The Impact of Unions on US Direct Care Workers in Long Term Care Settings: a Systematic Review

Abstract

Objectives:

To meet a growing demand for direct care workers (DCWs) in the US, structural, organizational, and policy-related solutions are needed. Unionization of the workforce may be one such mechanism, however its impact on outcomes remains poorly understood. To examine the impact of unionization on DCWs’ financial well-being and employment attitudes, as well as patient outcomes.

Design:

A systematic search of AgeLine, CINAHL, PubMed, Scopus, and Web of Science from database inception through June 20, 2024. We included peer-reviewed empirical studies that used observational, quasi-experimental, and experimental designs.

Setting and Participants:

Studies pertained to DCWs who provided care in the home and long-term care settings. We focused on studies that illustrated the financial outcomes of DCWs (wages, compensation, benefits), employment outcomes (job satisfaction, turnover), and health-related outcomes of DCWs and their patients.

Methods:

Covidence was used to screen studies for inclusion criteria. Study characteristics were abstracted manually by pre-specified domains. The Downs and Black tool was used for quality assessment. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

Results:

A total of 19 studies met inclusion criteria; they were predominantly observational (94%), with local (50%) and national (50%) samples. Three studies focused on compensation and al found that unionization was associated with higher wages and benefits among DCWs. Seven studies focused on employment, finding that unionization was associated with greater job satisfaction, quality, and retention, particularly among nursing home staff and home health aides. Unionized workplaces reported better care quality and safety, including fewer injuries and better equipment provision. Unionization’s impact on patient outcomes showed mixed results, particularly among nursing home residents. Overall, the quality of the research studies varied, with limitations in methodology and sampling affecting reliability.

Conclusions and Implications:

Unionization among DCWs was generally associated with higher wages, benefits, and job satisfaction, as well as reduced turnover. However, its impact on worker and patient outcomes varied across studies. The overall quality of the studies was fair to poor, highlighting the need for more rigorous research in this area.

Summary:

DCW unionization was shown to improve wages and benefits, improve job satisfaction and retention, and improve care quality and safety. However, unionization showed varied findings on patient outcomes.

Introduction

Direct care workers (DCWs), which include home health aides (HHAs), attendants, personal care aides, and nursing assistants (NAs), provide care to older adults and those with disabilities across various long-term and community-based settings.¹ Although their roles may differ, DCWs generally assist with personal and medical care on a daily or near-daily basis.² With an aging population and a push for shorter hospital stays, demand for DCWs has surged.³ In the United States, there are currently 4.8 million DCWs; estimates suggest that an additional 9.3 million more workers will be needed by 2031.⁴ Yet, the supply remains low, partly due to poor job quality, structural inequities, and challenging working conditions.⁴ Predominantly middle-aged women and people of color, DCWs often face low wages (median $13.56/hour), irregular hours, and inadequate benefits, leading to high turnover rates.^5–7

One way to potentially improve the working conditions of DCWs and reduce turnover is through unionization.⁸ In other occupational settings, unions have been associated with increased wages, benefits, and improved outcomes among workers and patients. ^{9 10} Notably, in a study of other occupational groups in healthcare, Dube et al. found that California hospitals that employed unionized nurses had better outcomes than nonunionized hospitals across 12 patient outcomes, including infection rates and morbidity and mortality.¹¹ A more recent study found that registered nurses (RNs) who were union members had lower turnover rates but also higher job dissatisfaction than nonunionized nurses.¹²

While the impact of unions has been studied among other healthcare workforces, their impact on DCWs remains less known. To that end, we conducted a systematic review of the peer-reviewed literature to examine the impact of unions on the DCW workforce, including outcomes at the worker and patient level.

Methods

Search Strategy

The research team, with the help of a medical librarian, searched the following databases from inception through June 20, 2024: MEDLINE, AgeLine, CINAHL, and Web of Science. The team used MEDLINE as the initial search database and then used Systematic Review Accelerator’s “Polyglot” feature to translate the search terms to the remaining databases.¹³ From there, the team exported the search results from all the platforms. Additionally, we used literature that was identified through other cited reference searching. We produced a protocol, which was submitted and registered with PROSPERO (registration # CRD42023448627; Supplemental Figure 1). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed (Supplemental File 3).

