Resident Mortality And Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020-21

Empowering Physicians Through Collective Action: A Position Paper From the American College of Physicians

Physicians are increasingly frustrated with the nation's health care system. The erosion of the patient-physician relationship, diminished clinical independence, the mounting burden of administrative tasks, and the growing influence of nonclinicians in the health care system have left many physicians disempowered, demoralized, and burned out. As a result, physicians, most of whom are employed by hospitals, health systems, and other organizations, are exploring collective action to enhance their ability to deliver high-quality care to patients, regain control of their profession, and improve their well-being. In this position paper, the American College of Physicians offers recommendations on how physicians can become effective advocates for their patients and their profession through advocacy, the organized medical staff, responsible collective bargaining, and other means.

What Do Unions Do for Direct Care Workers? Assessing Employment and Economic Outcomes

OBJECTIVES

Our study investigates unionization trends among direct care workers (DCWs) in the United States and examines the association between unionization and their wealth outcomes.

DESIGN

This is a cross-sectional study using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 to 2023.

SETTING AND PARTICIPANTS

Our study is based on US representative household surveys. The sample includes 17,522 DCWs (eg, personal care aides, nursing assistants, home health workers).

METHODS

The prevalence and trend in labor unionization among DCWs and the association between their union status and wealth outcomes (hourly wage, employer-sponsored health insurance, pension plans, and poverty status) were analyzed. Union status identified by formal union membership or coverage by a union without formal membership.

RESULTS

The sample was composed of mostly women (87%); they had a mean age of 41.8 ± 14.5 years, 38.1% were non-Hispanic White, 30.4% were non-Hispanic Black, 21.6% were Hispanic, and 9.9% were Asian and other. Overall, 12% (n = 1850) of DCWs were unionized. The Cox trend test showed decreasing in unionization rates over the study years. In fully adjusted models, unionized DCWs earned more than nonunionized DCWs ($1.2; 95% CI, $0.8-$1.6; P < .001). They were also more likely to have employer-sponsored health care insurance (odds ratio, 2.0; 95% CI, 1.8-2.3; P < .001) and pension plan (odds ratio, 1.8; 95% CI, 1.6-2.0; P < .001), with higher employer's contribution to health insurance ($561.2; 95% CI, $303.1-$819.3; P < .001). Also, unionization was negatively associated with DCWs' poverty status (odds ratio, 0.7; 95% CI, 0.6-0.9; P < .001).

CONCLUSIONS AND IMPLICATIONS

Unionization is an effective means of improving the financial well-being of DCWs, a workforce that is currently facing challenging working conditions and high levels of turnover.

Place-Based Disparities Among Nursing Homes During the COVID-19 Pandemic: A Systematic Literature Review

Introduction

Disasters have disproportionately impacted nursing home (NH) residents. COVID-19 impacted NH more so than the community-dwelling population, but there was much variation in mortality rates among NH residents. These disparities have been studied, but place-based disparities have received less attention. Place-based disparities are differences in health due to physical location, including factors like rurality, local socioeconomic conditions, and the physical environment.

Methods

We searched three databases for peer-reviewed studies of place-based factors associated with mortality in U.S. NHs during the COVID-19 pandemic, ending in January 2024. Data were organized using the National Institute on Minority Health and Health Disparities research framework.

Results

We identified 27 articles that included individual, interpersonal, community, and societal place-based factors associated with mortality during the pandemic. Differences in mortality were related to local community socioeconomic factors, staff neighborhood socioeconomic factors, urbanity, community viral spread, and state-level factors, including political leaning and social distancing policies. Rurality was associated with lower mortality but was also associated with racial disparities.

Discussion

Place-based disparities at the individual, organizational, community, and societal levels were identified. Rurality and local COVID-19 spread were the most commonly studied place-based factors associated with NH deaths during the pandemic. Neighborhood factors may be most impactful through the impact on NH staff. Racial disparities were linked with location, highlighting the effects of historical systemic racism on NHs. Policies to protect NH residents during disasters must be sensitive to local characteristics.

