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New research suggests Big Tech and Wall Street are using on-depend nursing services to extract profits and hurt health care — all to solve a problem that doesn’t exist. Also: Rock the boat.
The Dangerous Lie Behind On-Demand Nursing
By Helen Santoro
 A traveling nurse walks down a hallway at a Rhode Island field hospital set up to handle a surge of COVID-19 patients on Feb. 10, 2021. (AP Photo/David Goldman) [View in browser] Big Tech and Wall Street are deploying an on-demand “Uber for nursing” model that’s racking up hundreds of millions in investments while creating unsafe, high-stress conditions for nurses and patients — all to solve a supposed nursing shortage that doesn’t really exist. The influx of patients and lack of resources during the COVID-19 pandemic led to unprecedented levels of burnout among nurses. The subsequent rise of gig-nursing platforms like CareRev, ShiftKey, and ShiftMed has been heralded as a way to bring in more nurses and provide these workers with additional flexibility. However, amid growing public outcry over the state of the country’s health care system, a new study published by researchers at the Roosevelt Institute, a liberal think tank, found that these on-demand nursing apps can create high-risk, low-reward working conditions that endanger medical professionals and patients alike. “These apps encourage nurses to work for less pay, fail to provide certainty about scheduling and the amount or nature of work, take little to no accountability for worker safety, and can threaten patient well-being by placing nurses in unfamiliar clinical environments with no onboarding or facility training,” the study’s authors wrote. Companies in the newly formed gig-nursing industry have also been lobbying on labor rules that could allow them to shortchange nurses, further reducing the quality of patient care.
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On-demand nursing services fail to address decades of health care consolidation by for-profit corporations that have pushed bare-minimum staffing and high-risk work environments as a way to save money, said Katie Wells, a senior fellow at the progressive economic policy think tank Groundwork Collaborative who coauthored the new study. “[What has happened to] the corporatization of health care so that so many managers think this is the solution?” she asked. “What’s happened to this workforce that they can’t find jobs that work for their families’ needs?” Wells and her colleague interviewed 29 gig nurses and nursing assistants about their experiences with on-demand nursing apps, which allow nurses to select their desired locations, hours, and shifts from different health care facilities. According to Wells, it’s like Uber for nursing — and the job comes with many of the same concerns lobbed against the rideshare app. “You really have no one to talk to if… you’re needing help,” said Aisha, a 24-year-old nursing assistant in Atlanta. “There’s no one for you to complain to if there’s any mistreatment… or abuse [of patients] there. You really don’t know the chain of command.” Meanwhile, on-demand nursing platforms including CareRev, Clipboard Health, ShiftKey, ShiftMed, and IntelyCare have collectively raised more than $850 million from private investors over the past few years, with Clipboard Health’s CEO claiming this model enables “facilities to fill shifts” while “empowering healthcare professionals to earn more and exercise greater control over their schedules.” Since 2023, ShiftMed, ShiftKey, and IntelyCare have also spent $730,000 lobbying on issues related to the classification of health care workers as independent contractors. Rideshare apps Uber and Lyft have been known to classify gig workers as contractors to avoid providing them benefits such as overtime pay, paid family leave, sick days, unemployment insurance, and the ability to collectively bargain. Nurses are in this profession because they care, Wells told The Lever. However, “they’re in it alone and they’re struggling to take care of these people and they want to do good,” she said. “One question I always asked these workers was: Are any of the facilities you’ve been to… places where you would take your loved ones? And the answer to that question just really rings in my ear, because it’s a big ‘no.’” The “Nursing Shortage” That Isn’tThe rise of on-demand nursing is in part tied to growing worries about a nationwide nursing shortage. In 2023, the Biden administration went as far as to award more than $100 million towards nurse training to address the problem. The concern isn’t new; the country has been grappling with potential nurse shortages since the mid-1930s, when an increase in hospital use and patient-care requirements put more demands on nurses’ time. But according to experts, technically, there is no nursing shortage. The country currently boasts more than five million licensed and registered nurses — an all-time high. The problem, advocates say, is that a growing number of nurses and nursing assistants refuse to accept chronically underpaid, unsafe, and high-stress workplaces. “The U.S. has a robust and growing supply of registered nurses with enough new nurses to more than replace retiring nurses through 2035,” University of Pennsylvania nursing professor Karen Lasater wrote in a paper about the nurse-retention crisis. Yet rather than addressing “the low retention caused by employers’ chronic understaffing, rigid scheduling options, and lack of responsiveness to clinicians’ recommendations to improve care,” as Lasater noted in her paper, tech companies have teamed up with Wall Street firms to create on-demand nursing apps. Early research on the matter already showed that these platforms don’t solve the root problem of nurse burnout. In fact, gig nursing negatively impacts “facility operations, nursing staff cooperation, and quality of care,” including higher rates of catheter use and medical errors, according to a 2023 study from a researcher at Washington University in St. Louis. These findings aligned with what Wells uncovered through interviewing nurses for her new study. Aisha, the nursing assistant in Atlanta, told Wells that she showed up late at night for a gig-nursing shift only to find that the facility’s doors were locked and she couldn’t contact anyone to open them. Even when she’s inside, she doesn’t feel at ease, as gig-based health providers are not always required to complete onboarding. Such lack of training puts workers at an increased risk of making medical errors, yet contracts at companies like ShiftKey holds the worker liable if a nursing licensure board or hospital takes disciplinary action.