Inclusion and Exclusion Criteria

We included any English-language articles published through June 20, 2024, that pertained to DCWs who provided care in nursing homes, home health care agencies, and long-term care (LTC) facilities and included unionization or union status of the workforce. We included studies that were quantitative (observational only), quasi-experimental, and randomized controlled trials. We excluded studies that were abstracts only, conference presentations, observational (qualitative), book chapters, white papers, lay-press articles, narrative or systematic reviews, and case reports. We excluded studies that focused on physicians, nurse practitioners, RNs, and physician assistants. The complete search strategy can be found in Supplemental File 2.

Data Collection and Extraction

The initial search yield and final study sample are shown in Figure 1. All articles yielded from the search were imported into Covidence, a software tool designed for systematic reviews, which facilitated the screening, data extraction, and management of studies.¹⁴ Two authors (K.A. and J.S.) reviewed the search yield and completed a title and abstract screen. Next, two authors (K.A. and D.S.) completed a full-text screen and determined whether each study met inclusion criteria; a third author (M.R.S.) resolved differences. Next, two authors (K.A. and D.S.) extracted the following data from the studies that met inclusion criteria: study title, author, publication year, publisher, study type, workforce population, type of workplace, objective, outcome, independent variables, and dependent variables. Studies were grouped based on their outcomes.

Figure 1.

Union Outcomes—DCW

Quality Assessment

We used the Downs and Black (DB) tool to assess the quality of the included studies.¹⁵ This tool employs a series of 28 questions to evaluate various aspects of study quality, including reporting, external validity, internal validity and bias, internal validity and selection bias, and power. Two authors (K.A. and D.S.) independently graded each study using this tool. Scores assigned by these authors were then reconciled by a third author (M.R.S.) to ensure consistency and accuracy in the quality assessment process.

Results

Description of Included Studies

Characteristics of the 19 studies are shown in Table 1. The studies were published from 1987–2024 and appeared in medical, labor, and health services-focused journals. All but two of the studies were observational (n=17), with just under half of those (n=7) being descriptive in nature. The two non-observational studies were quasi-experimental. One is a regression discontinuity design and the other is a difference-in-difference event study. Eight of the 19 studies (42%) exclusively examined care provided in the home by HHAs, home care aides (HCAs), homemakers, and personal care assistants, while another nine (47%) focused on care delivered in nursing home settings by nursing home workers, NAs, licensed practical nurses (LPNs), and RNs. Two studies (11%) examined broader settings of care, including: hospitals, physicians offices, and therapists’ offices. About half of the studies (n=9; 47%) used local samples for data collection and analysis, whereas the other half (n=10; 53%) used national samples and data. None of the studies include workers based outside of the US.

Table 1 –

Characteristics of Included Studies that Examine the Impact of Unionization on DCWs

