Unions help prevention worker turnover
By University
of California, Los Angeles
Edited by Gaby Clark, reviewed
by Robert Egan
The findings on the role of DCW unionization, published in the peer-reviewed JAMA Network Open, apply to both for-profit and nonprofit organizations, suggesting that unionization can play a significant role in keeping DCWs in the workforce—and save the health care 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.
Why direct care worker turnover matters
"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.
Key retention findings by sector
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
- Nonprofit
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 nonprofit organizations, Gusoff said.
"Given their mission-orientation and lack of
profit-motive, we thought nonprofits 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
nonprofits as at for-profits."
Study limitations and next research steps
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.
Publication details
Geoffrey M. Gusoff et al, Unionization, Ownership Status,
and Direct Care Worker Turnover, JAMA Network Open (2026). DOI:
10.1001/jamanetworkopen.2026.4636
Journal information: JAMA Network Open
