 interviewees
	Public ownership	7 interviewees
Part of a social service	A sole social worker	8 interviewees
	Part of a social service	7 interviewees
Gender	Female	13 interviewees
	Male	2 interviewees

Procedure

The study was conducted by means of a semi-structured, in-depth interview, to facilitate an understanding of the complex experiences and perceptions of interviewees (Fontana and Frey, 2000). The interviewer based herself on the relevant literature, and addressed the various aspects of the social worker's role in a nursing home. The study was approved by the ethics committee of the researchers' university.

The interview focused on the obligation dilemma of the social worker in that kind of institution. Selected questions addressed the respondent's perceptions of her main tasks in the institution; times at which the respondent experienced difficulties and uncertainty about her professional role; the emotional and professional support available to the respondent; perceived relationships and conflicts with residents, families, staff and management; and the way the social worker managed these conflicts. Interviewees were not asked directly about elder abuse or about their coping strategies in this context. The interview guide instructed researchers to ask the following questions: The average duration of the interviews was one to one and a half hours. All interviews were recorded and transcribed.

What work-related experiences do you find most satisfying?

What work-related experiences do you find most difficult/challenging?

How do you manage work-related difficulties?

Have you ever experienced pressures, from any particular direction at work? Has this influenced your professional judgement? How did you manage this?

Significant space was given to the ethically sensitive nature of the research. This sensitivity could have been reflected by the interviewees' concern to expose negative information about their workplace. In addition, the interviewees could have been concerned about the repercussions associated with exposing information regarding their own ways of coping with the conflicting obligations to the residents and the institution. Whereas acting against their obligation to the institution could risk their employment, acting against their obligation to the residents could be viewed as unethical or unprofessional. All interviews began with a conversation about these ethical concerns. The interviewer reassured all interviewees on complete confidentiality and a non-judgemental approach.

All interviewees signed an informed consent, recognising their choice as to how much information to reveal, and their prerogative to abort the interview at any time, with no consequences. Because of the sensitivity of the topic, it was left to the interviewees to choose the venue for the meeting. Most of the interviewees preferred the convenience of their workplace. The personal details of the interviewees were changed in order to conceal their identity.

The rationale for carrying out the research derived from the personal experiences of the first author, who had worked as a social worker in a private nursing home for several years. The first author was fully aware of the fact that she in fact was part of the research population. This has significant implications on the reflective aspects that accompanied the research. Awareness to these reflective aspects, along with guidance from her mentor (the second author), strengthened her openness and empathy to the interviewees' diverse experiences and perspectives.

Analysis

In the first stage of data analysis, interviews were analysed by creating preliminary categories of information, which in turn contained sub-categories and characteristics (Strauss and Corbin, 1990). Data were not forced into preconceived themes, but instead an open coding approach was employed, so that interview data guided the creation of the categories (Creswell, 1998). A comparison of the categories and sub-categories within and across interviews led to a reduction in their number. Subsequently, the various categories and sub-categories were organised in a table: the fifteen interviews on the vertical axis, and the categories and sub-categories on the horizontal axis. The table allowed for a comprehensive overview of all the categories and sub-categories with the intention of isolating the core category, and finding links between it and the other categories (Strauss and Corbin, 1990). The table was analysed both horizontally and vertically. The horizontal perspective revealed the obligation dilemma as the core category, in light of the significance that most of the interviewees attached to it. The links between the different categories for each of the interviewees were analysed horizontally in relation to the main category. This was then followed by a vertical review of each of the interviews as a whole interview in an attempt to identify prototypes of social workers who follow a unique response pattern on the particular themes identified.

The analysis of the interviews was followed by an additional approach to the interviewees, with the intention of sharing the findings of the study with them and inviting them to respond. Most of the respondents reported that the findings clearly reflected their experiences. One respondent was disturbed by how emphatically most of the interviewees blamed the work environment for the dilemmas and difficulties facing social workers, while placing less personal responsibility on the social workers themselves. This tension between environmental and personal factors is discussed at the end of this article. Findings were also presented to various audiences of social workers in long term care settings. The overall response was that of acknowledgement and agreement with the findings.