Author and Year	Study Design	Sample Size	Workforce	Setting of Care	Study Objective	Outcome(s) of Interest	Key Findings
Zechter et al., 1987	Cross-sectional descriptive study	421	Homemakers	Home Care	To characterize the occupational hazards that unionized domestic workers experience while providing home care.	Occurrence of work-related injuries	46% encountered hazards; more prone to musculoskeletal issues such as back problems and muscle strains. General population was more likely to report nonspecific symptoms.
Hunter et al., 2000	Mixed methods (interviews and survey)	152	Nursing Home Workers	Nursing Home	To understand what determines job quality in nursing homes.	Standardized index of job quality comprised of benefits, job characteristics, and employee opportunities	Job quality varies across employers. Niche market employers offer higher-quality jobs. Local labor markets did not significantly affect job quality. Unions improved job quality for otherwise low-quality jobs but did not enhance already good jobs. Good jobs were more common where managers had undergone standardized professional training programs.
Howes, 2004	Retrospective cohort study	268,363	Home Care Workers	Home Care	To analyze union effort for home care workers in California, exemplifying how unions specifically helped improve pay, thus improving the work environment and the quality of care that HCW employed. Additionally, these higher wages led to lower turnover.	Probability of an IHSS provider quitting within a year in 2003 in California	Higher wages were linked to lower worker turnover. Primary income providers were less likely to quit. Unemployment rates were higher in rural counties. The presence of health insurance in a county was not statistically significant, but low eligibility for health insurance was. Turnover decreased as the number of consumers per provider and authorized work hours increased. Russian workers were less likely to leave, while African American workers were more likely to leave.
Temple et al., 2009	Cross-sectional observational study (survey)	944	Nursing Assistants	Nursing Home	To examine nursing home organizational characteristics and specific job characteristics of staff in relation to turnover of NAs.	Nursing assistant turnover	Staffing levels of 4.0 hours per patient day or more were linked to higher odds of low turnover and lower odds of high turnover. Higher wages and union membership increased the odds of low turnover. Wages, fully paid health insurance, employee assistance benefits, and involvement in resident care planning reduced the odds of high turnover.
Delp et al., 2010	Mixed methods comprised of focus groups and cross-sectional observation	1,614	Home Care Workers	Home Care	To investigate determinants of job satisfaction among home care workers in a consumer-directed model.	Job satisfaction	Consumer abuse, unpaid overtime, caring for multiple consumers, and work-health demands were linked to lower satisfaction. Surprisingly, some physical and emotional job demands were associated with greater satisfaction. Social support and job control positively correlated with job satisfaction.
Sojourner et al., 2010	Retrospective cohort study	188,803	Nursing Home Workers	Nursing Home	To provide context for the proposed labor law reform by shedding new light on the role of organized labor in the provision of nursing home care. The authors documented the trends and distribution of unionized staff and new organizing activity across time, geography, and nursing home characteristics.	Nursing homes’ probability of being union. nursing homes’ probability of winning a union election	The fraction of workers covered by union contracts decreased by about one-third from 1985 to 2009. Nursing homes with more residents, a higher share of Medicaid and Medicare residents, and those that are hospital- or chain-based are more likely to be unionized. Church-related nonprofit nursing homes are more likely to be unionized than corporate for-profit ones. Homes with a higher percentage of private-pay residents are less likely to be unionized.
Delp et al., 2011	Mixed methods comprised of focus groups, interviews, and surveys descriptive study	4,530	Home Care Workers	Home Care	To discuss the role of home care policies, particularly the importance of unionization, on home care work in California.	Physical and emotional demands of job, schedule, financial, and health related concerns, and worker control and support	47% of survey respondents found it somewhat or very difficult to pay their bills, and 40% were unable to see a doctor in the past year due to financial reasons. Home care workers have relatively high decision latitude. 54% worry about becoming unemployed. 97% of workers said union membership is somewhat or very important, with 57% stating it is very important.
Banijamali et al., 2014	Mixed methods (interviews and survey) descriptive study	402	Home Care Workers	Home Care	To understand the reasons why unionized home care workers in Washington State left the profession between August 1, 2007, and October 31, 2010.	Reasons for leaving the profession	Home care workers that left the profession were more highly educated, had higher household income, and were more likely to be White. Workers who left home care and are in employed in a new profession have better benefits, wages, hours, and career mobility than they had in their home care jobs.
Sojourner et al., 2015	Retrospective cohort study using quasi-experimental regression discontinuity design	627	NAs, LPNs, RNs	Nursing Home	To understand the impact of unionization on productivity, care quality, employment, and earnings.	Staffing levels for (CNAs, LPNS and RNs), nursing home quality, resident acuity, nurse productivity, earnings, competitive structure of local markets and union density	Unionization in nursing homes is linked to lower staffing levels but does not decrease care quality, suggesting increased labor productivity. Facilities in less competitive markets and those with initially lower union presence show more significant employment effects post-unionization. Unionization generally results in higher wages but also shifts workforce composition away from higher-earning employees.
Quinn et al., 2016	Cross-sectional survey	1,249	Home Care Workers	Home Care	(1) assess quantitatively the OSH hazards and benefits for a wide range of HC working conditions, and (2) compare OSH experiences of HC aides who are employed via different medical and social services systems in Massachusetts, USA.	Sharps injuries, low back pain, other injuries, verbal violence, physical violence, job satisfaction, job security, perceptions of safety, home environmental conditions, musculoskeletal injuries, and hazards	Musculoskeletal strain, exposure to infectious agents and cleaning chemicals for infection prevention, and experience of violence are the most frequently occurring hazards for home care aides. Client-hired and agency-hired aides had similar hazard experiences except for sharps use (client-hired aides were more likely to experience) and verbal violence (agency-hired aides were more likely to experience)
