The “Nursing Shortage” That Isn’t

The 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 toward 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.

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 twenty-nine 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.

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 anticompetitive 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.