Do Nursing Unions Improve Patient Outcomes? Evidence from CMS Quality Data

• In Event: Supply-Side Healthcare Policies: Effects on Entry, Access, and Quality

Abstract

Because nurses heavily influence the provision of health care in hospital settings, the nursing workforce can be key in affecting healthcare quality. Election of nursing unions present a hospital-level shock to the nursing workforce which could alter care provision and patient outcomes. This study examines the effects of nursing unionization on hospital performance, focusing on nurse-sensitive patient health and satisfaction outcomes. I also explore possible mechanisms behind my findings, including nurse staffing and travel to full-time staff ratios. I construct a panel dataset of U.S. short-term acute care hospitals from 2005 to 2021 using publicly available data from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare, the Healthcare Cost Reporting Information System (HCRIS), and county-level Area Health Resource Files (AHRF). To estimate the effects of successful nursing union elections, I apply difference-in-differences models that account for staggered unionization timing (Callaway & Sant’Anna, 2021). 

I find a statistically significant improvement in patient satisfaction with nurse communication following a successful nursing union election. Specifically, satisfaction increases by 4.15 percentage points (95% CI: 2.82, 5.47; p < 0.001), representing a 13.2% improvement relative to baseline pre-treatment levels. In contrast, effects on nurse-sensitive patient health outcomes, including central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), are statistically insignificant (CLABSI: -0.104, 95% CI: -0.44, 0.23; p = 0.542 | CAUTI: 0.092, 95% CI: -0.14, 0.32; p = 0.447). 

Exploratory analyses suggest that staffing conditions may condition union effects. For example, each additional nurse per hospital bed is associated with a reduction in CLABSI incidence (-0.043 percentage points, 95% CI: -0.09, 0.00; p = 0.10). This finding is marginally significant, but may support the hypothesis that reduced nurse workloads improve patient care. Higher ratios of contract to full-time staff yield mixed results, with suggestive improvements in patient satisfaction for medication explanation and prompt help, though estimates remain imprecise.  

These findings contribute to the literature on labor unions and organizational performance by highlighting the role of worker empowerment in improving service delivery. Specifically, unionization appears to enhance nurse job performance through improved communication with patients, an aspect of care closely tied to workload and working conditions. However, the mechanisms underlying these effects, particularly staffing dynamics, remain somewhat ambiguous. Further research is needed to explore causal pathways and evaluate longer-term implications of nursing unionization for patient health outcomes. 

Author

• Victoria Elizabeth Bethel, University of Georgia
  Presenting Author