Uber for Nursing: How an AI-Powered Gig Model Is Threatening Health Care

Executive Summary

The gig economy’s labor model and its algorithmic management technologies now have a foothold in one of the largest labor sectors in the country: health care. On-demand nursing companies such as CareRev, Clipboard Health, ShiftKey, and ShiftMed have promised hospitals more control and nurses more flexibility. Through original interviews with 29 “gig” nurses and nursing assistants, this brief finds that 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. On-demand nursing platforms are also using the Uber playbook to lobby state legislatures in an attempt to exempt themselves from existing labor regulations. In the wake of the COVID-19 pandemic, nurses have fled the profession as a result of poor working conditions, creating what some have incorrectly identified as a “nursing shortage.” As gig nursing platforms falsely promise to empower workers and meet their needs, it is up to legislators, policymakers, civic leaders, and community organizations to act to solve the real problems at the root of this crisis.

“Wall Street’s takeover of US health-care infrastructure and Silicon Valley’s introduction of gig nursing apps are a dangerous duo that is eroding our health-care system and eviscerating our ability to take care of each other.”

The Black Box of On-Demand Nursing Apps

Ashley, a 31-year-old certified nursing assistant in rural Pennsylvania, has worked in hospitals and nursing homes through the ShiftKey app.¹ Though Ashley has worked on the app for the last two years, there’s a lot she doesn’t know about it—like how the company allocates shifts. She is not the only one in the dark. In the gig nursing world, there is zero transparency about how jobs are algorithmically allocated or automatically scheduled. 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 can be paid different amounts by the same app. The gig nursing industry looks more like a black box than a clear process or a fair set of rules. The industry’s opaque and personalized pay structures create what Veena Dubal (2023) terms “algorithmic wage discrimination,” a kind of discrimination in which workers are paid different hourly amounts based on ever-changing calculations and informational asymmetries. Gig nursing apps may determine pay by what the firm knows about how much a nurse was willing to accept for a previous assignment, how often they bid for shifts, or how much credit card or other kinds of debt they might hold. These uncertainties combine to create frustrating and precarious conditions for the workers who rely on these apps.

Competing for a Shift

To sign up for shifts on a gig nursing app, workers agree to a background check and upload three sets of documents about (1) their active professional licenses or certificates, (2) their vaccine records for, in most cases, hepatitis B and COVID-19, and (3) negative test results for tuberculosis and a drug urine screening. There are no interviews as part of the job application—the hiring process has been relegated to algorithmic software systems that screen and evaluate applicants. Performance management, too, has been reduced to a series of metrics that are difficult if not impossible for workers to contest. Gig nurses—like Uber drivers and DoorDash delivery couriers—also receive a series of ratings. Some of these ratings are given by the medical facilities for attendance, timeliness, and onsite performance. Other ratings—which have similarly little transparency—are given by the on-demand nursing companies. ShiftMed, for instance, gives a reliability score to workers based on how many shifts they complete, how early they cancel shifts, and whether they stay late on a job (which can, oddly, hurt one’s score). Higher reliability scores lead to earlier access to shifts while lower ratings result in temporary or permanent suspensions and, workers suspect, lower pay offerings.

                 

These screenshots of the ShiftKey and ShiftMed apps show how workers can view and select open shifts.

For Dana, a 29-year-old nurse in St. Louis, Missouri, one of the hardest parts of working on the CareRev app is not knowing whether she will actually get to work a shift that she accepted. Even after she is matched with a shift at a nearby hospital and arranges childcare for her son, she won’t know for sure if she’ll be able to earn money that day. She says, “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.”² If a hospital cancels her shift more than two hours before the start time, CareRev does not compensate her at all. If the cancellation is closer to the planned start time, she sometimes earns two to four hours of what she was supposed to have earned if she worked the entire shift.³ Hospitals may also shorten shifts while a nurse is on the job; in these cases, the app does not pay the nurse for any of the unworked hours. (Of course, nurses are not paid for any unexpected additional hours they may work.) If Dana were to cancel a shift at the last minute or leave in the middle of a shift, she would be penalized. Her attendance rating would dip, which would negatively impact her access to future shifts or the app itself.

