There’s a common assumption in long-term care: more union power means better staffing, and better staffing means better care. A new study out of Health Affairs complicates that story considerably.
Researchers who tracked unionization trends in nursing homes over nearly a decade — from 2013 through 2021 — found that while unions reshaped how facilities staff their floors, they didn’t move the needle on care quality. What they did do, it turns out, is accelerate a quiet substitution that management has been running for years: swapping out registered nurses for licensed practical nurses to manage rising labor costs.
The Substitution Effect
Six years after workers voted to unionize, nursing homes saw LPN staffing ratios climb by 0.34 hours per resident day — roughly a 4.2% increase, translating to about 2.7 additional LPN hours per day in an average-sized facility. Meanwhile, RN hours dropped by 0.041 hours per resident day, or about 9.1% — a loss of 3.2 RN hours daily at an average-sized home of 79 residents.
Researchers say the explanation isn’t complicated. When unions successfully negotiate higher wages and benefits, management responds by protecting its margins. RNs cost more. LPNs cost less. The math writes itself.
“Previous research has shown that nursing homes adjust their staffing mix in response to other financial pressures,” the study noted, pointing to how facilities previously reshuffled staff after the switch to Medicare’s prospective payment system.
No Meaningful Impact on Care Quality
Despite the shift in staffing mix, the study found no meaningful change in care quality outcomes — either for better or worse. That finding might seem reassuring, but the researchers caution against reading it as good news.
The problem, they argue, is what isn’t happening. Prior research has consistently linked higher RN staffing levels to better resident outcomes — fewer hospitalizations, fewer pressure wounds, lower mortality. When RN hours shrink, even incrementally, the potential upside of unionization gets neutralized.
There’s a tension baked into the system: unions push for better conditions, but employers push back on cost. Residents end up in a kind of stalemate — not worse off, but not better either.
Unions may offset some of the quality decline through other channels, researchers said — reduced staff turnover, stronger training, better coordination between workers and management, and advocacy for safety standards that keep problems from getting worse.
The Staffing Mandate Question
The study lands at a moment when federal staffing requirements are very much in flux. The researchers flagged the now-defunct federal staffing rule — which would have set minimum RN thresholds — as the kind of policy that could have prevented facilities from pulling back on skilled nursing staff even after unionization.
Without a floor on RN hours, facilities have room to maneuver. And based on this data, they’re using it.
The findings add another layer to an ongoing debate about how the industry is meeting — or not meeting — its staffing obligations. Federal and state authorities have taken increasingly aggressive stances on staffing enforcement in recent months. The Biden-era federal staffing push invested more than $200 million into workforce development campaigns, recognizing that the pipeline problem runs deeper than any single regulation can solve.
The researchers suggested future policy should consider not just minimum staffing totals, but the composition of those totals — specifically, whether RN hours are being quietly drained by cost-management decisions that happen to look fine on paper.
It’s a finding worth watching. Unions may win better pay and safer conditions for workers. But if operators respond by replacing the most clinically skilled nurses with lower-cost alternatives, residents could end up paying a price that never shows up in a star rating.