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Nurses also reported “hospitals, surgical centers, and long-term care facilities breaking all sorts of rules, such as not properly locking up controlled substances and medications or looking the other way when workers show up to a shift under the influence of drugs,” Wells wrote in the study. A health care provider working for on-demand nursing company Clipboard Health noted that the most difficult part of the job was “seeing the care that is provided is not adequate.” A nurse for CareRev, another gig-nursing platform, said hospitals use the apps because they are “desperate” and “have no staff at all.” “I think it’s just a Band-Aid because once hospitals can’t pay these high rates… no one’s going to do [this care work],” the CareRev nurse said. Like Uber drivers and DoorDash couriers, gig nurses receive ratings from medical facilities for their timeliness, attendance, and performance. A dip in ratings — which may arise from situations like needing to cancel a shift due to illness — negatively impacts nurses’ ability to get future shifts, and lower ratings can result in temporary or permanent suspension. In one case, a nursing assistant went to work at a hospital while sick with COVID-19 to avoid lowering her rating, according to the new report. Additionally, the researchers found that nurses on apps like Clipboard Health and ShiftKey are encouraged to bid against each other for shifts, and in doing so, sometimes take the lowest hourly rate available. Four of the 29 gig nurses and nursing assistants interviewed earn so little that they qualify for Medicare or Medicaid. On-demand nursing companies are not shy about boasting how much money medical facilities can save by employing their apps. “Travel nursing rates continue to exceed the budgets of national healthcare providers, which is unsustainable,” according to a press release by ShiftMed. Unlike gig nurses, traveling nurses pick up their lives and move to different locations for longer contracts, which is key for hospitals that need to temporarily fill staffing gaps, especially during seasonal patient spikes. ShiftMed claims they offer a solution that “decreases reliance on travel agencies,” thereby “reducing operating costs by 30-40 [percent] compared to travel staffing alternatives.” A Page From Uber’s Playbook Over the years, Uber has thrown massive amounts of money into lobbying for laws and regulations that critics say strip workers of critical protections. In 2020, for example, California voters passed a ballot measure letting app-based services like Uber, Lyft, and DoorDash classify their workers as independent contractors instead of employees. At the time, Uber praised the measure, saying it will “deliver historic benefits and protections to drivers, while keeping their independence.” But worker advocates say the law allows these companies to avoid providing workers benefits such as minimum wage, overtime, and paid family leave, even though many of these gig workers have a level of dependence on the rideshare company that goes beyond typical independent contractors.
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They can't scam who they can't find.
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Since 2022, on-demand nursing apps have adopted a similar approach by backing a number of bills and ballot measures that define health care gig workers as independent contractors. This includes a ballot initiative in California, bills in Minnesota and Ohio, and legislation in Colorado. Of these efforts, only the Colorado bill passed. The state now defines a “health-care worker platform” as one that “sets hourly rates and other terms of hire and the health-care worker, as an independent contractor and not as an employee or agent of the entity that maintains the platform, decides whether to agree to the hourly rates and other terms of hire.” By doing so, companies are not required to provide employment benefits, according to Colorado law. Now nursing advocates are sounding the alarm. “Tech industry health care investors, and health care employers looking to cut costs, want to apply this exploitative gig-work employment model to misclassify nurses as independent contractors and deprive them of the rights and benefits granted to regular employees, including the right to organize in a union,” National Nurses United, the largest union of registered nurses, wrote in a statement on the issue. If Uber and other rideshare apps are any indication, however, it may be hard to rein in the on-demand nursing services. States including Minnesota, Massachusetts, New York, and Washington have stipulated minimum rideshare driver pay and required rideshare companies to provide additional driver benefits. However, Uber continues to adopt a long list of anti-competitive business practices like setting the prices that customers pay and limiting drivers’ ability to choose which ride they accept. The Federal Trade Commission, an independent agency that protects consumers from unfair business practices, recently opened an investigation into Uber’s subscription policy for automatically signing customers up to their premium service and making it hard to cancel, though it’s yet to be seen whether such efforts will lead to meaningful reforms. Wells suspects that on-demand nursing companies will continue to follow in Uber’s footsteps — with worrisome results. “I think the risks [of on-demand nursing] are significant for public safety in terms of both worker health and also patient health and I think community health,” Wells said.
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