To work on the CareRev app, Dana must be on-call for all of the shifts she selects but is only paid for her actual hours worked. Almost all of the workers we interviewed shared frustrations about the way gig nursing companies do not compensate nurses for canceled or shortened shifts. Several workers described with resentment the experience of receiving a cancellation notice in the app just as they arrive at a facility’s parking lot. When this happened to Robin, a 41-year-old health-care worker living near Miami, Florida, she couldn’t find another shift and did not work that day.⁴

A Race to the Bottom for Wages

For workers, the old adage of equal pay for equal work has gone out the window. Personalized pay is all the rage (Teachout 2023). On-demand nursing companies such as Clipboard Health and ShiftKey encourage workers to join in on personalized pay schemes by bidding against each other. On ShiftKey, Ashley not only expresses her availability for a shift but bids for one against peers by indicating the lowest hourly rate for which she will work. To win the shift, she lowers and lowers her rate until it’s well below a living wage. Like other gig workers who spend a considerable amount of work time not being paid (see Attoh et al. 2024), Ashley is not paid for the time she spends each month updating her profile, reviewing available positions, bidding for shifts, and sending messages in the app about errors in her wages. Some days, she says, ShiftKey feels like a race to the bottom. Others agree—four workers in this study earn so little as gig nurses or nursing assistants that they qualify for Medicare or Medicaid. Two others had no health insurance at all—Ashley is one of them.⁵

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Screenshots show how workers bid for gigs. Left to right: ShiftKey, Clipboard Health, ShiftKey

On ShiftKey, Ashley earns an average of $23 per hour, which is more than what she earned as a substitute teacher. For each shift, Ashley is required to pay $6 in fees.⁶ For many workers on gig nursing apps, the withdrawal of these oft-hidden fees from their paychecks is a surprise. Each day Ashley works, she is required to pay $3.67 for a “safety fee” (which the company describes as “costs associated with background checks, drug screens [if applicable], verification of credentials, and fraud detection and prevention”), $2.14 for occupational accident insurance, and $0.21 for medical malpractice insurance (ShiftKey 2024b; 2024c). It is not clear why these fees are priced per day, given that nurses do not get background checks or drug screens each day they work on the app. By the end of 2024, these fees will increase to a new total of $7 per shift. Ashley is also charged $2 per shift if she elects to cash out immediately rather than waiting a week for her pay to be transferred. Workers wish they could find out exactly what amount the facility pays to the gig nursing firm for their labor, and whether it is therefore gratuitous for the firm to extract fees from both the worker and the facility for each hour of a nurse’s labor. 

When all of these costs are taken into consideration, Ashley’s actual take-home pay as a nursing assistant drops sharply to roughly $13 per hour. She is not alone with these kinds of low-wage earnings. Of the 29 workers in this study, 14 say they could not make a living if on-demand nursing apps were their only source of income. 

Still, the rates on ShiftKey can be higher than what both employed nursing assistants and nurses earn, and it is this higher rate that often attracts these workers to gig nursing jobs. The average hourly rate for employed nursing assistants is $18.33 and for nurses is $45.42 (BLS 2024a; 2024b). By contrast, in this study, the average hourly rate reported by gig nursing assistants is $22; for gig nurses, it is $59. While the nursing app wages are often well-above most cities’ and states’ minimum pay rates, average nursing wages, and even travel nursing wages, the payout from on-demand nursing apps does not take into consideration the material expenses, such as equipment, licenses, and uniforms, for which workers are responsible. Gig nurses, for instance, must pay for and maintain differently colored scrubs (and sometimes shoes) for different facilities. Moreover, the payout does not account for the significant payroll taxes for which workers are responsible. ShiftMed is a welcome outlier in this regard as it treats its workers as W-2 employees with some basic labor rights.

High Risk, Low Rewards

The risks of gig nursing are also higher than that of employed work. For nurses and nursing assistants, ShiftKey and its peer companies provide no paid sick leave or unemployment insurance. As Ashley puts it: “You get treated differently [because] you’re not an employee.”⁷ By contrast, traditional health-care staffing agencies often treat temp nurses and nursing assistants as employees. When companies like CareRev, ShiftKey, and Clipboard Health classify nurses and nursing assistants as self-employed, many of the costs and risks of doing business are shifted onto the workers. These workers are excluded from the protections of local, state, and federal law on minimum wage, overtime pay, workers’ compensation, retirement benefits, employment-based health insurance, and paid sick days. 

Workers must also agree to be tracked on their smartphones to clock in and clock out at facilities, and to keep their location tracker on while en route to a facility. Some workers expressed frustrations about not getting full pay for shifts worked if the internet or cell service in a specific area is weak or prevents them from logging into the app and officially beginning their workday. 

Dana wishes she could find a full-time job as a nurse that would pay decently and wouldn’t require weekends. She feels as if hospitals like to hire new nursing school graduates rather than pay more for mid-career or senior positions that would be a better match for nurses like herself. She explains: 

“The only reason that I’m doing this right now is because I have no choice. This is what I went to school for and this is what is going to [do to] pay my bills in this . . . scary economic, you know, crisis that we have going on right now where you can barely afford to be alive . . . 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. But I hate being a nurse right now with [what] these greedy, immoral, corporate companies have done to health care.”⁸

– Dana, 29, St. Louis, MO

Footnotes and Suggested Citation

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