Results

The main theme, the obligation dilemma, was common to most of the interviewees. This theme is discussed in detail in Lev and Ayalon (2015). Three themes that emerged in the study are discussed in the current article: the place of the social worker in the nursing home; relationships between the social worker and management and other staff; and ways of coping with the obligation dilemma. Regarding these themes, there were clear differences of opinion among the interviewees. A result of the differences was the identification of four prototypes of social workers in nursing homes: the managerial type (two interviewees), the contented type (three interviewees), the fighter type (six interviewees) and the frustrated type (four interviewees). Table 2 summarises the four prototypes in relation to the relevant themes.

Table 2

The four prototypes

	The managerial type	The contented type	The fighter type	The frustrated type
The place of the social worker in the nursing home	Role definition is broad and flexible with a high status and managerial functions	Role definition is well-definedPart of a social service that provides formal and informal support to the social worker	Role definition is comprehensive and multidisciplinary with managerial functions	Role definition is limited with low status and little influence
Relationships of the social worker with management and other staff	Appreciation, trust and support from the managementHierarchical relationships with the staff without direct conflicts or confrontations	Openness, supportiveness and co-operation from the management	A tendency towards confrontations and conflicts with the management and staffHierarchical relationships and supervision of staff members	Tense relationships with management but mostly without a direct confrontation
Ways of coping with the obligation dilemma	The high status and the support from the management promote coping with the dilemma and solving it	The close relationships with the management promote dealing with the dilemma and solving it	Taking a clear position of obligation to residents even at the cost of conflictThe resources available were not always perceived as satisfactory	Sometimes the obligation to the management preceded the obligation to the residentsLooked for compromising ways in order to maintain the obligation to the residents

The managerial type

The social worker's place in the nursing home

The managerial type tended to describe her place in the nursing home as broad, flexible and connected to other disciplines. Another aspect that characterised the ‘managerial’ role definition was an emphasis on initiative and assertiveness. The broad involvement and assertiveness led to a perception of the role of the social worker in the nursing home as important and valuable. Managerial types in the nursing home are liable to see themselves as able to exert authority and having means at their disposal, to the extent of getting an unsuitable employee fired. The interviewee relates:

But I share everything with [the head nurse] in any event. And if I think she hasn't done enough, I go and tell her that: ‘You didn't talk to her’…‘It's happening again …’ If I see a situation that doesn't seem to be solvable, I say okay, it seems like this is where our ways part. … I make my voice heard, yes I do (Interviewee #15).

Relationships with management and other staff

The relationships between the managerial type and management are described in positive terms, emphasising the appreciation, the trust and the support that the social worker enjoys from management. On the other hand, relationships with the rest of the staff were characterised by a more hierarchical structure, although, in most cases, without direct confrontation and conflicts:

… with the staff as well. I simply trained them over the years that if I come and say that we'll have a group [meeting] today, then I'll be there, that's what I came for. Period. I do not have to organize them, I do not have to do anything, I do not have to get them together, and I do not have to fight with the male nurse or anyone else—like in other homes for the elderly—or with the administrator. So in this way I'm spoiled. Very (Interviewee #4).

Ways of coping with the obligation dilemma

When managerial types are faced with the obligation dilemma, they generally believe that they have the means to deal with it:

I'll tell you, what stands out in my case is that I was very close to the director … I meet social workers who [have the title of] deputy director, or something like that, but here I have become a sort of [mediator] when there are conflicts (Interviewee #15).

The contented type

The role of the contented type is well defined, and obviously acceptable to management and the multidisciplinary staff. In general, contented types believe that their role is respected and appreciated. Another important characteristic of the contented type is the fact that they are part of a social service that provides them with support and both formal and informal guidance. The contented type tends to view the social service as a resource which helps cope with and overcome the difficulties of working in a nursing home:

We're a very supportive team. The work is very hard, emotionally. We have to deal with tough personal issues, especially death, which is a difficult issue for all of us. Without the mutual personal support of the whole staff, I don't know if I could have lasted for 22 years (Interviewee #8).

In general, the contented type enjoys good relationships with the management, characterised by openness, supportiveness and co-operation, as described in the following interview:

I feel enormous openness. The relationship is really an open one. There is no issue of the management being aloof. I honestly believe I can come to them with any problem or dilemma that has arisen in the field. There is no problem with that (Interviewee #8).

When contented types face the obligation dilemma, they generally believe that they have the tools to handle it. One of the interviewees spoke about her close and open relationship with management, which helps her deal with this dilemma. She also noted that the management for the most part accepts her positions:

If I come to the management with a problem I've encountered in the field, first of all they listen to me, which is a big thing. In most cases they accept my position. Not always, but in most cases, yes (Interviewee #8).

