Pluralistic: Nurses whose shitty boss is a shitty app (17 Dec 2024)

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Originally published at: Pluralistic: Nurses whose shitty boss is a shitty app (17 Dec 2024) – Pluralistic: Daily links from Cory Doctorow



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A nurse, pouring medicine out of a bottle; she is terrified because she is being held a gunpoint by a male figure whose head has been replaced with the staring eye of HAL 9000 from Kubrick's '2001: A Space Odyssey.' The background is a sepia-toned early 20th C wartime infirmary, crowded with wounded men. In the top left corner there is a subtle 'code waterfall' effect as seen in the credit sequences of the Wachowskis' 'Matrix' movies.

Nurses whose shitty boss is a shitty app (permalink)

Operating a business is risky: you can't ever be sure how many customers you'll have, or what they'll show up looking for. If you guess wrong, you'll either have too few workers to serve the crowd, or you'll pay workers to stand around and wait for customers. This is true even when your "business" is a "hospital."

Capitalists hate capitalism. Capitalism is defined by risk – like the risk of competitors poaching your customers and workers. Capitalists all secretly dream of a "command economy" in which other people have to arrange their affairs to suit the capitalists' preferences, taking the risk off their shoulders. Capitalists love anti-competitive exclusivity deals with suppliers, and they really love noncompete "agreements" that ban their workers from taking better jobs:

https://pluralistic.net/2023/04/21/bondage-fees/#doorman-building

One of the sleaziest, most common ways for capitalists to shed risk is by shifting it onto their workers' shoulders, for example, by sending workers home on slow days and refusing to pay them for the rest of their shifts. This is easy for capitalists to do because workers have a collective action problem: for workers to force their bosses not to do this, they all have to agree to go on strike, and other workers have to honor their picket-lines. That's a lot of chivvying and bargaining and group-forming, and it's very hard. Meanwhile, the only person the boss needs to convince to screw you this way is themself.

Libertarians will insist that this is impossible, of course, because workers will just quit and go work for someone else when this happens, and so bosses will be disciplined by the competition to find workers willing to put up with their bullshit. Of course, these same libertarians will tell you that it should be legal for your boss to require you to sign a noncompete "agreement" so you can't quit and get a job elsewhere in your field. They'll also tell you that we don't need antitrust enforcement to prevent your boss from buying up all the businesses you might work for if you do manage to quit.

In practice, the only way workers have successfully resisted being burdened with their bosses' risks is by a) forming a union, and then b) using the union to lobby for strong labor laws. Labor laws aren't a substitute for a union, but they are an important backstop, and of course, if you're not unionized, labor law is all you've got.

Enter the tech-bro, app in hand. The tech-bro's most absurd (and successful) ruse is "it's not a crime, I did it with an app." As in "it's not money-laundering, I did it with an app." Or "it's not a privacy violation, I did it with an app." Or "it's not securities fraud, I did it with an app." Or "it's not price-gouging, I did it with an app," or, importantly, "it's not a labor-law violation, I did it with an app."

The point of the "gig economy" is to use the "did it with an app" trick to avoid labor laws, so that bosses can shift risks onto workers, because capitalists hate capitalism. These apps were first used to immiserate taxi-drivers, and this was so successful that it spawned a whole universe of "Uber for __________" apps that took away labor rights from other kinds of workers, from dog-groomers to carpenters.

One group of workers whose rights are being devoured by gig-work apps is nurses, which is bad news, because without nurses, I would be dead by now.

A new report from the Roosevelt Institute goes deep on the way that nurses' lives are being destroyed by gig work apps that let bosses in America's wildly dysfunctional for-profit health care industry shift risk from bosses to the hardest-working group of health care professionals:

https://rooseveltinstitute.org/publications/uber-for-nursing/

The report's authors interviewed nurses who were employed through three apps: Shiftkey, Shiftmed and Carerev, and reveal a host of risk-shifting, worker-abusing practices that has nurses working for so little that they can't afford medical insurance themselves.

Take Shiftkey: nurses are required to log into Shiftkey and indicate which shifts they are available for, and if they are assigned any of those shifts later but can't take them, their app-based score declines and they risk not being offered shifts in the future. But Shiftkey doesn't guarantee that you'll get work on any of those shifts – in other words, nurses have to pledge not to take any work during the times when Shiftkey might need them, but they only get paid for those hours where Shiftkey calls them out. Nurses assume all the risk that there won't be enough demand for their services.