Schoenfisch et al., 2017	Mixed methods (retrospective cohort study and focus groups) descriptive study	43,394	Home Care Aides	Home Care	To address safety and health concerns of unionized home care aides in Washington state.	Work hours, number of injuries, injury rate ratios	Injury rates were notably higher among those who were female, white, aged between 50 and 65, less experienced, spoke English primarily, and employed by agencies. Of the reported injuries, 28.4% led to compensated time off work (x͂ = $1,868/claim; x͂ = 122 days). Beyond immediate occupational risks, there were concerns over fluctuating workloads, income instability, and varying levels of supervisory and social support.
Berridge et al., 2020	Cross-sectional observational study (survey)	1,385	Nursing Assistants	Nursing Home	To examine the relationship between nursing assistant retention and a measure capturing nursing home leadership and staff empowerment.	Nursing home worker retention	High leadership and staff empowerment levels were associated with high nursing assistant retention. Higher occupancy rate, chain status, hours per day per resident, administrator turnover, and unionization were associated with higher rates of retention.
Pinto et al., 2021	Cross-sectional descriptive study.	256	Home Health Aides	Home Care	To assess the impact of COVID-19 on HHAs and to understand the challenges and opportunities for current and future pandemic planning.	COVID-19 infection risk, general mental and physical health, employment, economic security, and resources for meeting basic needs.	11% provided care to COVID-19 patients, 15% showed symptoms, and 23% tested positive for the virus. 25% concerned about accessing PPE, 78% have to obtain their own PPE. News media was main source of information about the pandemic for workers. 32.1% reported that the pandemic greatly exacerbated their mental and physical health challenges, and 10% felt less inclined to remain in the industry due to these difficulties.
Ahmed et al., 2022	Cross-sectional observational descriptive study	14,298	Physicians and Dentists, Advanced Practitioners, Nurses, Therapists, and Technicians and Support Staff	Home Care, Hospitals, Nursing Homes, Physicians’ Offices, Dental Offices, Therapist Offices	To understand the prevalence of labor unionization among US health care workers over the past 12 years, and to see the association with pay and benefits.	Mean weekly pay, noncash benefits, full premium-covered health insurance, employer’s contribution to the worker’s health insurance plan, and work hours	13.2% of respondents reported union membership or coverage, with no significant trend from 2009 to 2021. Racial or ethnic minorities and those in metropolitan areas were more likely to be unionized. Unionization was linked to higher weekly earnings ($1165 vs $1042; mean difference, $123), a higher likelihood of pension or retirement benefits (57.9% vs 43.4%; RR, 1.33), and employer-sponsored, fully covered health insurance (22.2% vs 16.5%; RR, 1.35). Union members worked more hours per week (37.4 vs 36.3; mean difference, 1.1 hours). Among nonunionized workers, White workers earned more than racial and ethnic minorities ($1066 vs $1001; mean difference, $65), but no significant difference was found among unionized workers ($1157 vs $1170; mean difference, -$13).
Dill et al., 2022	Retrospective cohort study	16,292	Certified Nursing Assistants, Home Health Aides, and Personal care Assistants	Home, Hospital, and Long-Term Care	To measure unionization in the direct care workforce and the relationship between unionization and earnings, looking closely at differences across race/ethnicity and gender.	Likelihood of unionization, natural log of weekly earnings	Male (12%) and Black (14%) direct care workers were most likely to be unionized, followed by Hispanic and other workers of color (10%). White workers had the lowest unionization rate (8%). Unionized direct care workers earned wages about 7.8% higher than nonunionized workers, with a larger effect for White union workers.
Olson et al., 2022	Retrospective cohort study	14,380	Nursing Home Workers	Private Nursing Home	This paper aims to determine whether unionization status is a significant predictor of resident COVID-19 mortality.	Resident mortality	No correlation was found between nursing home unionization and resident COVID-19 mortality rates: 10.2% at unionized homes vs. 10.7% at nonunionized homes. Higher resident COVID-19 mortality was associated with older average resident age, lower Medicare resident percentage, smaller size, for-profit ownership, and chain affiliation.
Dean et al., 2022	Retrospective cohort descriptive study	13,350	Nursing Home Workers	Nursing Home	To understand the role that labor unions play in improving workplace safety for nursing home staff during COVID-19.	COVID-19 mortality rates among residents, worker COVID-19 infection rates	16.8% of nursing homes had health care worker unions. Unionized facilities showed lower resident COVID-19 mortality rates, lower staff-to-resident hour ratios for certain roles, and lower percentages of White residents compared to nonunionized facilities. Unionized nursing homes were most prevalent in the Northeast and least in the South, and had lower worker COVID-19 infection rates.
Dean et al., 2023a	Cross-sectional observational study	12,633	Nursing Home Workers	Nursing Home	To understand the association of unions and health care staff turnover.	Staff turnover	Union presence is correlated with decreased turnover. This association is larger when the county-level proportion of unionized nursing homes was high.
Dean et al. 2023b	Quasi-experimental (difference-in-differences event study)	15,921	Nursing Home Workers	Nursing Home	To examine whether unionization increases the probability that nursing homes will comply with the requirement to report workplace injury and illness data to the Occupational Safety and Health Administration.	Binary measure of whether a nursing home complied with OSHA’s regulation requiring the submission of data on workplace injuries.	Unionization positively impacted nursing home compliance with OSHA reporting requirements for workplace injuries. In unadjusted analyses, unionized nursing homes were 9.5% more likely to report injury data one year after unionization and 9.7% more likely two years after. After adjusting for preexisting trends, unionized homes were 22.1% more likely to report after one year and 31.1% more likely after two years compared to nonunion homes.