The fighter type

Like the managerial type, fighters tended to see their role as broad, unrestricted, comprehensive and multidisciplinary. Fighter-type social workers stressed that their primary obligation was to the resident and the resident's family. Consequently, the social worker felt bound to become involved in every aspect of the life of the institution that affected the welfare of the residents and their families. The broad interpretation of the social worker's role, with strong managerial functions, was not clearly defined and not agreed upon with management and the other staff. The absence of clarity and agreement sometimes made fighters feel that their role was not understood nor given legitimacy by the institution management and their colleagues. As a result, the fighters felt that their influence in an institutional system is limited, and that the mandate they are given is too limited to cope with their obligation to the resident:

It creates moral issues. I know that something is not right here, but it's not something I can resolve on the spot. It's a process that can take months or even years. And it doesn't only depend on me. I cannot make the decision to fire someone. Even if I have opinions about what to do—and sometimes they're strong opinions—there is a director over me, and a staff I have to work with (Interviewee #7).

Relationships with the management and other staff

The relationships between the social worker and management were an important factor in the way fighter types experienced their work. A prominent characteristic of those relationships was the frequent preparedness of such social workers to confront the management when they felt compelled to protect the needs of residents against the demands of the institution, or when management's demands were incompatible with social work ethics. Some of the fighter types stated that their professional obligation to the residents and their commitment to their own professional principles overrode their fear of being dismissed as a result of confrontation with the management:

They [management] know. They know I'm not afraid of losing my job. I'm not here because a three-quarter-time position as a social worker is going to make me rich. I came here from a job that paid a lot more, and I have no problem going back there. I'm here because I believe in what I'm doing. I'm here because I want to do my job, not because I need the salary to feed my family. That's why I have no problem doing what it takes to achieve my goals (Interviewee #12).

Similarly to their relationships with management, the relationships of fighter types with the rest of their colleagues in the institution tended to be a significant part of how they experienced their work situation. For the most part, direct or covert tensions and confrontations were typical of these relationships. The role of supervisor and ‘trainer’ that the social worker took on herself, along with her obligation to the residents, often led the staff members to relate to her with suspicion and sometimes even hostility, a refusal to co-operate, denial of abuse and concealment of information.

From the beginning, they would often call me ‘KGB’ [the old Soviet secret service]. They're all Russians [immigrants from the former Soviet Union], and here I am with my file, and I speak with residents and take notes. And everyone has their suspicions. ‘She's KGB. Why do you ask him if he's doing okay? Why do you ask him …?’ It bothered them, until they understood that I wasn't there to do them any harm, but I'm there to work with them …. But the job, from my point of view, the job of a social worker in an institution is like being the residents' lawyer. She [the social worker] has to stand firm in unpleasant and uncomfortable situations (Interviewee#9).

The interviews with fighter types revealed that the obligation dilemma, in all its aspects, was very much a part of their work environment. The tendency of the fighter type to support the residents or their families, even if it meant confrontation with management and other staff, can be seen as the social worker's way of coming to terms with, and making a firm decision about, the obligation dilemma. There frequently was a gap between the fighter types' intense commitment to the residents and desire to protect their well-being and their rights, and their ability to carry it out in practice, owing to the suspicion and lack of co-operation they encountered from management and other staff. Because of this gap, several different tactics emerged, which paint a complex picture of the way fighter types deal with the obligation dilemma.

One of the ways that fighter types coped was coming to terms with the fact that she could not effect significant change, could not ‘change the world’, as they put it. Therefore, they set themselves achievable goals, like relief and assistance. Another way of coping was to group issues according to how fundamental they were. The distinction between more and less important matters was sometimes subjective, but sometimes was determined by the social worker discovering that there were official rules or procedures governing those matters. This separation allowed the social worker to concentrate on fighting for those issues that seemed more crucial, and conceding those that seemed less so:

If I run into dilemmas, about whether or not I am allowed to do things, ethically or legally, I try to verify information as much as I can with my colleague, the staff, the Ministry of Health social worker. I try to verify so that I won't do something that is illegal or forbidden. But as long as it is within the boundaries of what is allowed, and everyone does it in his own way, I am okay with it (Interviewee #12).

