The Impact of Unions on US Direct Care Workers in Long-Term Care Settings: A Systematic Review

Objectives

To meet a growing demand for direct care workers (DCWs) in the United States, structural, organizational, and policy-related solutions are needed. Unionization of the workforce may be one such mechanism; however, its impact on outcomes remains poorly understood. To examine the impact of unionization on DCWs’ financial well-being and employment attitudes, as well as patient outcomes.

Design

A systematic search of AgeLine, CINAHL, PubMed, Scopus, and Web of Science from database inception through June 20, 2024. We included peer-reviewed empirical studies that used observational, quasi-experimental, and experimental designs.

Setting and Participants

Studies pertained to DCWs who provided care in the home and long-term care settings. We focused on studies that illustrated the financial outcomes of DCWs (wages, compensation, benefits), employment outcomes (job satisfaction, turnover), and health-related outcomes of DCWs and their patients.

Methods

Covidence was used to screen studies for inclusion criteria. Study characteristics were abstracted manually by prespecified domains. The Downs and Black tool was used for quality assessment. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

Results

A total of 19 studies met inclusion criteria; they were predominantly observational (94%), with local (47%) and national (53%) samples. Three studies focused on compensation and all found that unionization was associated with higher wages and benefits among DCWs. Seven studies focused on employment, finding that unionization was associated with greater job satisfaction, quality, and retention, particularly among nursing home staff and home health aides. Unionized workplaces reported better care quality and safety, including fewer injuries and better equipment provision. Unionization's impact on patient outcomes showed mixed results, particularly among nursing home residents. Overall, the quality of the research studies varied, with limitations in methodology and sampling affecting reliability.

Conclusions and Implications

Unionization among DCWs was generally associated with higher wages, benefits, and job satisfaction, as well as reduced turnover; however, its impact on worker and patient outcomes varied across studies. The overall quality of the studies was fair to poor, highlighting the need for more rigorous research in this area.