Union representation is linked to a significant reduction in nursing home staff turnover, according to a first-of-its-kind research letter published Friday in JAMA Network Open.

Among the 17.3% of nursing homes that were unionized in 2021, researchers found a 3.2% relative drop in turnover. In counties where more than 75% of nursing homes were unionized, the effect was a 17.1% reduction.

“Unions fight to make jobs better for workers, and that could mean higher wages and better benefits, safer working conditions … infection control policies, PPE and protection from COVID-19 during the pandemic,” said Adam Dean, PhD, associate professor in the Department of Political Science at George Washington University. “So in all the ways that unions fight to make jobs better, we would expect workers to stay in those jobs because they’re better jobs.”

“I don’t think there’s anything particularly surprising about this,” Dean told McKnight’s Long-Term Care News Thursday. “That being said, there hadn’t been previous studies of the determinants of nursing staff turnover in US nursing homes because of data issues.”

The study is the first to compare turnover at union and non-union facilities, thanks in part to the Centers for Medicare & Medicaid reporting its first full year of total nurse staffing turnover for 2021. Data indicating union presence in facilities was supplied by the SEIU, the nation’s largest representative of nursing home workers. Dean said the total number of nursing homes with union representation (just under 2,000) includes workers represented by other labor organizations as well.

In addition to union presence, the paper also reviewed the link between several other factors and turnover. Dean and his colleagues also found that higher Five-Star ratings drove down turnover (with 5-star facilities having the strongest positive effect). Being a for-profit nursing home or part of a chain, however, was associated with a negative effect, or higher turnover.

The competition matters

A union reduced turnover about 1.7 percentage points from the 52.6% mean rate nationwide, and 9.0 percentage points in counties with more than 75% of facilities represented by a union, the study showed.

That’s because there’s naturally less reluctance from management about competing with non-unionized facilities in a “race to the bottom,” Dean said.

“That background pressure from non-union nursing homes, when that goes away, the results suggest that unions at the nursing home level are much more successful in getting the things that they’re fighting for,” he added. And that ultimately translates into higher retention.

Dean said those findings were especially important given the context around staffing minimums, which unions have been broadly and vigorously supporting. 

“If employers can come to unions as a partner in this, then there’s also an argument for  broader acceptance of unionization throughout the nursing home industry as way of raising the floor throughout the industry in a way that could be beneficial for workers, for employers in terms of staff turnover, and especially for residents,” he said.

The administration has already embraced more union influence in the workplace, promulgating at least two rules that would give unions a louder voice in nursing homes. 

The proposed staffing mandate calls for potential union representation in the facility assessment process, which would determine how many and what types of staff are needed based on resident acuity. And a recent Department of Labor proposal would allow outside union officials to participate in Occupational Safety and Health Administration inspections at workplaces that are not already unionized. 

Staffing mandate implications

The federal staffing proposal also calls for higher hourly care requirements among certified nurse aides and registered nurses. It does not specify an amount of hourly care to be provided by licensed practical nurses.

Notably, Dean’s research found that a better RN staffing ratio lowered average nurse turnover by about 1.2 percentage points, while a higher ratio of LPNs on staff increased turnover by nearly 1.4 points.

Deant’s previous research has found higher compliance with safety standards among unionized nursing homes and better COVID outcomes in unionized nursing homes. 

He said he plans to continue his current line of research and hopes to monitor for trends in both union representation in nursing homes and its effect on turnover as CMS turnover data becomes available for later years.

One consideration that will be important, he noted, was the fact that 2021 was a peak year for COVID, and unionization may have led employees in some facilities to stay because they felt safer. While acknowledging that having that baseline for the research was a limitation, he also said it made the case for union strength improving retention.

Other authors on the study were Jamie McCallum, PhD, of Middlebury College; Atheendar Venkataramani, PhD, of the University of Pennsylvania;  and David Michaels, PhD, of George Washington University.