In 2013, Tim Maughan published a short story called Zero Hours, which describes a day in the life of Nicki, a 19-year-old zero-hour contract worker. Before Nicki gets out of bed, she grabs her tablet and bids “like mad” on various retail shifts. Eventually, she secures shifts at Pret-a-Manager and Boots, a beauty and pharmacy chain—though both shifts pay below the national minimum wage. She resents that she still doesn’t have the right “badge” to compete on a shift for the comparably better job at Starbucks.
At her first shift, she is “stuck in a cold backroom sticking vacuum packed, pre-sliced organic cheddar” into baguettes. When her phone chimes in her pocket to let her know that the shift has ended after just two hours, she logs off the app, scans a manager’s QR code, and collects a slew of messages: “Shift completed! £12.64 received. Achievement unlocked! Sandwich Stuffer Pro badge!” At her next shift across town, her assignment involves lining up lipsticks on shelves by color and type in pre-assigned plastic holes. When she places one out of order, the shelf makes a record of her error, and Nicki assumes that the surveillance system is “telling someone else too, building stats on her, trails of data ranking her for efficiency.” At the end of her shift, she lines up next to other workers and wonders how much they are getting paid for the same work: in the anonymous online auction, “did they undercut her or the other way around?”
At the time it was written, Nicki’s story was intended to be a short work of dystopian fiction. Today, it reads more like a plausible description of the working world that an increasing number of American nurses inhabit.
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When Dana, a 29-year-old nurse in St. Louis, wakes up, she immediately checks her phone to see if the gig nursing app CareRev still has her scheduled to work at the local hospital. She’s already arranged childcare for her son, but cancellations are common. “It’s a gamble… I’ll wake up at 5:00 in the morning, and I’ll find out if I’m canceled or not,” she says. Dana also worries about what will happen on the shift, if it doesn’t get canceled. Sometimes, she shows up and finds out that she’s assigned entirely different work than she expected. Or she’ll find out that her shift has been shortened mid-way through a job, and she won’t be paid for the original number of hours she had booked. Other times, Dana is required to stay past her scheduled end-time. If she leaves, she risks losing points for her attendance score or, worse, being “de-activated” from the app.
Dana wishes she could find a full-time job as a nurse that would pay decently and be compatible with her childcare responsibilities. But at the moment, she has no other choice, even as her current working conditions are grinding her down. As she lamented, “The only reason that I’m doing this right now is because I have no choice.… So, this is what I have to do in order to survive, even though, you know, it’s not what I really want to do. But I hate saying that because I love being a nurse. I hate being a nurse right now with [what] these greedy, immoral, corporate companies have done to health care.”
As we explain in a recent study, Dana’s experiences on gig nursing apps are not unique. Through interviews with 29 nurses and nursing assistants, along with a lot of time spent lurking on nursing Facebook groups, we found that new gig nursing companies are facilitating a race to the bottom among healthcare workers. Whereas traditional travel nursing roles typically involve multi-week contracts at the same facility and are facilitated by an intermediary staffing agency, gig nursing companies are app-managed, on-demand, and usually dependent on workforces that are treated as independent contractors.
Since 2016, some of the largest US hospital systems have integrated “gig” nurses into their day-to-day health-care operations. New Uber-style firms like CareRev, Clipboard Health, ShiftKey, and ShiftMed use algorithmic scheduling, staffing, and management technologies to match understaffed medical facilities with nearby nurses and nursing assistants looking for work. Billed as an opportunity to “set your own schedule” and “transform the way you work,” the reality is far more complicated.
To win shifts—and yes, shifts on most of these apps must be won in an auction like the kind Tim Maughan foresaw—healthcare workers bid against each other. Ashley, a 35-year-old, from rural Pennsylvania bids against peers on the ShiftKey app by indicating the lowest hourly rate for which she will work. To compete, she lowers and lowers her rate until it’s well below a living wage. She normally secures an average rate of $23 per hour, which, after taxes and expenses, ends up being less than what she earned in the past as a substitute teacher. For each day Ashley works, she is required to pay $6 in fees: $3.67 for a “safety fee,” $2.14 for occupational accident insurance, and $0.21 for medical malpractice insurance. It is unclear why these fees are priced per day, given that Ashley does not undergo a new background check or drug screen each day she works. To speed up access to her earnings, Ashley also pays $2 per shift rather than waiting a week for the pay to be transferred.
