Creative Solutions to the Nursing Shortage - Mandy Richards, Chief Nursing Executive for Intermountain Health


How do we solve for nursing shortages in a thoughtful way in which we're reinventing the way we deliver care? That question is asked and answered on today’s episode of Raise the Line by Mandy Richards, Chief Nursing Executive for Intermountain Health which operates thirty-three hospitals in seven states. The veteran nurse leader believes the go-to strategies of doing a better job at recruitment and retention, while important, will not be enough, so it will be necessary to reskill the current workforce and redesign nursing education. Or as she puts it to host Michael Carrese, “Are we ensuring that our students in nursing school are getting taught and equipped with what they're going to need when they come out?” Richards is also keenly interested in improving the transition from education to practice -- in fact she’s pursuing her PhD at Yale on that topic -- especially at the very start of the clinical work experience to avoid what is known as “transition shock.” As part of her academic work, she’s created a research project featuring a dedicated educational unit that trains new graduate nurses in cohorts in the first month on the job. In addition to reinforcing critical thinking skills, the experience helps establishes peer relationships the new nurses can rely on going forward. Tune-in for a wealth of other ideas and insights on this key challenge in modern healthcare including establishing travel pools within health systems and the potential for ambient listening technology to improve nursing efficiency.




Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare and we're going to do that today with Mandy Richards, the Chief Nursing Executive for Intermountain Health, which is considered one of the nation's most innovative health systems for its focus on wellness and addressing the social determinants of health


In her role, Ms. Richards is responsible for the advancement of patient care services and clinical technology innovation across the continuum of care with a focus on strategy and operations. She joined Intermountain in January of 2023 from Hartford Health Care in Hartford, Connecticut, where she served as Chief Nursing Officer and prior to that, she spent fifteen years with Alina Health in Minneapolis. 


Ms. Richards holds bachelor's and master's degrees in nursing, as well as a mini-MBA, and she's currently pursuing a doctor of nursing practice from Yale University. Thanks so much for being with us today, it's great to have you. 


Mandy Richards: Thank you so much for having me. 


Michael: We like to start with our guests by finding out more about what first got them interested in healthcare, in your case, nursing, and then you are also interested in critical care. So how did that all come to be? 


Mandy: Well, quite the story, so let me share that with you. So for me, nursing's always felt right. I looked at business and I looked at finance and that just was never the fit for me. I've always had an internal drive to help people and always looking to help people at a time when they're in their most greatest need, like when you really need to have the opportunity to provide comfort and care for them.  


And so obviously, I'm not from the United States. I grew up in Australia with my parents and my sister, and in fact, it was a childhood experience for me that made me know that nursing was not just a job for me, but the call of my life. I was only ten years old. I have one sister who's a couple years older and I'll never forget the night where...you know how you wake up in the middle of the night, you're a little bit disoriented and there's chaos in the house? So, I see my parents and I know that something's wrong because you see that look in their eye and so I then see my sister sitting on the side of her bed and she was having her first ever asthma attack. It was pretty severe and so she was really gasping for air and then everything happened so quickly. 


All of a sudden, the ambulance whisked her off with my parents and I got sent to the neighbor's house. So, I had no idea. I was ten. I had no idea if she's going to be okay. I was really frightened. Then you fast forward a couple of days and mom and dad come over and say, “Okay, we're gonna take you to see your sister.” I don't even know what to expect because it's just been such a chaotic couple of days. So, I go to the hospital and I remember distinctly sitting in the waiting room and my sister's nurse came out to the waiting room. She sat next to me and she said, “Hello, I'm your sister's nurse,” and she's like, “I just want you to know she's okay and that I'm there with her the whole time and that she's gonna be okay and here's what to expect when you come and see her.” She was in critical care, and so she explained the breathing machines, she explained the pumps. I don't remember the exact words, but the feeling she made me feel of just being able to relax and I felt so comfortable that she was there with her all the time. 


I went into my sister's room and she's like, “You should talk to her, she can still hear you and she'd be so excited you’re here.” It was all of those things that made an impact on me as a ten-year-old. That was a defining moment for me as to why I went into nursing. Because I thought if I could have that same kind of ability to comfort someone of that age, at a time where it was so stressful, then why wouldn't you want to do that with your life? It's not just a job, it truly is a call. 


