Researchers attributed the maintained quality to potential union-driven gains in worker productivity, including reduced turnover, better training, and improved labor-management coordination.
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.
Dean, Adam, et al. “The Effects of Labor Unions on Nurse Staffing Ratios and Quality of Care in US Nursing Homes, 2013–21.” Health Affairs, vol. 45, no. 3, 2 March 2026. https://doi.org/10.1377/hlthaff.2025.00609
More LPNs, Fewer RNs: Nursing Home Unionization Reshapes Staffing but Not Quality
Researchers said there may be a “substitution effect” happening, where employers replace higher-paid RNs with lower-paid LPNs to offset increased labor costs associated with unionization. Such behavior aligns with economic models in which unions negotiate wages and benefits, while employers manage costs and retain control over staffing decisions.
— Skilled Nursing News, March 17, 2026
Unions Change Nursing Home Staffing Patterns, Not Care Quality: Study
While RN ratios declined, LPN hours increased, and the researchers reported in Health Affairs this week that they found no evidence that unionization had a causal effect on nursing home quality. “Unions do not appear to decrease quality, despite unionization leading to cost-cutting responses that reduce nursing skill mix,” wrote lead researcher Adam Dean, associate professor of political science at GWU.
— McKnight’s Long-Term Care News, March 04, 2026
