Trish Gallagher, Former CNIO
Healthcare has a serious problem. Nurses – and nursing leaders – are exiting the profession at alarming rates.
According to the National Council of State Boards of Nursing, about 100,000 registered nurses left the workforce during the past two years, and another 610, 388 reported an intent to resign by 2027.
“It’s scary,” said Trish Gallagher, who until recently served as CNIO at an academic health system. What it isn’t, she said during a recent interview with healthsystemCIO, is a numbers problem.
“We don’t have a nursing shortage; we have a shortage of nurses who want to work at the bedside because of the environment,” noted Gallagher, who is hardly alone in having that viewpoint. In a recent memo, National Nurses United cited data from 2022 showing that there are as many as 1 million registered nurses with active licenses who were not employed. Furthermore, the number of candidates who passed the nursing licensure exam has steadily grown.
“There is no shortage,” according to NNU. “But there is a staffing crisis.”
The question, of course, is why. And there’s perhaps no one more suited to answering that than Gallagher, who opened up about why she walked away from a ‘dream job,’ the role technology – and the speed of adoption – has played in clinician burnout, and how she hopes to leverage 25 years of experience to help organizations stop repeating the mistakes that are prompting nurses to pack up and leave.
Q&A with Trish Gallagher, Former CNIO
Gamble: Hi Trish, thank you so much for taking the time to speak with us. You and I have actually spoken before when you were part of a CNIO Panel back in 2017.
Gallagher: I remember that.
Gamble: I was looking back at that discussion, and I remember someone saying at the end that it felt like a support group. I thought that was so fitting given what we’re talking about today. Being able to talk about challenges and relate with other people is really important.
Gallagher: It’s interesting you say that because at my last job I was part of an Epic CNIO group, and a lot of it was that — thinking strategically, of course, but also hearing where people had the similar struggles. What I’ve found is that everybody is feeling the same thing right now; the pace at which our health systems are trying to implement change is so fast, and there’s no more time for education.
When you look at the downstream effect of that on our clinicians — who aren’t just getting it from the technology side, but also from clinical practice side with operational changes — and you compound all of that, it’s contributing to some of the massive burnout in healthcare.
“It’s not about retention bonuses”
Gamble: I want to get into what you think are some of the core issues, but first can you walk me through your own decision and why you ultimately chose to walk away?
Gallagher: I will say that sometimes your title and your responsibilities don’t match. One of the things that probably impacted me was losing an extremely strong CNO at the organization where I worked, and another person who was truly a champion for nursing. Through them, I felt like we could move the needle on nursing strategic initiatives; that even if there were a lot of other competing priorities, we had enough of a voice to get funding.
Once those two individuals left the table, it was really difficult. And this is something I’ve heard other CNIOs say; we keep talking about retaining nurses, but what are we really doing about it? It’s trying to get a focus on what we’re trying to do operationally to change the culture and the environment of nursing care today. And it is not by any means all about technology, but making sure the organization is truly focused on change.
And it’s not all about retention bonuses. We hear a lot about that; and yes, money is important. But I think having an organization where nurses feel heard and are at the table is important too. When you lose the people who are champions, it can feel like there’s no way to get the work done that nurses need done.
Taking on additional roles
For me in particular, another factor is that after six months, I was asked to take on an interim role over the clinical application team. And so, now in addition to being CNIO, I was also Associate CIO of Clinical Applications. That went on for a year, and during that time, I had to shift my focus more to the application role, because there was so much demand and so many things that needed to be fixed in that area. The reason I had left my previous role with Ascension was to move away from managing applications, and I found myself doing that again. And I understand that interim roles need to be filled, but there were multiple things that put it on hold. It was nobody’s fault. But for me, keeping that pace for a year just did me in.
Gamble: The CNIO role doesn’t seem like one that can be done when you have another full-time position. I’m sure that was very frustrating.
Gallagher: It was. I mean, there were some synergies that made sense, and there are things that may have been harder to do if informatics and applications were separated, but it was the icing on the cake. I felt like I couldn’t keep doing it. And really, I was doing much because I felt I was doing a half-assed job with everything.
