The Effects Of Labor Unions On Nurse Staffing Ratios And Quality Of Care In US Nursing Homes, 2013-21

Labor unions representing workers in US nursing homes bargain for higher wages and safer working conditions, which may reduce staff turnover and increase the quality of care. However, if higher labor costs lead employers to reduce nurse staffing, unionization may reduce care quality. We used a difference-in-differences event study design to estimate the effects of unionization on nurse staffing ratios for total nurse staffing and separately for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs), as well as the effects of unionization on the quality of care, during the period 2013-21. We found that unionization had no effect on total nurse staffing levels but had opposing effects on RNs and LPNs. Unionization increased LPN staffing by roughly 2.7 nurse hours per day in the average nursing home, but it decreased RN staffing by roughly 3.2 nurse hours per day. Despite this substitution from RNs to LPNs, we found that unionization did not appear to reduce the quality of care, a result consistent with unions increasing nurse productivity.