While unionization in nursing homes drastically changed staffing patterns in the sector, it didn’t measurably affect overall care quality. In reality, the union effect on care quality is more nuanced – unions don’t appear to harm care quality but they’re not improving it either, mostly due to cost-cutting responses from management.
Following unionization, nursing homes increased their use of licensed practical nurses (LPNs), with staffing ratios rising by 0.34 hours per resident day, or 4.2%, six years after staff joined a union. It’s a small but meaningful increase in the total LPN hours per day by 2.7 hours, according to a study published in Health Affairs, which examined the effects of unionization in nursing homes for nearly a decade, between 2013 and 2021.
Meanwhile, registered nurse (RN) staffing declined by 0.041 hours per resident day on average, or 9.1%, the study found. On average, RN hours per resident dropped noticeably, further emphasizing a shift in workforce composition. Researchers said there may be a “substitution effect” happening, where employers replace higher-paid RNs with lower-paid LPNs to offset increased labor costs associated with unionization.
In an average-size nursing home of 79 residents, this substitution translates to a drop in 3.2 RN hours per day, researchers found. Such behavior aligns with economic models in which unions negotiate wages and benefits, while employers manage costs and retain control over staffing decisions.
“Previous research has shown that nursing homes adjust their staffing mix in response to other financial pressures, such as the switch to the Medicare prospective payment system,” researchers noted.
There’s a tension between labor gains and employer strategies to control expenses, they said, limiting potential improvement in care. Regulations to establish minimum RN staffing levels could curb employers reducing skilled nursing staff in response to unionization, according to the study, with a reference to the defunct federal staffing rule.
The federal rule, which would have set a minimum RN staffing threshold, would have restricted many facilities from cutting RN hours, researchers said. But similar policies in the future might help ensure efforts to manage costs doesn’t undermine care quality.
And as for care quality, there wasn’t a meaningful difference one way or another, despite prior research linking higher RN staffing levels to better care quality.
Researchers said little change in care quality due to unionization could come down to how unions improve workplace conditions in other ways: reducing staff turnover, enhancing training and improving coordination between workers and management.
Union advocacy for safety standards may have helped prevent declines in care quality too, despite changes in staffing mix.
Companies featured in this article:
Centers for Medicare & Medicaid Services, CMS, Health Affairs
