Unionization in Healthcare: Examining Working Conditions and Worker Outcomes in Hospital Settings

Background and Purpose: Healthcare unions have long advocated for better wages, job security, and working conditions, yet their impact on healthcare workers’ mental health remains understudied. The COVID-19 pandemic intensified systemic challenges like staffing shortages and burnout, prompting renewed interest in unionization as a means of support. While unions are known to improve wages and benefits, they also shape workplace safety, job satisfaction, and overall well-being, positioning them as key social determinants of health. Despite their role in sustaining the workforce during the pandemic, little is known about their broader effects on mental health. To address this gap, this study examines how unionization influences workplace conditions and mental health among hospital-based healthcare workers.

Methods: Data were collected from 1,466 nurses, service and technical workers employed in hospitals across Southwest Pennsylvania, via an online survey conducted through Qualtrics in March 2022. The sample, selected purposefully, consisted of both unionized and non-unionized employees, with participants recruited through union outreach efforts. The explanatory variable was unionization status (unionized vs. non-unionized). Outcome variables included working conditions (e.g., wages, work hours, benefits, workplace safety) and mental health outcomes (e.g., depression, anxiety, PTSD, professional quality of life). Covariates used in propensity score matching (PSM) included sociodemographic characteristics (e.g., age, gender, education, race, marital status) and work-related factors (e.g., job type, tenure). PSM matched unionized and non-unionized workers on these covariates to reduce potential biases. To examine the effects of unionization on outcomes, multivariate regression models were applied, incorporating matching weights and all covariates.

Results: Among the 1,466 participants, 40% held unionized jobs. The sample was 84% female and 89% white, with an average age of 37.5 years (±12.5), and 66% had a bachelor’s degree. Nearly 45% were married, and 30% were parents. Most (90%) worked full-time, primarily as registered nurses, earning an average hourly wage of $32.4. Unionized workers were younger, less educated, more likely to be parents, and had longer hospital tenures. PSM achieved covariate balance between groups, reducing bias and eliminating significant baseline differences. Multivariate models using matching weights and covariates showed that unionization was significantly associated with better working conditions—including predictable raises, fewer multiple-job holders, reduced overtime pressure, access to dental insurance and retirement programs, higher raises, and less workplace harassment. Unionized workers also reported better mental health outcomes, with lower rates of PTSD and perceived stress.

Conclusions and Implications: This study highlights the important role of unionization in improving the mental health and well-being of healthcare workers. By enhancing working conditions, unionization provides key benefits such as increased job stability, access to better benefits, and a reduction in workplace stressors like harassment and excessive overtime. These improvements contribute to healthier, more supportive work environments, which in turn have positive effects on workers' mental health. Policymakers should prioritize supporting unionization efforts, recognizing their potential to create more equitable and sustainable healthcare settings. Additionally, further research is needed to explore the specific mechanisms through which unionization affects worker well-being, particularly by examining how collective bargaining and union advocacy can further maximize these benefits.