Measures to Prevent and Control COVID-19 in Skilled Nursing Facilities: A Scoping Review

Importance

Skilled nursing facilities (SNFs) experienced high mortality during the COVID-19 pandemic, leading them to adopt preventive measures to counteract viral spread. A critical appraisal of these measures is essential to support SNFs in managing future infectious disease outbreaks.

Objective

To perform a scoping review of data and evidence on the use and effectiveness of preventive measures implemented from 2020 to 2024 to prevent COVID-19 infection in SNFs in the US.

Evidence Review

Two analyses were performed. First, an analysis of the federal COVID-19 SNF Database was conducted to describe time trends in COVID-19 incidence, deaths, testing, vaccination, and treatment among SNF residents and staff, as well as shortages in staff and personal protective equipment (PPE). Then, a comprehensive literature search was conducted from May 2023 to April 2024 to identify high-quality evidence on the use and effectiveness of modifiable preventive measures used among SNF residents. Both nonpharmacologic (facility characteristics, PPE, cohorting, and isolation, visitation, staffing, testing) and pharmacologic (vaccination, treatment) measures were reviewed.

Findings

Nationwide data indicated early shortages of PPE, infrequent testing, and persistent staff shortages in SNFs. Other nonpharmacologic measures, such as visitor restrictions or ventilation modifications, were widely adopted but there were no available national data to quantify their effectiveness. These nonpharmacologic measures lacked high-quality studies to verify effectiveness. In contrast, the effectiveness of vaccination and antiviral treatment was shown in multiple studies. Evidence also showed associations between COVID-19 outcomes in residents and crowding, staff size, hours per residents and networks, and surveillance testing of residents and staff. Despite high initial uptake, up-to-date vaccination status was suboptimal in residents and staff from 2022 to 2024. Only a minority of infected residents received antiviral treatment.

Conclusions and Relevance

This scoping review found that although many preventive measures were implemented in SNFs in the US throughout the COVID-19 pandemic, few were based on clear evidence of their effectiveness. Pharmacologic measures, such as vaccination and antiviral treatment, had more robust evidence supporting their efficacy than nonpharmacologic interventions. Using the scarce resources and staff of SNFs on measures of questionable effectiveness could distract from known effective ones such as vaccination and antiviral treatment. When possible, implementation efforts should be commensurate with the demonstrated effectiveness of available preventive measures.

Solidarity in disaster scholarship

Disaster scholarship purportedly promotes disaster risk reduction and resists disaster risk creation, thereby deeply engaging with transboundary existential risks, justice, and political power. It is thus a commitment to humanity, and for it to become truly equitable and just, solidarity must lie at its heart. In this paper we connect solidarity with knowledge production and assess the implications of disaster scholarship and the relationships on which it is built. We offer a critique of the kind of research produced by neoliberal academic institutions and provocations for resistance through solidarity. We call on disaster scholars to use these prompts to reflect on their practice, research ethics, and their commitment to other human beings, inside and outside of the academy. Solidarity can help scholars to avoid the saviourism, self-congratulation, and paternalism that are common in academia. Solidarity in disaster scholarship is a worthy endeavour precisely because it yields a concrete alternative vision of resisting disaster risk creation through knowledge production.

The Impact of Unions on US Direct Care Workers in Long-Term Care Settings: A Systematic Review

OBJECTIVES

To meet a growing demand for direct care workers (DCWs) in the United States, structural, organizational, and policy-related solutions are needed. Unionization of the workforce may be one such mechanism; however, its impact on outcomes remains poorly understood. To examine the impact of unionization on DCWs' financial well-being and employment attitudes, as well as patient outcomes.

DESIGN

A systematic search of AgeLine, CINAHL, PubMed, Scopus, and Web of Science from database inception through June 20, 2024. We included peer-reviewed empirical studies that used observational, quasi-experimental, and experimental designs.

SETTING AND PARTICIPANTS

Studies pertained to DCWs who provided care in the home and long-term care settings. We focused on studies that illustrated the financial outcomes of DCWs (wages, compensation, benefits), employment outcomes (job satisfaction, turnover), and health-related outcomes of DCWs and their patients.