The frustrated type

The position in the institution of the frustrated type is lowly and of little influence. The frustrated type felt that their work in practice does not match their professional perception of the substance of their role and its list of priorities, and that management determines the role for its own bureaucratic or financial reasons:

From the point of view of the management, this is our role. In other words, they give us a job that is not ours to do. Perhaps a clerk should be doing it, or a secretary, but not a social worker. Maybe the management itself [should be doing it]? I know that in some of the other institutions the management itself deals with it. In our institution it's not like that—and it makes me angry every time! (Interviewee #2)

A different interviewee saw the low status of the social worker in an institution as the result of the definition of the role, not of outside factors:

The profession of the social worker in an institution is nothing special, in my opinion. The medical approach is what counts: the doctor, the nurses, and the care-givers who take orders from [the medical staff]. Social work is sort of decorative, on the sidelines. [It's only] because the Ministry of Health decided that there has to be a social worker [there], and there are some forms that only the social worker can sign. So, okay, it's nice that I can be [someone's] guardian, and fill out this form or that form (Interviewee #10).

The frustrated type tended to attribute the tense relationships with management to the disparity between their respective definitions of the role of the social worker in the institution. The disparity was most glaring when it came to financial issues: frustrated social workers felt that management imposed tasks on them that served the financial interests of the institution, but that did not serve, or at times were even incompatible with, the welfare of the residents. In some of the interviews, the social workers expressed their understanding of the financial constraints of the institution and, consequently, of the demands made of them, despite the difficulties and conflicts of interest involved:

I have a hard time with this. On the other hand, it's part of working in an organization like this. That means that however much we are here for the old people, and they do need the help and the treatment and the concern and everything—you know—there is still the financial side, and you cannot ignore it. It's hard for me sometimes (Interviewee #14).

As for the fighter type, the obligation dilemma was an important factor in the work environment of frustrated types. They often felt a contradiction between their obligation to the management of the institution and their obligation to the residents and their families. By contrast with the fighter type, the frustrated type did not express an unequivocal bias on behalf of the residents vis-à-vis the management. They often were reluctant to oppose management and other staff, even if the matter conflicted with their professional assessment and obligation to the residents. This tendency was a frequent source of frustration and despair for the social worker:

And however much I have spoken with this administration, they do not get it. They see my role differently to me. It will go on forever, it seems, because those that were here before us supported that approach and never objected. It's a tradition of many years, and it's hard to change it (Interviewee #3).

Despite the difficulty in defying the obligation to the institution, the frustrated types often found more complex ways of coping. One was a middle road, trying to maintain their obligation to the residents without directly undermining their obligation to the management:

I resolved the dilemma in a staff meeting. I told the boss that according to the directives of the Ministry of Health, we need to reassess if this is the right place for that person, because I don't think he fits the definition of nursing care. But I didn't follow her around to see if she did something about it. In that way, I more or less resolved the dilemma (Interviewee #10).

Although frustrated types found it hard to stand up to management and the other staff, the interviews revealed that, in certain cases, if the social workers felt that the resident had been mistreated, they were motivated by their obligation to the resident, even at the cost of confrontation with the staff and to the detriment of their obligation to the management:

I felt that it hurt my conscience, [and that] I couldn't keep quiet. Coincidentally, a welfare officer was on a visit to the institution just at that moment, and it was just then that [the incident] was troubling me. So we sat and talked. Although the director told me ‘tell her it wasn't exactly abuse, only bothering [the resident], and she shouldn't report it,’ I nevertheless reported it to the welfare officer, and she took the matter further (Interviewee #2).

Discussion

The goal of the present study is to describe how the nursing home social worker deals with the obligation dilemma, in the context of her perceived role and relationship with the institution management and multidisciplinary staff. There was wide agreement among the interviewees regarding the nature of the obligation dilemma, but differences arose with respect to three issues: the position of the social worker in the nursing home; the relationships between the social worker and management and other staff; and the way the social worker grapples with the obligation dilemma. These differences prompted a definition of four prototypes of institutional social workers: the ‘managerial type’, the ‘contented type’, the ‘fighter type’ and the ‘frustrated type’.

