Unionization and working for a public employer are associated with significantly lower turnover among direct care workers (DCW), a group that provides daily care for older adults and those who are disabled and unable to care for themselves, UCLA-led research suggests.
The findings on the role of DCW unionization, published in the peer-reviewed JAMA Network Open, apply to both for-profit and non-profit organizations, suggesting that unionization can play a significant role in keeping DCWs in the workforce—and save the healthcare system $1.5 billion a year in turnover costs. It can also lead to improvements in care quality due to increased job satisfaction and lower stress.
"Direct care workers provide essential daily care for millions of older adults and people with disabilities, but very high levels of worker turnover make it increasingly difficult for people to receive the consistent care they need," said study lead Dr. Geoffrey Gusoff , assistant professor of family medicine at the David Geffen School of Medicine at UCLA . "Reducing turnover and retaining workers in the direct care workforce is essential for meeting the need for high-quality direct care services."
DCWs in the study included home care workers and nursing assistants at nursing homes and hospitals.
DCWs are currently leaving the caregiving workforce entirely at alarming high rates (up to 40% per year) due to various factors such as low pay, high stress, and lack of control over their work. Previous research led by Gusoff suggests that new strategies are needed to recruit and retain caregivers. One study , for instance, found that home care cooperatives could alleviate the shortage of paid caregivers for older Americans by providing DCWs with greater respect, control, job support, and compensation than their counterparts in traditional care services. Another found that worker input into care planning, co-ownership, selective hiring of high-performing workers, and access to high-quality training spurred improvement in care quality at the cooperatives.
For this new study, Gusoff and his collaborators examined the effect of unionization and employer ownership on DCW retention.
The researchers used turnover data for 18,200 DCWs for the years 2009 to 2024 from the Outgoing Rotation Groups of the Current Population Survey. They compared turnover rates between unionized and non-unionized workers. The average age was 44 years and about 87% of DCWs were female.
They found significantly less turnover at unionized organizations. Here are their key findings:
- Overall, 37% of unionized workers left the DCW workforce compared with 45% of non-unionized workers
- Non-profit organizations saw 34% workforce turnover among unionized DCWs vs. 47% of their non-unionized counterparts
- At for-profit organizations, 35% of unionized workers left the workforce vs 46% of non-unionized workers
- 40% of unionized DCWs in the public sector left compared with 41% of non-unionized workers
- Comparing overall public and for-profit providers, 39% of workers at the former left the workforce, compared with 42% at the for-profits.
The researchers were surprised to find that unionization led to lower turnover at both for-profit and non-profit organizations, Gusoff said.
"Given their mission-orientation and lack of profit-motive, we thought non-profits might have lower DCW turnover and have less of a role for unions," he said. "However, our findings suggest the turnover reductions associated with unionization is at least as strong at non-profits as at for-profits."
Study limitations include the use of cross-sectional data, which researchers say makes it difficult to make causal links, a bias potential stemming from reliance on participant-reported data, and possibly missing variables. There is a need for more research to understand how unionization and ownership improve DCW retention.
"To build on these findings, we plan to study which factors among unionized DCWs, such as wages, benefits, and worker voice, may be contributing to most of the lower rates of workforce turnover," Gusoff said. "After identifying the important role of organizational ownership in turnover, we also plan to explore how specific ownership models -- worker-owned cooperatives, private equity, and public corporations -- impact retention of direct care workers."
Additional co-authors are Heeeun Jan, Daniel Spertus, Kiran Abraham Aggarwal, Ariel Avgar, and Dr. Madeline Sterling of Cornell University.
A Career Development Award from the National Institute on Aging (K01AG088782) supported this study.