Each Shiftkey nurse is offered a different pay-scale for each shift. Apps use commercially available financial data – purchased on the cheap from the chaotic, unregulated data broker sector – to predict how desperate each nurse is. The less money you have in your bank accounts and the more you owe on your credit cards, the lower the wage the app will offer you. This is a classic example of what the legal scholar Veena Dubal calls "algorithmic wage discrimination" – a form of wage theft that's supposedly legal because it's done with an app:

https://pluralistic.net/2023/04/12/algorithmic-wage-discrimination/#fishers-of-men

Shiftkey workers also have to bid against one another for shifts, with the job going to the worker who accepts the lowest wage. Shiftkey pays nominal wages that sound reasonable – one nurse's topline rate is $23/hour. But by payday, Shiftkey has used junk fees to scrape that rate down to the bone. Workers have to pay a daily $3.67 "safety fee" to pay for background checks, drug screening, etc. Nevermind that these tasks are only performed once per nurse, not every day – and nevermind that this is another way to force workers to assume the boss's risks. Nurses also pay daily fees for accident insurance ($2.14) and malpractice insurance ($0.21) – more employer risk being shifted onto workers. Workers also pay $2 per shift if they want to get paid on the same day – a payday lending-style usury levied against workers whose wages are priced based on their desperation. Then there's a $6/shift fee nurses pay as a finders' fee to the app, a fee that's up to $7/shift next year. All told, that $23/hour rate cashes out to $13/hour.

On top of that, gig nurses have to pay for their own uniforms, licenses, equipment and equipment, including different colored scrubs and even shoes for each hospital. And because these nurses are "their own bosses" they have to deduct their own payroll taxes from that final figure. As "self-employed" workers, they aren't entitled to overtime or worker's comp, they get no retirement plan, health insurance, sick days or vacation.

The apps sell themselves to bosses as a way to get vetted, qualified nurses, but the entire vetting process is automated. Nurses upload a laundry list of documents related to their qualifications and undergo a background check, but are never interviewed by a human. They are assessed through automated means – for example, they have to run a location-tracking app en route to callouts and their reliability scores decline if they lose mobile data service while stuck in traffic.

Shiftmed docks nurses who cancel shifts after agreeing to take them, but bosses who cancel on nurses, even at the last minute, get away at most a small penalty (having to pay for the first two hours of a canceled shift), or, more often, nothing at all. For example, bosses who book nurses through the Carerev app can cancel without penalty on a mere two hours' notice. One nurse quoted in the study describes getting up at 5AM for a 7AM shift, only to discover that the shift was canceled while she slept, leaving her without any work or pay for the day, after having made arrangements for her kid to get childcare. The nurse assumes all the risk again: blocking out a day's work, paying for childcare, altering her sleep schedule. If she cancels on Carerev, her score goes down and she will get fewer shifts in the future. But if the boss cancels, he faces no consequences.

Carerev also lets bosses send nurses home early without paying them for the whole day – and they don't pay overtime if a nurse stays after her shift ends in order to ensure that their patients are cared for. The librarian scholar Fobazi Ettarh coined the term "vocational awe" to describe how workers in caring professions will endure abusive conditions and put in unpaid overtime because of their commitment to the patrons, patients, and pupils who depend on them:

https://www.inthelibrarywiththeleadpipe.org/2018/vocational-awe/

Many of the nurses in the study report having shifts canceled on them as they pull into the hospital parking lot. Needless to say, when your shift is canceled just as it was supposed to start, it's unlikely you'll be able to book a shift at another facility.

The American healthcare industry is dominated by monopolies. First came the pharma monopolies, when pharma companies merged and merged and merged, allowing them to screw hospitals with sky-high prices. Then the hospitals gobbled each other up, merging until most regions were dominated by one or two hospital chains, who could use buyer power to get a better deal on pharma prices – but also use seller power to screw the insurers with outrageous prices for care. So the insurers merged, too, until they could fight hospital price-gouging.

Everywhere you turn in the healthcare industry, you find another monopolist: pharmacists and pharmacy benefit managers, group purchasing organizations, medical beds, saline and supplies. Monopoly begets monopoly.

(Unitedhealthcare is extraordinary in that its divisions are among the most powerful players in all of these sectors, making it a monopolist among monopolists – for example, UHC is the nation's largest employer of physicians:)

https://www.thebignewsletter.com/p/its-time-to-break-up-big-medicine

But there two key stakeholders in American health-care who can't monopolize: patients and health-care workers. We are the disorganized, loose, flapping ends at the beginning and end of the healthcare supply-chain. We are easy pickings for the monopolists in the middle, which is why patients pay more for worse care every year, and why healthcare workers get paid less for worse working conditions every year.

This is the one area where the Biden administration indisputably took action, bringing cases, making rules, and freaking out investment bankers and billionaires by repeatedly announcing that crimes were still crimes, even if you used an app to commit them.