Ashley and other health care professionals we interviewed expressed frustrations with the lack of transparency about how the algorithm allocates or schedules jobs. Different shifts will show up on different workers’ phones—often for different amounts of pay. On the same day, at the same hour, in the same hospital, two different gig nurses will often be paid different amounts by the same app. This new compensation scheme depends on what anti-monopoly advocate Zephyr Teachout calls “surveillance wages” and leads to what legal scholar Veena Dubal calls “algorithmic wage discrimination,” a wage-setting system that depends on vast mountains of granular, surveillance data about individual workers and incredible power imbalances between those workers and the companies that hold the keys to the data castles. A gig nursing company may determine a worker’s hourly rate by what the company knows about how little that worker was paid for previous assignments, how often that worker bids for shifts, or how much credit card debt that worker might hold.
Of the 29 healthcare workers in our study, 14 say they could not make a living if on-demand nursing apps were their only source of income. Four workers earn so little that they qualify for Medicare or Medicaid. Two others, rather ironically given their profession, had no health insurance at all—Ashley is one of them.
There are no paid or even un-paid orientations for gig nurses at many medical facilities and long-term care institutions. Workers with whom we spoke often do not know where supply closets are located, how to access patient portals with medical histories and current medication lists, or whom to contact in the chain of command when things go wrong. They are dropped into facilities like players in a survivalist video game. Aisha, a 24-year-old certified nursing assistant in Atlanta, Georgia, described the constant sense of isolation: “I just feel like I am on an island by myself a lot.”
For Kristin, a 40-year-old certified nursing assistant who lives near Portland, Oregon, this isolation exacerbates the physical risk she faces while working for Clipboard Health. Once, while moving a patient, she developed a hernia: “I was on the floor in tears and throwing up from just the pain. And I could not get ahold of anybody. They called the paramedics for me. And then I couldn’t get approval to leave, and the paramedics left without me.” In the end, a facility director re-assigned her duties and allowed her to go home. But Clipboard Health did not pay her for any of the hours that she worked that day because, according to the company, she left her shift early. To make matters worse, her account was deactivated for this alleged infraction.
On another day, Kristin tested positive for Covid-19 and couldn’t figure out how to cancel her shift without losing attendance points (which would affect her ability to access work later in the month). She tried to no avail to get a hold of Clipboard Health as well as the facility to ask them to cancel the shift so she would not be penalized. In the end, despite being sick, Kristin showed up for the nursing job.
Legally, workers like Kristin have little legal recourse to address this mistreatment. CareRev and Clipboard Health require their healthcare workers to arbitrate any issues outside of a court of law. Even more alarmingly, these workers face significant legal risks while working for these gig nursing apps. In a rare move that a former Department of Labor attorney called “crazy,” workers for CareRev and Clipboard Health are also required to indemnify the companies and the facilities that use the companies. What this means is that gig workers agree to pay for any potential losses or damages that they may cause, thus protecting the company and the facility. Who protects the workers? No one. Nursing gig companies have successfully transferred their risks onto workers, a bridge too far for dystopian fiction.
Fifty years of financialization, consolidated corporate power, the rise of business administrators, and the takeover of hospitals by private equity have built a new for-profit health care empire that is ripe for Silicon Valley to exploit. Is there a problem with health care staffing? Yes. Are Silicon Valley’s AI-powered and predatory staffing solutions the answer? No. Wall Street’s takeover of U.S. healthcare infrastructure and Silicon Valley’s introduction of gig nursing apps are working to erode our health-care system and eviscerate our ability to take care of each other.