Losing nursing champions
Gamble: Right. You mentioned losing people who are champions for nurses; this might be something where people don’t realize the potential impact. What did that mean to you?
Gallagher: The problem comes when the CNIO doesn’t have a seat at the strategic table, at the senior level. When you don’t connect the nursing counsel to the senior counsel, there’s a lot missing.
I felt myself getting frustrated on a daily basis. My husband noticed that I was tense all the time; that I was not myself. I was snapping at people. And I felt like I was doing the same things I was doing 20 years earlier. People aren’t listening to what the experience is telling them. And so I thought, ‘why am I here? I’m not helping this organization in any way.’
Gamble: I’m sure it wasn’t an easy decision. It’s something that probably weighed on you quite a bit.
Gallagher: It did. It was probably close to 6 months of feeling that way. And so, my husband and I started to talk about me doing something different.
The other part is that I had a change in my life. I had my first grandchild and we moved to be closer to family. I wanted to be able to help out; that’s why we moved. I didn’t want to be stuck at my computer for 10 hours a day. And so, I think that personal change really tipped me over the edge. I thought, ‘this is not the way I want to finish my career, because I’m going to finish it early if I keep at this pace,’ versus, I need to take a step back and figure out what I want to do. Because I’m not ready to retire yet, and I wanted to do something that gives me better work-life balance.
Timelines above all else
Gamble: Right. That’s another thing that can be so challenging, and it goes across the board. No one wants to feel like they’re doing a half-assed job, at work or at home.
Gallagher: Right. I think a lot of the work part is being asked to do things that go against your recommendation based on your expertise. If you say, ‘my recommendation would be to take this approach, and people without experience in the IT world say, ‘no, we’re going to do it our way,’ and you have to work in that environment where you know you’re not doing the right thing for clinicians, but you’re forced to do it because of a budget or timeline, that’s really hard. I kept feeling I had to shorten the timeline by eight weeks because that’s what senior leadership wanted, and because of that, I’m not going to deliver a good training experience for clinicians. That’s what — and who — is going to suffer. And that’s really hard.
Gamble: It goes back to what you said about not feeling heard or seen, which can be really detrimental.
Gallagher: It’s funny, my kids used to say, ‘my mom used to be a nurse.’ I would always remind them that I am a nurse at heart; even though I’m sitting on this side of the table my entire role is to protect nurses. I very much feel that, and when you can’t do that and you can’t help them, you start to feel paralyzed.
Technology’s role in burnout
Gamble: As you know, ‘burnout’ has become a buzzword. But to you, how does it affect nurses who are on the frontline?
Gallagher: When I think about the way we’re pushing the technology out, we’re doing everything so fast. The pace of change being thrown at clinicians is doing the same thing to bedside nurses.
Part of my burnout stemmed from the fact that we’re all over the board strategically. We bounce all over the place; there’s a fire every day. Things are changing constantly, and you can’t get anything done when you work in that environment. I feel like nurses are getting hit with the same thing. There’s a change in the process, and because of that, there’s a change in Epic and a new process. And instead of training you on it, we give you a sheet of paper so you can read about it. Those are coming at them fast and furious and all they want to do is take care of patients. Let me take care of my patients and stop this.
Is it the right solution?
And we’re all doing it for the right reasons. We’re doing it to improve processes. But I think we’re still in a very bad state where our operational leaders think technology is going to fix every people problem. That’s one thing I learned: you have to stop and ask yourself if technology is really the right solution. Because those required fields, BPAs, and pop-ups — they don’t change people’s behaviors. You have to look at that differently. I think every time there’s an event, we try to change technology, which is more change for clinicians, and it comes up fast and furious. I truly believe from the bottom of my heart that the amount of stuff we put in the EHR for nurses to do has absolutely been a contributing factor.
Revamping nursing documentation
One of the things I tried to do at MUSC, and the first CNO I had was on board with it, was to completely revamp nursing documentation. If nobody is looking at this data, why are we putting it in EHR? You need to look at where your nurses are doing non-value-added activity; that’s where the administrative burden is. And so, I think the pace of change has absolutely contributed to clinician burnout.