The kind of treatment these apps mete out to nurses is illegal, app or no. In an important speech just last month, FTC commissioner Alvaro Bedoya explained how the FTC Act empowered the agency to shut down this kind of bossware because it is an "unfair and deceptive" form of competition:

https://pluralistic.net/2024/11/26/hawtch-hawtch/#you-treasure-what-you-measure

This is the kind of thing the FTC could be doing. Will Trump's FTC actually do it? The Trump campaign called the FTC "politicized" – but Trump's pick for the next FTC chair has vowed to politicize it even more:

https://theintercept.com/2024/12/18/trump-ftc-andrew-ferguson-ticket-fees/

Like Biden's FTC, Trump's FTC will have a target-rich environment if it wants to bring enforcement actions on behalf of workers. But Biden's trustbusters chose their targets by giving priority to the crooked companies that were doing the most harm to Americans, while Trump's trustbusters are more likely to give priority to the crooked companies that Trump personally dislikes:

https://pluralistic.net/2024/11/12/the-enemy-of-your-enemy/#is-your-enemy

So if one of these nursing apps pisses off Trump or one of his cronies, then yeah, maybe those nurses will get justice.

(Image: Cryteria, CC BY 3.0, modified)

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All of the (probably illegal in most places) underpayment and wage-fiddling games aside, as if those alone weren’t bad enough…

When you sign up to a gig employment system, you are handing an option to the employer to put you into work, or not. That option you just handed over has value. The value is roughly “with this employer, how much would knowing the future be worth to me?” Say you sign up for some $500 shifts but the gig app hosed you about ½ of the time at the last minute. You’ve given them an option worth about $250 per shift, because you could have taken a shift with another company if you had known beforehand.

Gig workers should be paid up front for that option.

It should not come off their wages either: it is a separate thing from the payment for work. If workers reneg on the shift, then the money goes back, sure, but that’s an easier and more transparent arrangement than gameifying the situation with a score.

I was chatting with some unionized boilermakers at a trade fair last month. They get money for the option of their work and call it “being paid to sit on your ass”. In their profession and their union, it happens a lot because when they are needed for a gig, they are really, badly needed. (Note the word ‘union’ in the preceeding.)

We need legislation to price the transfer of risk from gig employer to employee, and mandate that this be paid as an “option fee” up front. The absolute floor for that “option fee” needs to be minimum wage for the hours covered, but it would be pretty straightforward to apply some basic pricing theory to the problem to get a better solution.

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Of course, there is an alternative, even in a system with only one employer.

Over here, the NHS is effectively the only employer for clinical nursing staff, and it has its own way to cope with uncertain demand for nursing- the staff bank, where shifts are advertised for qualified people to pick up. this really does work as the “gig economy” promises, with staff able to pick up overtime, or qualified workers who want occasional work can voluntarily pick up what becomes available.

The key difference is unionisation, and the absence of the profit motive from healthcare. Watch out, though. I’m sure privatisation-fancier and all round political shitweasel Wes Streeting is on the lookout for ways to introduce the American experience to the UK as well.

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Seeing this happen to skilled and educated workers is a chilling reminder of the shitty technology adoption curve. We all must stand with nurses like we must stand with delivery drivers and prisoners because otherwise these apps are coming for all of us. There is no it can’t happen to me scenario here.

and equipment

But there are two

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Thanks! Fixed.

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Another innovation to aid in employee control: the policy-driven enterprise browser, e.g., https://island.io/ as described by:
Risky Biz Soap Box: “Cool compliance tricks with the Island enterprise browser” (podcast at https://www.youtube.com/watch?v=1tOecvkpPWU.

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«Libertarians will insist that this is impossible, of course, because workers will just quit and go work for someone else when this happens, and so bosses will be disciplined by the competition to find workers willing to put up with their bullshit.»

The situation is where there is bidding competition among workers to sell labor hours and a bidding competition among employers to buy labor hours, and the claims seems to be that if both are competitive the outcome should be fine. But that only applies if they are equally competitive, if the bidding on one side is less competitive that side gets the advantage, for example in the extreme case a monopolist.

Here our blogger makes what I think is a common misunderstanding, blaming mostly monopolism (traditional enemy of 19th century liberals).

The real problem is unbalanced competitiveness between the sellers and buyers. Consider an extreme example:

  • 2,000 people suffer from a deadly disease.
  • 1,800 doses of life-saving medicine are available.
  • then the market price of the 1,800 doses is everything that is owned by the 1,800 richest people among the 2,000.
  • The remaining 200 simply die (without losing anything they own).

