A groundbreaking new study led by researchers at UCLA reveals that unionization plays a critical role in reducing turnover rates among direct care workers (DCWs), a workforce segment that provides essential daily assistance to older adults and individuals with disabilities. Published in the peer-reviewed journal JAMA Network Open, the research highlights how union membership, regardless of the ownership status of the employing organization, significantly enhances worker retention. This insight carries profound implications for healthcare systems striving to maintain a stable workforce amid rising demand for caregiving services.
Direct care workers are indispensable to the fabric of long-term care. Their responsibilities encompass tasks vital for the well-being and dignity of millions, including personal hygiene assistance, medication management, and emotional support. Yet, despite their importance, DCWs are among the most transient workers in the healthcare ecosystem, with turnover rates that can reach an alarming 40 percent annually. High turnover disrupts continuity of care, burdens healthcare providers with replacement costs, and diminishes the quality of life for care recipients. This phenomenon demands urgent, evidence-based solutions.
The UCLA-led investigation meticulously analyzed labor market data spanning from 2009 to 2024, obtained from the Outgoing Rotation Groups of the Current Population Survey. This dataset included information on approximately 18,200 DCWs, with an average age of 44 years and a demographic composition prominently featuring women at 87 percent. Employing rigorous statistical techniques, the team compared tenure and attrition patterns between unionized and non-unionized DCWs across multiple care settings, including home care agencies, nursing homes, and hospitals.
Results from this extensive analysis confirmed a robust association between union membership and lower turnover rates across all types of organizations — for-profit, non-profit, and public sector employers. Specifically, unionized direct care workers exhibited a 37 percent departure rate from the workforce compared to 45 percent among their non-unionized peers. This trend was evident even in non-profit agencies, where unionized DCWs had a markedly lower turnover rate of 34 percent versus 47 percent for non-unionized staff. Likewise, for-profit organizations saw a significant decrease, with 35 percent turnover among unionized workers compared to 46 percent among those not unionized.
Surprisingly, the study found minimal difference in turnover rates between public sector unionized and non-unionized workers, with figures standing at 40 and 41 percent respectively. Nonetheless, overall workforce retention was better in public sector settings relative to for-profit providers, with 39 percent turnover in the former compared to 42 percent in the latter. These nuances underscore the complexity of factors influencing DCW retention and suggest that ownership status interacts with unionization in multifaceted ways.
One of the most compelling aspects of this research lies in its challenge to preconceived notions about non-profit organizations. Traditionally viewed as more mission-driven and less commercially oriented, non-profits were expected to inherently foster greater worker stability, rendering the role of unions less impactful. Contrary to this assumption, the data demonstrated that unionization’s positive impact on retention is as pronounced in non-profits as it is in for-profit establishments. This finding invites a reevaluation of workforce management strategies across different ownership models.
The high turnover rates among DCWs are driven by a constellation of workplace challenges, including low wages, demanding workloads, emotional stress, and limited autonomy over daily tasks. Previous research by the same research group underscored innovative models such as home care cooperatives, which empower workers through shared ownership, enhanced job control, and better access to benefits and training. These cooperative structures were shown to improve both job satisfaction and care quality, exemplifying alternative pathways for addressing worker retention beyond traditional employer-employee frameworks.
While the current study confirms the benefits of unionization, it also hints at the underlying mechanisms that warrant deeper exploration. For instance, union representation may improve wages, enhance benefits, increase bargaining power, and elevate worker voice in care planning and organizational decisions, all of which can mitigate burnout and foster loyalty. The researchers acknowledge the limitations inherent in their cross-sectional design and reliance on self-reported data, which restrict causal inferences and may omit critical variables affecting workforce dynamics.
Dr. Geoffrey Gusoff, the study’s principal investigator and assistant professor of family medicine at UCLA’s David Geffen School of Medicine, emphasized the essential nature of retaining direct care workers amid escalating demand driven by an aging population. He noted that “consistent, high-quality care hinges on a stable workforce, and reducing turnover is paramount in this endeavor.” Future research efforts by the team aim to dissect the specific attributes of unionized work environments—such as compensation structures, benefits, and governance models—that most significantly contribute to improved retention.
The study also sets the stage for investigating how distinct ownership forms, including worker-owned cooperatives, private equity-backed firms, and public corporations, influence labor stability. Such analysis could offer critical insights for policymakers and care providers seeking sustainable frameworks in a sector characterized by rapid demographic changes and chronic labor shortages. Moreover, understanding these nuances could inform legislative and regulatory approaches to better support the direct care workforce.
This seminal research was made possible through funding from the National Institute on Aging, reflecting the urgent public health priority associated with long-term care workforce sustainability. Co-authors, including Heeeun Jan, Daniel Spertus, Kiran Abraham Aggarwal, Ariel Avgar, and Madeline Sterling from Cornell University, collaborated closely with Dr. Gusoff to deliver a comprehensive epidemiological assessment of unionization’s role in a pivotal yet vulnerable occupational segment.
In sum, the findings illuminate the critical function of labor unions in stabilizing a workforce essential to elder care and disability services. They challenge institutional preconceptions about non-profit versus for-profit care delivery models and point toward nuanced policy interventions aimed at reducing DCW turnover. By highlighting the financial, operational, and qualitative benefits of unionized workplaces, the study contributes a vital perspective to ongoing debates on healthcare workforce reforms in the United States.
The study’s implications resonate beyond immediate clinical settings, suggesting that strengthened labor protections and participatory governance may be essential strategies not only to retain direct care workers but also to elevate caregiving quality system-wide. As the healthcare sector grapples with historic workforce challenges, embracing such evidence-based approaches could ultimately safeguard the dignity and health of millions reliant on direct care services.
Subject of Research: People
Article Title: Unionization, Ownership Status, and Direct Care Worker Turnover
News Publication Date: 2-Apr-2026
Web References:
- Article DOI: 10.1001/jamanetworkopen.2026.4636
References:
- Gusoff, G., Jan, H., Spertus, D., Aggarwal, K. A., Avgar, A., & Sterling, M. (2026). Unionization, Ownership Status, and Direct Care Worker Turnover. JAMA Network Open.
Keywords: Direct Care Workers, Unionization, Workforce Turnover, Elder Care, Disability Services, Labor Unions, Health Workforce Retention, Non-Profit Organizations, For-Profit Organizations, Public Sector, Care Quality, Worker Cooperatives