Impact of unionization on DCWs’ wages and benefits

Three studies characterize the association between unionization among DCWs and wages and benefits.^8,10,16 While the studies vary in the workforces studied, all three found that unions were associated with higher wages, better benefits, or both. For example, using the Current Population Survey (CPS), a national data set by the BLS, Ahmed et al. focused broadly on healthcare workers (n=14,298), which included physicians, dentists, advanced practitioners, nurses, therapists, technicians, and support staff. The study, which included data from 2009 through 2021 found that among the sample, union coverage was associated with significantly higher weekly earnings ($1,165 for union vs. $1042 for nonunion; mean difference, $123, p < .001) and better non-cash benefits (likelihood of having a pension is 57.9% for union vs. 43.4% for nonunion; risk ratio [RR], 1.33), as well as a greater number of working hours (37.4 hours vs 36.3 hours).¹⁰ Dill and Tanem also used the CPS data but limited their sample to include only DCWs who worked full-time from the years 2010 to 2020 (n=16,292). They found that DCWs, which included personal care aides, home care workers (HCWs), and NAs, who were unionized or represented by a union earned higher wages than those not unionized by 7.8%. Of note, they found that the impact of unionization differed by Race/Ethnicity with unionized workers of minority groups receiving smaller wage increases from unionization than their White counterparts.⁸ Finally, using survey data from Massachusetts nursing homes (n = 161, survey completed by administrators), Hunter et al examined the association between unionization of nursing homes on NA job quality, defined as a bundle of practices including benefits and wages. They found that unionized nursing homes were associated with improved job quality among NAs.¹⁶

Unions and employment-related factors among DCWs

Seven studies investigated the association between unions and employment outcomes, such as worker retention and turnover.^17–23 Four studies focused on nursing homes and staff.^17,19,20,23 Of them, three were observational in design, and one was quasi-experimental. Sojourner et al. used a quasi-experimental regression discontinuity design to isolate the effect of unions on employment levels and productivity among NAs, licensed practical nurses (LPNs), and RNs employed in nursing homes. The authors linked records from the National Labor Relations Board and the Federal Mediation and Conciliation Service to health systems data collected by CMS to ascertain data on union elections, collective bargaining, and unionization status (n = 22,357 facilities). The study also examined individual-level worker outcomes by matching them to the U.S. Census Bureau’s Longitudinal Business Database and Longitudinal Employer-Household Dynamics data. The study found that unionization was associated with reduced staffing in nursing homes but not decreased care quality; the authors conclude that the findings suggest unions boost labor productivity for skilled nurses in nursing homes.¹⁷ Dean et al. focused on the impact of unions on staff turnover among NAs, LPNs, and RNs using national datasets. The authors pair data on nursing home staff turnover from CMS with data from a large healthcare union to get a dataset of 11,417 nursing homes (1,971 of which were unionized); they found that union presence is associated with decreased turnover and that this association is larger when the county-level proportion of unionized nursing homes was high.²³ Berridge et al. used data from the Nursing Home Culture Change survey, which is a nationally representative cross-sectional survey. Their study of 1,386 NAs found that unionization was significantly associated with greater retention in the highest category (91%−100%) compared with the lowest category (0% - 50%) by a factor of 3.85 (CI:1.84–8.05).¹⁹