METHODS

Covidence was used to screen studies for inclusion criteria. Study characteristics were abstracted manually by prespecified domains. The Downs and Black tool was used for quality assessment. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

RESULTS

A total of 19 studies met inclusion criteria; they were predominantly observational (94%), with local (47%) and national (53%) samples. Three studies focused on compensation and all found that unionization was associated with higher wages and benefits among DCWs. 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. Unionized workplaces reported better care quality and safety, including fewer injuries and better equipment provision. Unionization's impact on patient outcomes showed mixed results, particularly among nursing home residents. Overall, the quality of the research studies varied, with limitations in methodology and sampling affecting reliability.

CONCLUSIONS AND IMPLICATIONS

Unionization among DCWs was generally associated with higher wages, benefits, and job satisfaction, as well as reduced turnover; however, its impact on worker and patient outcomes varied across studies. The overall quality of the studies was fair to poor, highlighting the need for more rigorous research in this area.

The relationship between union membership and self-rated health among racially diverse U.S. healthcare workers: The role of control over work schedules and locations

BACKGROUND

Labor unions are associated with better wages, improved working conditions, and greater worker empowerment, which may result in better health. However, less is known about the relationship between unionization and health among U.S. healthcare workers, whether the relationship differs among racially diverse workers, and how much control over workplace schedules and location mediates the relationship.

METHODS

We analyzed a cross-sectional survey of a nationally representative sample of 3000 U.S. healthcare workers collected from March 14 through April 5, 2023. Using ordinal logistic regression, we evaluated whether unionized healthcare workers had better self-rated health (SRH) than their nonunionized counterparts and examined potential differences between White and racially minoritized respondents. We quantified the mediation percentage explained by control over one's schedule and workplace location in the total and stratified samples using Karlson, Holm, and Breen decomposition analysis.

RESULTS

Over a third (36.1%) of racially minoritized respondents were unionized, compared to 22.3% of White respondents. Among racially minoritized workers, a greater share of unionized workers reported excellent health (40.6% vs. 21.8%) than their nonunionized counterparts. In confounder-adjusted ordinal logistic regression analyses, labor union membership was associated with better SRH overall, with a stronger association for racially minoritized workers. Among White healthcare workers, control over workplace arrangements explained 68.1% of the union membership and SRH relationship. For racially minoritized workers, control over workplace arrangements partially mediated the relationship, explaining 17.4% of the variation, suggesting that labor unions may impact health through additional pathways for these workers.

CONCLUSIONS

This study provides empirical evidence of the relationship between labor union membership and health among U.S. healthcare workers. We demonstrate that control over schedules and location is an important mechanism by which unionization may protect healthcare workers' health. Among racially diverse healthcare workers, labor unions may play an important role in health through various pathways beyond workplace control.

The Effect Of Labor Unions On Nursing Home Compliance With OSHA's Workplace Injury And Illness Reporting Requirement

All US nursing homes are required to report workplace injury and illness data to the Occupational Safety And Health Administration (OSHA). Nevertheless, the compliance rate for US nursing homes during the period 2016-21 was only 40 percent. We examined whether unionization increases the probability that nursing homes will comply with that requirement. Using a difference-in-differences design and proprietary data on union status from the Service Employees International Union for all forty-eight continental US states from the period 2016-21, we found that two years after unionization, nursing homes were 31.1 percentage points more likely than nonunion nursing homes to report workplace injury and illness data to OSHA. Data on injuries occurring in specific workplaces play a central role in injury prevention. Further unionization could help improve workplace safety in nursing homes, a sector with one of the highest occupational injury and illness rates in the US.

Nursing homes and mortality in Europe: Uncertain causality

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing.

Trends in Labor Unionization Among US Health Care Workers, 2009-2021

IMPORTANCE

Labor unionization efforts have resurged in the US, and union membership has been shown to improve worker conditions in some industries. However, little is known about labor unionization membership and its economic effects across the health care workforce.

OBJECTIVES

To examine the prevalence of labor unionization among health care workers and its associations with pay, noncash benefits, and work hours.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using data from the Current Population Survey and Annual Social and Economic Supplement from 2009 through 2021. The US nationally representative, population-based household survey allowed for a sample of 14 298 self-identified health care workers (physicians and dentists, advanced practitioners, nurses, therapists, and technicians and support staff).

EXPOSURES

Self-reported membership status or coverage in a labor union.

