This post was good up until the LLM part, which is largely bullshit and applause lights which make no sense if you actually think about it (ah yes, I'm sure some 'audits' will fix this).
The whole thing might be LLM slop. Where do ICU nurses have a low enough workload that they can slack off on the job without consequences?
What drew my attention wasn’t the quality of the work but the attitude—assuming these can be meaningfully separated. I’m not qualified to assess the quality, but the attitude was notably negative, something that anyone observing the same situation might recognize. This led me down a rabbit hole: why would someone who chose a high-stress, well-compensated profession display such behavior? While workload might explain it—and I acknowledged that possibility in my original post—the purpose of my analysis was to explore other potential factors.
I should mention that this happened on day one. I ended up staying overnight with a family member, which led me down a separate rabbit hole about how many patients suffer or even die due to poor-quality sleep caused by excessive medical alert noise pollution. Over the next two days, however, I encountered several nurses with a positive attitude, which was a refreshing change.
I agree with the description of signaling, but the entire solution seems mistaken. What you actually need is more potential nurses. Then, the ones who slack off can be fired and replaced by someone else.
The proposals (generated by an LLM?) sound... naive. If conspicuously slacking is the thing that gives you high status, why do you expect that public displays of metrics would change that? Everyone already knows; now they will... what?... know twice as strongly? If slacking is a high-status thing, then giving someone an excellence award would probably make them an official loser.
If you reduce the slacker's salary, and as a consequence the slacker quits, do you have a replacement ready? If not, then you are in trouble. If yes, why are you waiting for all the proposed steps, when you could simply fire the slacker right now?
Why do highly-paid hospital workers slack off and complain so often? Most would say "because they can" or "they're just lazy" or "it's a tough job, stress release." But I suspect there's a deeper status game at play - one that may illuminate broader patterns of institutional decay.
Consider: I recently observed an ICU Registered Nurse who makes at least ~$236K/year, in a highly rated hospital in San Francisco, demonstrating conspicuous low effort. They:
The conventional view says this is just poor work ethic or a "burned out" employee. But notice - they're not just working little, they're signaling how little they work. This is key.
In most workplaces, appearing hardworking is high status. But here we see the opposite - there's status in showing how little you care. Why?
I suspect it's about demonstrating market power. By conspicuously slacking while keeping their high-paying job, they signal: "I'm so valuable that I can get away with this." It's like a peacock's tail - wasteful display that proves fitness.
The unhealthy food in the hospital setting amplifies this signal: "I'm so secure in my position that I don't even need to maintain appearances."
But there's more. By discouraging others from working hard, they're engaging in a subtle status competition. Each person working hard makes their slack more conspicuous. By convincing others to slack, they maintain their relative status position.
This matches broader patterns. High-status people often signal by breaking rules that bind others. Think of celebrities wearing ripped clothes or tech CEOs in hoodies.
If this model is right, simply raising wages won't help - it might even make it worse by increasing the status value of conspicuous slacking. The more you're paid, the more impressive it is to visibly slack off.
This pattern connects to several institutional failure modes:
We need to reshape the status landscape through several interventions:
This model makes several testable predictions:
To test these predictions:
Control variables would need to include:
This case study suggests several general principles:
This pattern might explain similar phenomena in:
For organizations wanting to test these ideas:
The key insight: Institutions run on status games. The trick isn't eliminating them, but aligning them with institutional goals. Any solution must make positive behaviors higher status than negative ones.
Remember: I'm not making moral judgments - just examining how status incentives shape behavior. If we want better institutions, we need to understand their real dynamics, not just their formal structures.
I'm particularly interested in hearing from readers who've observed similar patterns in other institutions. What status games have you noticed that others miss? What interventions have you seen work or fail?
[This post builds on ideas from Zvi's "Immoral Mazes" sequence]
P.S. Yes, healthcare workers do crucial work. That's exactly why getting these incentives right matters so much.
P.P.S. Some will say this analysis is too cynical. But if we want to improve systems, we need to understand how they actually work, not how we wish they worked.