Three studies focused exclusively on HCWs in the context of employment outcomes.^18,21,22 Using data from a telephone survey of 1,614 Los Angeles-based HCWs, Delp et al. found that union involvement was associated with greater job satisfaction.¹⁸ Banijamali et al. examined the impact of unionization on the retention of HCWs. The authors used healthcare union data and surveyed 402 currently employed HCWs in 2011 and compared them to those who had left the profession. They found that unions increased retention; one possible explanation is that unions offered jobs that have better benefits, wages, hours, and career mobility.²¹ Howes et al used data from CMIPS in California from 2003 (n = 10,574) and found that unions were associated with improved job quality and better benefits among HCWs. The authors also found that unions were associated with higher retention rates.²²

Impact of Unions on DCWs’ occupational health and patient outcomes

The remaining nine studies examined the relationship between unionization and outcomes for workers or patients. Five of the studies focused on worker outcomes, and three focused on patient outcomes.^24–31

Among those that focused on worker outcomes, Pinto et al. conducted a cross-sectional survey of 256 unionized HHAs and attendants in New York, NY, to understand their occupational and health-related experiences providing care to patients during and after COVID-19. They found that nearly a quarter (23%) tested positive for COVID-19 and over three quarters (78%) had to source their own personal protective equipment (PPE) during the pandemic. Notably, two thirds of aides reported struggling with mood and stress, and 10% of aides felt less inclined to remain in the industry because of this experience.²⁴ Delp et al. used a probability sample of 4,350 English and Spanish-speaking home health workers in Los Angeles and found that 40% of the surveyed workers were unable to see a doctor in the past year for financial reasons, 47% found it somewhat or very difficult to pay their bills, and a striking 97% responded that belonging in a union is somewhat or very important to their wellbeing. The authors’ findings suggest that unions help provide the support necessary for home health workers to receive the necessary medical care.³⁰ Schoenfisch et al., Zechter et al., and Quinn et al. characterized the occupational safety concerns of HCAs, homemakers, and HCWs, respectively. For example, Schoenfisch et al. surveyed 43,394 HHAs in Washington state and found, in 2017, that 28.4% of reported injuries led to compensated time off work, with a median cost of $1,868 per claim. When aides took paid leave, the median duration was 122 days (IQR not reported).²⁵ Zechter et al. surveyed 421 unionized HHAs and found, in 1987, that 46% encountered hazards while working in clients’ homes and, compared to the general population, were more prone to musculoskeletal issues such as back problems.²⁵ Quinn et al. surveyed 1249 unionized HCAs in Massachusetts from September 2012 to April 2013. The aides reported that musculoskeletal strain, exposure to potentially infectious agents, and experience of violence were the most frequently occurring hazards that they faced.²⁷ Separate from these studies pertaining to HCWs, Sojourner et al. used national data from 1985 to 2009 to study 22,357 licensed nursing home facilities and their workers. They found that the unionization rate for the nursing home industry has been steadily declining over the past two decades (with the number of nursing homes where workers are covered by union contracts has gone down by ~33%).²⁸ Dean and colleagues, in a quasi-experimental study of 15,291 nursing homes across the 48 continental states, found that unionization positively impacted nursing home compliance with OSHA reporting requirements.³² After adjusting for preexisting trends, they discovered that one year after unionization, nursing homes were 22.1% more likely than nonunion homes to report workplace injuries to OSHA. This likelihood increased to 31.1% two years post-unionization.

Two studies examined unions and patient outcomes in LTC, albeit with different findings. Dean et al. and Olson et al. both examined the association between nursing home unionization and resident (patient) COVID-19 mortality rates. Dean et al. used data from all nursing homes in the US and found that, from 2020 to 2021, labor unions were associated with 10.8 percent lower resident COVID-19 mortality rates (95% CI: 3.9, 17.3; p =0.003) when compared to nonunionized nursing homes. During the same period, labor unions were associated with a 6.8 percent lower worker COVID-19 infection rate (95% CI: 2.7, 10.7; p =0.001) when compared to nonunionized facilities.²⁹ Olson et al. included 15,486 nursing homes from the CMS COVID-19 Nursing Home Data and found no evidence of an association between unionization status and COVID-19 mortality resident rates.³¹

Risk of Bias

Overall, the quality of the studies was fair to poor, with DB quality scores ranging from 10 to 18 with a mean score of 14.7 (SD = 2.37). Eight studies were poor, and 11 studies were fair. Since none of the studies involved interventions or randomized controlled trials, the DB questions pertaining to interventions, losses to follow-up, and randomization were not applicable, bringing down the DB scores. For reporting, about half of the studies (9) did not report actual probability values, five did not provide estimates of random variability in their data, and six did not provide lists of principle confounders. External and internal validity (bias) were also weak areas for these studies. Ten of the studies did not have representative/generalizable samples, and none of the studies were able to blind patients or researchers. More details on individual study limitations are provided in the DB Quality Assessment supplemental file.