Critical care for me was a passion because I always wanted to have the greatest impact that I could. I've often been influenced by my own personal mission statement and so I thought I'd read that to you. So it is: To live to my potential with determination, to have the greatest impact on healthcare that I can and to make a difference in the lives of patients at a time of their greatest need of comfort and care. That's truly what my sister's nurse did for me. I think I'm very fortunate to have a distinct moment as to why I went into nursing, because I tell you that each and every day, it draws me back to the why of why I do this work. It's not a job, it truly is a call on your life to really provide that comfort and care at a time of greatest need. 


Michael: So, that experience you carry with you, like on a daily basis? 


Mandy: You bet I do. Yeah. And although I'm not taking care of patients at the bedside anymore I always go back to that experience of, how would this feel for patients? Or how would this feel for families? And so I think that's where our own healthcare experiences really do help us on our journey to know what things feel like for patients and families.


Michael: Yeah, they always say it's not what you say, it's how you make people feel. 


Mandy: Yeah, exactly. And that's what it was for that nurse for me and even at a young age, I didn't know what I wanted to do, but she certainly...it was how she made me feel. 


Michael: So obviously, you've had a big impact doing direct patient care, but as you mentioned in your personal statement, you want to have the biggest impact possible, which helps explain why you pursued nursing leadership. Tell us how that all started and how it unfolded. 


Mandy: Well, it is interesting, because you don't go into nursing to say, “Oh, I'm going to be a nurse administrator or a nursing leader, or…” I just wanted to be the best nurse. I just wanted to be the best nurse I possibly could and make the biggest impact. But like many of us, you get the, ‘hey, have you ever thought of being the nurse manager’ discussion. And so for me, that's how the leadership happened. 


Although I would take a step back. The true first leadership position I had was I became an Advanced Practice nurse. As I said, I always wanted to do the most I could with, you know, the gifts and talents you've got to make the biggest impact. So, I actually became a clinical nurse specialist in critical care, which is a very research-focused, advanced practice nurse. After that role is when I moved to the United States and started doing nursing over here and started off as a clinical nurse specialist, but then got that question, ‘hey, do you want to be the nurse manager?’ 


What I love about nursing leadership is you can be a leader of nursing at the bedside in advanced practice roles or the administrative side, like I have now, or in academics as well and sometimes it's a combination of at the bedside and academics. That's what I love about nursing is that there's so many facets to nursing leadership, both clinically as well as administratively, and so many options of what you can do and the impact you can make. And so I'm thankful for the first nursing leader that asked me about being a nurse manager, because that opened my eyes to a whole new track in nursing to continue to have that impact that I was talking about that I never thought was there. I didn't really understand that it was there. I thought it was just, oh, you're clinical and I've done all that I can clinically. So that's where you stop. 


So, that's what excited me about nursing leadership. There really is something for everyone's gifts and talents. 


Michael: I want to get into your work as a leader in a minute, but I think it'd probably be helpful for folks to learn a little bit about Intermountain Health. I mentioned that it's got a national reputation for being progressive with value-based care and population health and all that sort of thing. But what do you want our audience to know about Intermountain?


Mandy: Intermountain is exactly what you said. It is an incredible place. It is a place of innovation. But I tell you, we have 66,000 amazing caregivers. We don't call them employees. Everyone's a caregiver, whether you're a direct clinical caregiver or if you're a caregiver in environmental services. Of those, we have 28,000 nurses. I couldn't be more proud of the work that they do each and every day. 


We're in seven states in the mountain west. It includes thirty-three hospitals. We have one virtual hospital, which is incredible, very, very incredible to see what they do in there. We have an insurance plan, Select Health, with over a million members. We have 4,800 licensed beds. We've got 4,600 employed physicians and advanced practice providers and about 385 clinics. So, just an incredible footprint and span and amazing work that's happening each and every day that truly is innovative.


I've admired Intermountain for many, many years. Prior to me joining Intermountain, I was in another two health systems. Intermountain certainly is known for its innovation, but also its willingness to share what it is that makes it special to get those outstanding clinical and experience results. It's that secret sauce that's like, it's too good to share. So it's exciting to see what that is and how that feels being at Intermountain Health. I couldn't be more proud to work there with the amazing people. 


Michael: I have to ask you about the virtual hospital because I've actually never heard of a virtual hospital. What is that all about? 


