Los Angeles, California — A nursing home’s staffing crisis often gets blamed on wages, burnout, or short-staffed shifts. But a new study says two structural factors — union membership and public sector ownership — may do more to keep frontline workers in place than any individual retention bonus ever could.
The research, published this week in JAMA Network Open, examined direct care workers across nursing homes, home health settings, and hospitals using data from the Current Population Survey. The findings: workers who are unionized leave their jobs at meaningfully lower rates. Workers employed at publicly owned facilities leave at even lower rates. And workers who are both unionized and employed in public sector settings? They had the lowest turnover of all.
“Employer ownership status and unionization were independently and jointly associated with DCW workforce turnover rates, suggesting that these structural factors may play an important role in DCW retention,” wrote the study authors, led by Geoffrey M. Gusoff, MD, of UCLA.
Why This Matters for Nursing Homes
Turnover among certified nursing assistants and other direct care workers has been a defining challenge for skilled nursing facilities for years. Facilities spend thousands of dollars per worker to recruit, hire, and train replacements — and even then, a new hire often leaves within a year. That cycle drives up costs, disrupts resident relationships, and erodes care quality.
The study’s authors argue the problem isn’t just about pay — it’s about the underlying structure of how workers are employed. Public employers tend to offer more stable job conditions, stronger benefit packages, and clearer paths for advancement. Unions, meanwhile, give workers collective leverage to negotiate better wages and working conditions, which the study found translates directly into staying on the job longer.
The researchers used a cross-sectional design, analyzing data on a broad workforce that includes home health aides, certified nursing assistants, and personal care aides — the same workers nursing facilities depend on daily. The findings build on earlier research showing that unionization in nursing homes reshapes staffing patterns in complex ways, and add new weight to the argument that structural policy changes — not just hiring bonuses — may be the more durable fix.
Policy Implications
The authors say their findings point toward specific legislative interventions. State and federal policies that make it easier for direct care workers to organize — or that expand public sector employment models for this workforce — could significantly reduce turnover rates industry-wide.
That’s a significant claim at a time when nursing homes are operating under intense staffing pressure. Federal staffing mandates have been challenged, rescinded, and reintroduced by competing congressional factions. Medicaid reimbursement cuts loom in multiple states. And operators are warning that without financial support, they can’t afford the wages it takes to compete for workers.
This study suggests another piece of the equation: workers don’t just want more money. They want stability — the kind that comes from collective agreements and employment structures that don’t shift with each new administrator.
The study was published April 2, 2026, in JAMA Network Open (doi: 10.1001/jamanetworkopen.2026.4636). Public comments on related CMS staffing proposals are due June 1, 2026.
