Unionization, Ownership Status, and Direct Care Worker Turnover

Importance: Direct care workers (DCWs) provide essential support for millions of older individuals in the US, but high workforce turnover-the rate at which workers leave the DCW workforce-undermines care access and quality. Structural factors associated with DCW working conditions, such as unionization and employer ownership status, may play an important role in DCW retention, but their association with DCW workforce turnover is not known. Objective: To assess the association of unionization and ownership with workforce turnover among DCWs. Design, Setting, and Participants: Data on DCW turnover for this cross-sectional study were obtained from the Outgoing Rotation Groups of the Current Population Survey, an annual survey of 60 000 US households, from January 1, 2009, to December 31, 2024. The study population included individuals aged 15 years or older who were employed as DCWs. Exposures: Unionization (whether the respondent was covered by a union through their DCW role) and employer ownership status (whether their employer was for profit, nonprofit, or publicly owned). Main Outcomes and Measures: The main outcome of interest was workforce turnover at 1 year, defined as reporting a non-DCW occupation or no occupation 1 year after the initial survey. Bivariate analyses and logistic regression were used to compare DCW turnover rates across union status and employer ownership type and test whether ownership type moderates the association between unionization and turnover. Results: The overall sample included 18 175 DCWs (mean [SD] age, 44.0 [14.7] years; 15 860 female DCWs [86.5%]). In the fully adjusted models, the estimated probability of turnover was significantly lower among unionized DCWs than nonunionized DCWs overall (37.4% vs 45.0%; odds ratio [OR], 0.72 [95% CI, 0.64-0.81]), at nonprofit organizations (33.6% vs 47.1%; OR, 0.56 [95% CI, 0.39-0.80]) and at for-profit organizations (35.2% vs 45.9%; OR, 0.63 [95% CI, 0.54-0.75]), but not at public employers (39.8% vs 41.0%; OR, 0.95 [95% CI, 0.78-1.16]). Public ownership was also directly associated with lower turnover (39.1% vs 41.8%; OR, 0.89 [95% CI, 0.80-1.00]) compared with for-profit ownership. Conclusions and Relevance: In this cross-sectional study of DCWs, 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. State and federal policies that facilitate DCW unionization or public employment of DCWs may significantly improve DCW retention.