CAROW Examines How Unions Can Help Direct Care Workers
Unionized direct care workers – personal care aides, nursing assistants and home health care workers – are likely to earn more money and are more likely to have employer-sponsored health care insurance and pension plans than non-unionized direct care workers. Unionization was also associated with greater job satisfaction, and unionized workplaces reported better care, quality and safety for their workers.
These findings come from a pair of published papers, part of a series being released by the CAROW Initiative on Home Care Work, a partnership between the ILR School, Weill Cornell Medicine, and Cornell Tech that conducts research at the intersection of work, the home and long-term care workforce, health and health care delivery, and technology.
“More and more people want to age in place, and we need a sustainable workforce to be able to support them,” said Madeline Sterling, A&S ’08, MD, MPH, MS, associate professor of medicine at Weill Cornell Medicine and Director of the Initiative on Home Care Work. “Our team is looking at the factors that impact direct care workers and that will allow them to keep doing this work while being well compensated with a high degree of job satisfaction.
“Because our Initiative is comprised of scholars from all three campuses, we are able to bring together this focus on labor and health to ask questions about the workforce that haven’t been asked or answered in a rigorous way. And these two papers are setting the stage for us to do this on a bigger scale.”
In addition to Sterling, the research team that conducted these two studies consisted of Ariel Avgar, Ph.D. ’08, the David M. Cohen ’73 Professor of Labor Relations at ILR School, Russell Weaver, director of research at the Cornell ILR Buffalo Co-Lab, Daniel Spertus, assistant research coordinator at Weill Cornell Medicine, Joanna Bryan Ringel, data analyst at Weill Cornell Medicine, Heeeun Jang, post-doctoral associate at the ILR School, Andy Hickner, assistant librarian at Weill Cornell and ILR undergraduates Kiran Abraham-Aggarwal ’25 and Joseph Spak ’25.
“These two papers – the systematic literature review on the one hand, and then our analysis of Current Population Survey, a national dataset on the other – really give us a better, clearer sense of how unions impact working conditions and outcomes for workers in health care, and specifically low-wage direct care workers,” said Avgar, Director of CAROW and Senior Associate Dean for Outreach and Sponsored Research at ILR.
The paper “The Impact of Unions on US Direct Care Workers in Long-Term Care Settings: A Systematic Review” was published in the Journal of the American Medical Directors Association on September 3.
Led by Abraham-Aggarwal, it is a literature review of 19 studies pertaining to direct care workers and focusing on the financial outcomes (wages, compensation, benefits), employment outcomes (job satisfaction, turnover), and health-related outcomes of direct care workers and their patients.
Their findings showed that of the three studies focused on compensation, all three found that unionization was associated with higher wages and benefits. 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. Additionally, unionized workplaces reported better care quality and safety, including fewer injuries and better equipment provision.
The research also found that unionization's impact on patient outcomes showed mixed results, particularly among nursing home residents.
“There's an emerging and relatively robust body of literature on what unions do in health care, but they often look at higher wage workers, such as nurses and physicians,” Avgar said. “What we know less about, and that's the area that we're trying to fill in, is, what do unions do for direct care workers? And how do they help us recruit and retain a skilled, strong workforce? Our goal is to better understand what unions do, not just for doctors and nurses but also for frontline direct care workers, because we are having a tremendously difficult time getting people to join these occupations.”
The second paper, “What Do Unions Do for Direct Care Workers? Assessing Employment and Economic Outcomes,” was published in the Journal of the American Medical Directors Association on December 18.
Led by Jang, the researchers analyzed a sample size of 17,522 direct care workers in the United States and found that unionization among direct care workers was associated with greater take-home pay, employer-sponsored health care and pension plan benefits, and lower levels of poverty, compared to direct care workers who did not belong to a union.
The findings of these two studies show the important role that unions can play in improving working conditions, as well as curtailing the high turnover rate, ultimately contributing to stabilizing the direct care workforce amid a dramatic increase in demand for care.
“For both of these papers, the glass half full is that unions can have a positive effect on workers, and specifically on a group of workers that we desperately need,” Avgar said. “We need these jobs to be better, and unions can help us do that. That's the glass half full. However, clearly, unions can do more or can think about strategies that do more to represent these workers who are often invisible and neglected, not just by employers but by society at large.”