Mandy: So, yeah. As everyone knows, we were forced into COVID at a time where there wasn't as much virtual care as there is now and so we were very fortunate. We were very ready. In the virtual hospital, there is virtual nursing. So, we'll do nursing about more rural or regional hospitals to support them. There's also physicians that are working in the intensive care space as e-ICU doctors. There's also nurses in pediatric ICU and neonatal ICU supporting each other. There's telemetry monitoring. There's transferring patients throughout a whole system. There's coordinating the air flight. There's also one-to-one attendants, which is where a patient may need a little more oversight just because they might want to try and get out of bed all the time. So. we've got that center as well and then obviously, I'm sure we will touch on the topic of AI in nursing, but there's obviously a lot of work going on in what the next stages of these virtual hospitals can be so basically it literally is a hospital without beds. But that expertise of our nurses and physicians going to areas where we don't necessarily have that level of expertise, but the patients are getting the same exceptional care and expertise of those of our clinical team as if they were there virtually. So, it is pretty amazing. 


You can be in a rural hospital and have a stroke neurologist right there or a critical care nurse or physician helping guide the team there, which keeps patients local, which is what is often needed to stabilize them because they don't need to come to the city. I mean, if we can keep them in their rural community, it's far less stressful for the patient and the families. 


Michael: Oh, absolutely. Yeah. It makes total sense. 


Mandy: Yes. It's a lot of fun. 


Michael: So, let's get to your job. Tell us day to day what you're doing and what are your two or three top priorities?


Mandy: Yeah, sure. I get asked this question a lot. It's like, well, explain to me what this is. What do you do? So you take care of patients is usually what the first question is. I'm like, well, indirectly, sure. But what I love about the Chief Nurse Executive role is that it is a unique role where you don't get this with every role in the health system. You think about, you know, Chief Operating Officers, they are very strong in strategy and business, but they're not clinical, necessarily or not required to be. But nursing is unique. Nursing is obviously clinical, so you use your clinical skills every day, as we've talked about but it’s very strategic.


I mean, you think about this time now in healthcare, we're going to change this care model. We are not going to have enough nurses. So if you ask me what's top of mind, it is how do we solve for the nursing shortages that we're going to anticipate in the future and how to do that in a thoughtful way, which we're reinventing the way we deliver care, which is exciting because Intermountain is one that will embrace that and is really innovative. 


So, strategy is a big part, but then also business, it's operations. Hospitals, for example, are made up of a lot of the inpatient nursing units, and the inpatient nursing units are run by nursing leaders. And so we're talking about not just their clinical care, but we're talking about all the patient experience, we're talking about hiring all the nurses, we're talking about the supplies, the labor. I mean, you're talking about business, true business operations. And so for nursing leaders, and for the Chief Nursing Executive, you get all three, which is pretty unique. 


As I think about what our focus is, yes, it's obviously education, professional development of our current caregivers, it's ethics and patient advocacy, quality and safety, obviously that clinical side, a lot of regulatory compliance, everything we do has to be put through that lens, is it in compliance with our regulations? Obviously, it's developing our leaders and collaborating with different departments across the system, both internally and externally, and then that operations side of resource management. 


But right now, as I mentioned, the biggest challenge we have is the headwinds we see coming. And it wasn't just COVID. COVID certainly did exacerbate it, but we knew that our workforce is getting older. In fact, I saw a statistic that half of the workforce in nursing is over the age of 50 and people aren't going to work forever. At the same time, there's not enough positions in nursing schools. I heard another statistic of about 80,000 qualified nursing applicants nationally are turned away from nursing school every year and it's because there's not enough faculty. There's also the clinical rotations component to it and that's why we have to, as health systems, be really good partners for universities, so that we can be creative in how do we open up capacity to train these nurses? Because it really is a partnership, training them together. 


Michael: So, in addition to that step, what are some other steps that you're taking to deal with... I think you described it as headwinds. Some people are talking about it as a crisis.


Mandy: Yeah, absolutely. So what we've worked out is we can't recruit and retain our way out of this dilemma, if you like, that we're in. We're just simply not going to have enough nurses coming out of nursing school. So, we're going to have to re-skill our current workforce or redesign the way we do it. But we must do a really good job at recruitment and retention. And so we have been partnering really closely in all of our markets with our nursing schools to say, what does it look like for nursing in the future and are we ensuring that our nurses in nursing school are getting taught and equipped with what they're going to need when they come out and work in the workforce? 


What we found during COVID in particular was such an increase in the first year turnover for nurses. They weren't even staying a full year in the career that they've just spent four years at school for. You look at that and you go, what are we doing wrong here? Obviously during COVID, it was the stress of COVID and coming into a new profession at a time where it was new for everyone. We were learning as we were going. And so you can see, yes, there's that dynamic, but also, we need to onboard our nurses differently. We have to look at how do we expose nursing students to the environment of care delivery before they've even finished? 