Discussion

This systematic review found that, overall, unionization was associated with higher wages and greater benefits for DCWs in the US. Unionization was also associated with improved employment-related outcomes across the workforce, including job satisfaction and retention rates. Within nursing home settings, unionization of the DCW workforce had varying impacts on patient outcomes. In home care, the unionization of DCWs did not appear to improve occupational-related outcomes, including job safety.

Past research on the influence of unionization among providers in the healthcare sector has found that unions are often associated with higher wages, better benefits, and enhanced outcomes for both employees and patients.¹⁰ Specifically, research conducted by Dube and colleagues revealed that hospitals in California with unionized nursing staffs experienced superior performance across twelve patient outcomes, such as infection rates, and morbidity and mortality, compared to facilities without unionized nurses. ¹¹ Moreover, a subsequent study of nurses demonstrated that unionized RNs experienced a lower rate of turnover compared to their nonunion counterparts.¹² These reviews, however, have not focused on DCWs, a growing sector of the healthcare workforce poised to care for millions of older adults in the coming years. Our study fills this gap and advances our understanding of unionizations’ impact on DCWs. Specially, unionization was associated with higher wages, better benefits, and improved retention and job satisfaction. Notably, our findings differ by the type of DCW studies and the setting in which they provided care. For example, we found that unionization improved take-home pay for skilled and unskilled frontline workers in nursing homes. However, for employment-related outcomes (i.e. job quality and staff turnover), only outcomes for unskilled positions appeared to improve as a function of unionization. With respect to the home environment, most studies found that unionization improved economic and employment related outcomes for DCWs.

While our study also highlights the occupational safety concerns that DCW experience, such as infection risk and injuries on the job, it does not demonstrate definitively that unions can serve as consistent buffers for these. Similarly, we found mixed evidence regarding the impact of unionization on COVID-19 infection and mortality rates for patients and DCWs in nursing homes. Notably, no home care studies evaluated the impact of unionization on patient care outcomes, signaling an additional gap in the literature.

It is important to note that most studies included were of fair to poor quality, as assessed by the DB Quality Tool. Key drivers for this include their cross-sectional nature or observational study designs, the use of local, non-representative, or non-weighted samples, and limited assessment of outcomes. Also, most studies did not utilize strong analytic approaches which could account for confounding or clustering. Future studies could build on this work by exploring additional dimensions of employment quality, such as job security, career progression opportunities, and by employing more rigorous methodologies that ideally would allow causality to be established. Currently, no literature exists that examines other aspects of health; future studies should seek to address this by evaluating the impact of unionization on emotional, social, and psychological health. Studies should also further investigate the direct and indirect effects of unionization on patient care quality, particularly in home care settings where there currently is little to no evidence. Research focused on patient care quality should include patient satisfaction, adherence to care plans, and long-term health outcomes to provide a more comprehensive view of the impact of unionization. The role of unionization in advancing policy changes for DCWs, and their patients remains underexplored, and could benefit from quasi-experimental designs. Lastly, our study solely focuses on results from US DCWs. This impacts the generalizability of our findings. Future studies should explore the impact of unions on DCWs in care settings outside of the US.

Informed by our findings, future policy initiatives should consider prioritizing the strength of collective bargaining rights among DCWs to facilitate the enhanced wage and benefits outcomes associated with unionization. Policies should also provide stringent safety standards and facilitate support for training programs that elevate DCW skill sets and improve on-the-job safety. Policymakers should also note the systemic disparities faced by the predominantly middle-aged, female, and people of color workforce and ensure that future policies are inclusive and non-discriminatory.

Conclusion and Implications

This is the first systematic review to characterize and investigate the influence of unionization on DCWs. Our findings suggest that unions offer a promising way to improve job quality for the direct care workforce. However, for the most part, the studies included were not robustly designed. Despite the pressing need to rapidly expand the supply of DCWs, there is a dearth of high-quality research investigating how unionization may be a lever for change and impact jobs in the industry. Additional and more rigorous research is warranted on the potential role unions play in enhancing working conditions for DCWs and their patients.