MAIN OUTCOMES AND MEASURES

Prevalence and trend in labor unionization. Further comparisons included mean weekly pay, noncash benefits (pension or other retirement benefits; employer-sponsored, full premium-covered health insurance; and employer's contribution to the worker's health insurance plan), and work hours.

RESULTS

The 14 298 respondents (81.5% women; 7.1% Asian, 12.0% Black, 8.5% Hispanic, 70.4% White individuals; mean [SD] age, 41.6 [13.4] years) included 1072 physicians and dentists, 981 advanced practitioners, 4931 nurses, 964 therapists, and 6350 technicians and support staff. After weighting, 13.2% (95% CI, 12.5% to 13.8%) of respondents reported union membership or coverage, with no significant trend from 2009 through 2021 (P = .75). Among health care workers, those who were members of a racial or ethnic minority group (Asian, Black, or Hispanic individuals compared with White individuals) and those living in metropolitan areas were more likely to report being labor unionized. Reported unionization was associated with significantly higher reported weekly earnings ($1165 vs $1042; mean difference, $123 [95% CI, $88 to $157]; P < .001) and higher likelihood of having a pension or other retirement benefits at work (57.9% vs 43.4%; risk ratio [RR], 1.33 [95% CI, 1.26 to 1.41]; P < .001) and having employer-sponsored, full premium-covered health insurance (22.2% vs 16.5%; RR, 1.35 [95% CI, 1.17 to 1.53]; P < .001). Union members reported more work hours (37.4 vs 36.3; mean differences, 1.11 [95% CI, 0.46 to 1.75]; P < .001) per week. White workers reported mean weekly earnings that were significantly more than members of racial and ethnic minority groups among nonunionized workers ($1066 vs $1001; mean difference, $65 [95% CI, $40 to $91]; P < .001), but there was no significant difference between the 2 groups among unionized workers ($1157 vs $1170; mean difference, -$13 [95% CI, -$78 to $52]; P = .70).

CONCLUSIONS AND RELEVANCE

From 2009 through 2021, labor unionization among US health care workers remained low. Reported union membership or coverage was significantly associated with higher weekly earnings and better noncash benefits but greater number of weekly work hours.

Comparison of resident COVID-19 mortality between unionized and nonunionized private nursing homes

Using bargaining agreement data from the Federal Mediation Conciliation Services, we found that the median national resident COVID-19 mortality percentage (as of April 24, 2022) of unionized nursing homes and that of nonunionized ones were not statically different (10.2% vs. 10.7%; P = 0.32). The median nursing home resident COVID-19 mortality percentage varied from 0% in Hawaii to above 16% in Rhode Island (16.6%). Unionized nursing homes had a statistically significant lower median mortality percentage than nonunionized nursing homes (P < 0.1) in Missouri, and had a higher median mortality percentage than nonunionized nursing homes (P < 0.05) in Alabama and Tennessee. Higher average resident age, lower percentage of Medicare residents, small size, for-profit ownership, and chain organization affiliation were associated with higher resident COVID-19 mortality percentage. Overall, no evidence was found that nursing home resident COVID-19 mortality percentage differed between unionized nursing homes and nonunionized nursing homes in the U.S.

Gender, Race/Ethnicity, and Unionization in Direct Care Occupations

Objectives. The goal of this study was to measure unionization in the direct care workforce and the relationship between unionization and earnings, looking closely at differences across race/ethnicity and gender. Methods. Using data from the Current Population Survey from 2010 to 2020, we first used logit analyses to predict the probability of unionization among direct care workers across race/ethnicity and gender. We then measured the relationship between unionization and weekly earnings. Results. We found that male (12%) and Black (14%) direct care workers were most likely to be unionized, followed by Hispanic and other direct care workers of color. Unionized direct care workers earn wages that are about 7.8% higher than nonunionized workers, but unionized workers of color earn lower rewards for unionization compared with White direct care workers. Conclusions. Unions are a mechanism for improving job quality in direct care work, and protecting workers' rights to unionize and participate in collective bargaining equitably may be a way to stabilize and grow the direct care workforce. (Am J Public Health. 2022;112(11):1676-1684. https://doi.org/10.2105/AJPH.2022.307022).