We'll often have a lot of nurse apprentice positions or student nurse techs where they're working with us alongside the care team, and then usually they'll take their first job on that unit. So, there may be a student nurse tech, which is more of an assistive role for the nurses, and then they become a nurse on that unit, and it makes their transition a lot easier. So, we've been doing some things like that. 


But then, we've got to redesign. Some of the things that we've been looking at is redesigning the scope of practice, and redesigning how we schedule our nurses. We've been really creative. When there was a lot of travel nurses going all around, everyone was swapping nurses almost, right? But it wasn't adding to the pool of nurses we needed to take care of patients across the country, and so what we did at Intermountain is created our own flexible workforce because we heard that nurses wanted the ability to be able to travel as well as earn more money, and that's fine for a period of time. So we're like, okay, that's great, because we have a need all over. We've got seven states, as I mentioned. How about we create our own internal travel pool so that our own caregivers never have to leave the Intermountain family. 


That was wildly successful actually, because our nurses were like, “This is great. I understand the same way we deliver care, the same policies, procedures. I’m not having to learn that new, but I'm getting to experience other sites of care that we have in Intermountain.” It actually has made the family closer. We got to know each other, went to each other's houses, you know, like, as far as our care locations, and so that was a wildly successful way of redesigning the way we staff and schedule. 


Then I think there's also a lot we can do with automation, with the way we deliver care. Technology is going to play a huge role in reducing the burden that we have on nurses now that could be automated because that's really the only way that we're going to be able to truly redesign the way we deliver care. 


Michael: Well, give me some examples of that. 


Mandy: I'm ready for this one because I knew that this would come up. So, as I mentioned, we've got the virtual hospital, which is great. We're really positioned well for how we'll start to deliver care differently. But as we look at it, it's not just artificial intelligence, it's intelligent automation, is kind of how we're looking at it. So, there's the natural language process of ambient listening like Siri or Alexa. We're really hoping that through ambient listening -- and we've seen some of the work that’s coming out with some of the physicians -- there has to be a way if we're doing this already in our homes with Siri and Alexa, we need to have a way where there's an ability to have ambient listening that then goes directly into the electronic health record. Because we know a nurse spends about 30% of their time charting. So, if we're able to reduce that burden by automating it, then that's more time at the bedside. 

We already do that, actually, with ventilators and pumps. It used to be that every hour, the ventilator setting had to be documented in the EHR manually. Now, it all comes across and you just validate. You obviously always have to validate that that's correct, but that's saved a lot of time. So, there's more along those lines. But truly with ambient listening, a nurse can narrate their care, and it would go straight into the chart. There's nothing out there right now, but that's where we need to head because I think that's where the most opportunity is if 30% of a nurse's time is doing that. 


The other pieces would be, you know, really looking at chatbots, software assistance. So, even beyond the bedside, how do people engage with Intermountain or different health systems in a more convenient way so they have greater access to care? We've seen robotics already a little bit with the DaVinci surgical robot. We're starting to see robots going and getting supplies and things like that. That's kind of very, very different. There's just a lot of innovation happening. I would say right now, we are looking at every type of technology out there that would make it easy for our caregivers and some of it will stick. Some of it will be like, this is great, this is perfect. But I think we're all learning together from a technology side as well as a clinical side. We're all learning together as to what's working, what's not. But I think the biggest thing is that willingness to try something new and willingness to pilot something and know when it's not working. I mean, it's just as important to know, oh, this is great, let's keep going versus this is really not getting the desired results. We need to spend our effort somewhere else in pursuing some other kind of technology.


Michael: You mentioned chatbots there. Talk to me about that. Is that using that interface to answer basic patient questions...say they're having a surgery coming up or they just had a surgery? What are you planning to use it for?


Mandy: It would actually be more on the lines of what you'll see in some of these retail sites. You'll have a question and it will help you to make sure you're getting to the right place. It could be, you know, do you have a question for scheduling? Great, and so it would just be helping to get to the right person more quickly. But there's also the ability for knowing when someone's calling in to say, “Oh, I noticed that you needed to have a colonoscopy screening, can I schedule that for you as well today,” in order to make it more convenient. 


We know what preventative care is required. But if that was to come straight to the caregiver whilst they had someone on the phone, let's schedule it all for you so that we can do more and more preventative care. So, it's those sort of things and getting people in and getting them to the right caregiver to then have that human connection to carry out all of the access and scheduling that they need.


Michael: You know, you had mentioned the transition from student to actually working and enhancing that and improving that experience as a way to maybe forestall some turnover early on. That's also a research area for you -- the transition from nursing education to the workforce -- and you're working on your doctorate at Yale. So can you dive into that a little deeper? And I'm wondering, you know, obviously everybody's familiar with residencies...are nursing residencies something that we should be moving toward, or some form of that?