There need not be any monopoly in the supply of the 1,800 doses of medicine, each could be owned by 1 seller, 1,800 sellers eagerly competing with each other to sell to 2,000 buyers. It is really as simple as that: the 2,000 compete among themselves much harder to buy the one of the doses than the 1,800 sellers compete among themselves to sell they dose they own. Monopolies just make that situation more common as they have an incentive to make situations like that happen by restricting supply or demand (depending on which side of the transaction they are in a market).

That is exactly the case of the “zero hours” apps: the buyers of labor demand less hours of work than the workers who supply labor must sell to get enough to live on, so inevitably some workers will not get any hours or insufficient hours, and therefore to avoid that will accept any conditions and any pay:

«Many of the nurses in the study report having shifts canceled on them as they pull into the hospital parking lot.»

From a libertarian point of view that is exactly how it should be: the workers who cannot sell enough work hours because there is an oversupply of workers will eventually “disappear” from the labor market and then there will be balance between demand and supply of work hours. Just as in the example above the excess demand for medicine is resolved by the “disappearance” of the demand for medicine doses by 200 of those 2,000 (“fiat libertas, ruat caelum”).

If the “disappearance” of workers must be avoided “because reasons” a competitive market must be replaced by a managed market, that is by rationing:

  • In the example above which 1,800 of the 2,000 demanding medicine doses get them and which 200 “disappear” from the market is decided not by competition but by “fair and just philosopher-kings” and these set the price of each dose to cost plus a “fair and just” profit margin.
  • In the “zero hours” apps situation workers could write their own apps (“algorithmic labor unions”) to bid for work hours from the “zero hours” apps ensuring that the total work hours they bid to supply is the same or less than that demanded by the “zero hours” apps and accept that some of them will get no wages, but the wages paid to those who do get hours are shared among all workers.

The “algorithmic labor union” case is in effect workers limiting the supply of labor hours as a group to balance the limited demand for labor hours in order to get an overall better price and create a group-insurance scheme against not being able to sell enough labor-hours to live on.

Note: similar apps exist in business-to-business bidding markets.

But there is a big problem if the imbalance between demand for wage hours and supply of wage hours is intrinsic and significant because that creates a situation quite similar to a “prisoners dilemma” and some workers will be tempted to “defect” and bid for wage hours individually.

And that partially explains why there are no popular “zero hours worker apps” and only “zero hours bosses apps”.

Some years ago this short story scenario was “near future” sci-fi:

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«Of course, these same libertarians will tell you that it should be legal for your boss to require you to sign a noncompete “agreement” so you can’t quit and get a job elsewhere in your field.»

That is part of “freedom of choice” and “freeedom of consent”, and freedom of choice and consent are very important classic liberal principles which include freedom of choice to have a doctor remove from one’s body their gonads or uterus, or to consent to a marriage to a person of the same gender or sex, or to consent to terminating a fetus or one’s entire body, or of choice to have an official change your publicly recognized gender.

The liberal argument is that if it is an absolute individual freedom of choice to have parts of their bodies removed, or to consent to have life terminated, etc., and then that applies also to the choice to consent to a “noncompete” clause.

Or to sell for money a “bond of service or labour”. Establishing the right of choice to consent to the latter is quite clearly the end goal for liberals, because freedom of choice and consent are important liberal principles. :-/

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Sure, why not, with regulated wages/benefits and terms, and the freedom to cancel such a bond at any time. Of course, it’s unclear why a person should enter into such an affair when, in the liberal fantasy land you’re alluding to, everyone’s basic needs are met (food, shelter, healthcare) by the abundance of resources and technology we have.

EDIT: Just to spell it out for you: let’s create a world where people are free to sell themselves into slavery, but where no one ever need to.

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«why not, with regulated wages/benefits and terms, and the freedom to cancel such a bond at any time.»

That is not how debt slavery ever worked :-(.

«create a world where people are free to sell themselves into slavery, but where no one ever need to.»

That would apply to other freedoms, but the freedoms to remove a fetus, marry same sex, get transition surgery, get self-termination assistance have been pushed and sold as absolute, because if they are conditional they cannot be “real” freedoms.

I reckon that the people working patiently to reintroduce the choice to consent to a “bond of service or labour” as collateral for debts have been doing a great job to establish the notion of unconditional “freedom of contract”, and that individual/private freedom to choose and consent should never be restricted because of social/public considerations.

PS: consider the already established “liberal” freedoms: in every case several different arguments could have been used in favour, but the liberal campaigns for them have always and mainly if not solely based on unconditional private/individual freedom about unconditional (property) rights (“I own my body” etc.). Liberals have campaigned hard to establish as a principle that individual and property rights should not be restricted by collectivist or social considerations.

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