The tension experienced by social workers when they act in accordance with their moral and professional obligation to the resident against the interests of the institution can be viewed through Payne's (2005) classification. Similarly to the fighter and managerial prototypes, socialist–collectivist views in social work emphasise the obligation of advocating and empowering clients, while promoting social change, even in the face of confrontation. The individual–reformist views in social work resemble the frustrated and contented prototypes, found in this study, because they tend to avoid confrontation and maintain social order (Payne, 2005).

Nelson list five strategies available to social workers faced with obligation dilemmas: avoidance, conciliation, compromise, problem solving and forcing. The appropriateness of each is determined by the nature and seriousness of the conflict. Our study shows differences among the various social worker prototypes in choosing strategies for coping with the obligation dilemma. For the most part, the differences are not merely determined by the nature and seriousness of the conflict, but are influenced by the personal characteristics and work environment of each prototype. The managerial type, for example, tends to be a problem solver, bridge builder and negotiator, with almost no need to resort to forcing. The fighter type, who enjoys less co-operation from management and other staff, tends to complement her problem-solving strategy with one of forcing. The frustrated type generally finds it difficult to confront management directly, and is likely to choose a strategy of avoidance.

Nevertheless, there are situations where the seriousness of a conflict was a more prominent factor than the personal and environmental resources in determining the way interviewees coped. Fighter types sometimes tended to concede or ignore issues that seemed less critical. Frustrated types noted that, in situations where they felt residents were at risk, they were guided by their obligation to them, even at the expense of their obligation to management.

The different prototypes generally had a different view of the influence of personal and environmental factors on their position in the institution, their relationships with other staff and the way they dealt with the obligation dilemma. The managerial types tended to emphasise personal characteristics, especially initiative and authority, as the dominant factors. The frustrated and contented types saw the environment as having a decisive influence on how they felt about their work, with no direct connection to personal factors. The fighter types typically had a more complex perspective, which allowed significant room for both personal and environmental influences in their experience of the workplace.

The study stresses the importance of the social workers' perceived personal and environmental resources, which potentially help them to deal with the obligation dilemma and protect the resident's needs. Thus, a social worker who perceives having high environmental resources, such as the managerial and the contented prototypes, would be able to use the trust, the appreciation and co-operation of the management and staff, to protect the residents' needs and to enhance their quality of life. On the other hand, when the environmental resources of the social worker are perceived as low, such as in the case of the fighter and the frustrated prototypes, it would be much more difficult for her to act in accordance with her obligation to the residents.

Similarly, a social worker who has high personal resources, such as the managerial and fighter prototypes, would believe in her professional skills and her moral position, even in confrontational situations, and in the absence of co-operation from the management and staff. Such a worker would be able to protect the residents and enhance their quality of life. On the other hand, when the personal resources of the social worker are viewed as low, as in the case of the frustrated prototype, she would not believe strongly enough in her capabilities and therefore, in a conflicting situation, would have more difficulties protecting her residents.

It is important to emphasise that the prototypes mentioned represent ideal types. Although some of the interviewees fully matched the prototype, others were more complex and did not clearly fit any individual prototype. In reality, social workers may vacillate between different prototypes or move from one prototype to another during their professional development. Due to the qualitative nature of this study and the small number of interviewees, we cannot draw a correlation between the interviewees' socio-demographic profile and the type of strategy adopted. We recommend examining such a relationship in a large-scale survey.

Although this study focused on social workers' obligation dilemma in the specific context of the nursing home, it carries broader implications to the profession of social work. The bureaucratic nature of most welfare institutions coupled with the commercial interests of some of these institutions could challenge the ability of social workers to act in accordance with their obligation to their clients (Hyde, 2012; McAuliffe and Sudbery, 2005; Papadaki and Papadaki, 2008).

An awareness of the dilemmas that social workers face, and the importance of personal and environmental resources in dealing with these dilemmas, should lead to the development of organisational bodies and educational training that are geared towards providing professional and emotional support and supervision to social workers in nursing homes. These goals could be achieved through professional enrichment using courses and workshops, formal and informal individual and group support by professionals, or online support forums. This kind of support should empower social workers, improve their professional performance and their emotional health, and prevent burnout (Hamama, 2012; O'Donoghue and Tsui, 2015). It is also important to address these ethical issues as a significant part of the curriculum in schools of social work. By strengthening, empowering and supporting social workers in institutions, it is expected that the health, security, emotional well-being and quality of life of nursing home residents will also be enhanced (Van Voorhis and Hostetter, 2006).