Mandy: Yeah. And of course, I'm going to get pretty excited about this because I'm in my third year of the program. A wonderful program, by the way. But I've spent the last three years thinking about this question and researching this question and actually I’m in the process right now of implementing the project. So, I’m really excited. 


What I saw was the transition of nursing students into the workforce was really difficult during COVID. To your point, nurse residency programs are brilliant and that was one of the requirements to say, look, if you have a nurse residency program, it better equips our nurses. It's a year long and there's two schools of thought: some health systems have their own homegrown residency programs, and then there's other, more accredited residency programs. But it's more about how do you support that newly graduated nurse through that first year into practice and it looks at a lot of evidence-based practice and how you look at that and projects and support. So, it is very much a year-long course that supports nurses throughout that first year. 


But it doesn't touch that bridge from new graduate nurse into the workforce, like, that first four weeks. So, the research I was looking at was on what they call “transition shock,” when it's that shock of the first four weeks in moving into a new area and how our schooling, as well as the new grad residency programs, don't really equip you for that transition to practice. That's where the emotional and psychological stress comes in. 


So, the project is centered around creating a dedicated educational unit that would bring in the new graduate nurse. It would equip them with using the Socratic teaching method with critical thinking to really help establish a foundation of learning. They would have their preceptors and they would be on this special unit, and they're in a cohort together. So, like college. I have a college-age daughter. She's got all her friends and all of a sudden, you go into the big world of being an adult and my first job, and none of your friends are around you. So it's like, you're so used to doing everything together in groups. 


So, we thought if we created this cohort of these new graduates, most of our new graduates have obviously come out of school. Most of them are a similar age, but they've had a shared experience and so they come out onto this dedicated educational unit. We have activities and fun things to get them acclimated. They're making connections because that's important, but then they're learning all the basic fundamentals of nursing, using the Socratic teaching method, having more support, and then they'll launch off into their home unit after four weeks.  


It's going really well. We have a look at how well they're doing by using a standardized tool, which is designed for new graduate nurses. It's been around for a long time. So, we give that to them before and give them four weeks of leading and so we're excited to see the results, to see whether it really has made a difference in teaching them those fundamentals and critical thinking skills. So, I’m pretty excited. 


But one thing I would say is learning is something that you never stop doing. For me, it was a twenty-year gap between doing my master's degree and my doctorate. I never actually thought I would go back and do it. I was like, “I don't need this for the job. I've got this job. It's great.” But it actually wasn't so much about job. It was more about you learn so much on the job, and then there's the formal training, and although I learned a lot on the job that has been in the course. I think the formal education has been so good in the sense of it filled the gap of, “Oh, now I understand the theory behind what I thought was common sense.” And I am excited because it's certainly giving me a new perspective on research as well. So, it's just been a phenomenal few years, and I'm really excited about the project and its outcome. 


Michael: Well, yes, and I'm also thinking you're a great role model for younger nurses because you have laid out a path for how you can continue to learn and earn credentials, throughout your career, even if you've achieved certain measures of success. 


I'm afraid to say we're almost out of time, but I do want to give you a chance to answer one of our favorite questions, which is, what is your advice to the learners in our audience and the early career professionals about meeting the challenges of starting a healthcare career at a time of such change and challenge? 


Mandy: I would say the one piece of advice is never say no. People are going to come to you and say, “Hey, would you like the opportunity to work on this work group or to take this role?” Never say no. It's never the perfect time. Say yes to the opportunities that come in front of you because you don't need to be equipped completely with having all the skills to do the job that's in front of you that you're being presented with. It's really more about your ability to grow and develop into that role. So, don't be afraid of, ‘oh, I don't know what I'm doing, how will I ever be a manager?’ We know that. But part of it is you've got the potential to learn. 


And so I would say, it's never going to be a perfect time. Life will throw you many challenges, but always say yes and lean in and just believe in yourself. You've got the ability to do it and you can learn these new roles, and it's pretty exciting when you do. Otherwise, you won't live to your potential, and you really won't know what impact you can truly have on healthcare.


Michael: Well, that is great advice and a wonderful note to end on. I want to thank you so much for spending the time with us today, Mandy Richards, and wish you all the best in your important work out there at Intermountain. 


Mandy: Thank you so much. Such a pleasure to be with you today. 


Michael: I'm Michael Carrese. Thanks for checking out today's show and remember to do  your part to raise the line and strengthen the healthcare system. We're all in this together.