A UCLA study in JAMA Network Open found unionized direct care workers (DCW) have a 37% turnover rate, compared with 45% for non-unionized workers, potentially saving the healthcare system up to $1.5 billion annually.
“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.”
The study analyzed 18,200 direct care workers from 2009 to 2024, using data from the Current Population Survey. Included were home care aides and hospital and nursing home nursing assistants. The average participant age was 44, and approximately 87% were female. These details provide context for understanding the turnover trends discussed next.
Unionization Tied to Lower Turnover Across Settings
Across the dataset, unionized direct care workers were less likely to leave the workforce than their non-unionized counterparts. This pattern held across different organizational structures, reinforcing the study’s central findings: When comparing employer types overall, 39% of workers in public settings left the workforce compared to 42% in for-profit organizations.
Researchers noted that the consistency of these findings across sectors was unexpected.
“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,” Gusoff said. “However, our findings suggest the turnover reductions associated with unionization are at least as strong at non-profits as at for-profits.”
Workforce Instability Remains a Persistent Challenge
Turnover among direct care workers can reach 40% annually, driven by low pay, high stress, and limited control over working conditions. For nurses and healthcare leaders, this instability affects care continuity, team cohesion, and patient outcomes.
Previous research cited in the study points to alternative workforce models that may improve retention. Home care cooperatives, for example, have shown promise by offering greater worker support, compensation, and involvement in care planning, along with improvements in care quality.
What Comes Next
While the findings highlight a strong association between unionization and workforce retention, researchers caution that the study design limits the ability to establish causation. The analysis relied on cross-sectional and self-reported data and may not account for all variables influencing turnover.
Future research will focus on identifying which factors within unionized environments, including wages, benefits, and worker voice, contribute most to improved retention. Researchers also plan to examine how different ownership models, including worker-owned cooperatives, private equity, and public corporations, affect workforce stability.
“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.