Archaic flowsheets
Gamble: That’s so important, and it’s not something that’s talked about very often.
Gallagher: I always joke when the whole buzz of AI started, it was all about the provider. Everything you heard was about relieving the burden on providers, and it’s like, hold on a second. Nursing hasn’t had any new technology from Cerner or Epic in 20 years. They’re still using archaic flowsheets. They’re hunting and packing to enter data.
Meanwhile, physicians have had voice technology for 20 years. We really need to be looking at nursing and modern how we’re doing nursing. Because it’s just crazy. Everything was about the provider. And I know Epic is doing some work with nursing in that space, and Nuance is as well. But it seems like nursing is always the second bird who gets it.
Gamble: It’s mindboggling and anyone who has received care knows who you’re dealing with or talking with most: it’s the nurses. They’re the ones who know everything about the patient.
Gallagher: It’s the biggest group in healthcare. And I love how you’re seeing so much on LinkedIn with nurses banding together. Nurses have had a bad reputation for eating their young.
But now we’re seeing this movement for innovation in nursing. I actually wrote a proposal around using voice for nursing documentation. We did a pilot at Ascension 5 or 6 years ago, but it didn’t gain much traction. I like the movement I’m seeing with nurses, but my worry is what will actually come of it. Still, it’s nice to see us banding together.
Digital transformation for nurses
Gamble: You talked about the need to revamp nursing documentation. Can voice technology play a role there?
Gallagher: I think so. I know Abridge is doing work in this space; I’m really encouraged by what I’ve seen. As a nurse, I should be able to do a head-to-toe assessment through a computer where it’s organized into cells. I shouldn’t have to sit there and navigate between these 5 cells to say what the urine looks like. I should be able to say, ‘urine is clear’ or ‘urine is cloudy,’ and the computer finds the right place to put it. I think something like that could be a game changer. It drives me crazy that nurses are stuck with these flowsheet concepts. I know that’s what we did on paper, but it goes back to the fact that if we’re truly doing digital transformation, who says we have to have 5,000 flowsheet rows for nurses? Why is that? I realize some of the initial design was around wanting to have discrete data, but does it have to be so archaic looking in the EHR? Why can’t the EHR handle that data differently? Because when I watch a nurse navigate those flowsheets, it just drives me bonkers. It’s just tedious work.
A better way
Gamble: When you know there could be a better way, I imagine it gets harder and harder to see people have to go through this.
Gallagher: It’s funny. When I was at Ascension, we ran into issues where vendors would say, ‘we can only do this with Epic’s architecture’ and so it goes back to Cerner: why is your architecture putting this barrier on nurses using voice? Why does it have to look like this?’
I think we need to push the vendors to be on board with this innovation and re-think the way it looks in the EHR. Nobody is reading flowsheets. They’re awful to read. They might go there looking for specific value. But no one is reading flowsheets. And the thing I still hear about EHRs is that the story of the nurse is missing. Or, the story of the patient is missing since we’ve moved away from that narrative. I’m not saying we should go back to narrative in any way but there’s got to be a better way to put this data together. I think the flowsheet concept has lived its day.
AI opening doors
Gamble: In terms of working with vendors and pushing on them to make these changes, that make a lot of sense. But I’m sure it’s challenging because people can get stuck in their ways. What needs to happen here?
Gallagher: We’re spending so much time working with Abridge or Nuance to figure out how we can leverage voice to get the data in these flowsheets, when really vendors could be working with Epic or Oracle to say, ‘this is the way it could look.’ AI has opened some doors. Let’s think about how this can actually look in the EHR too. Let’s modernize that piece of it. This is where nursing banding together and EHRs partnering with voice companies — maybe that could help gain some traction. But instead of looking for how we use voice in the current landscape, I don’t think any of our nurses are married to flowsheets and would not be disappointed if something different came along. I think that would be really cool to be part of.
No time for education
Gamble: You mentioned earlier that with a lot of these changes, there isn’t enough time for education. That’s something I think leaders need to be aware of. Can you talk about the effect it can have when there isn’t time for education on new processes or systems?
Gallagher: Part of that is the downstream effect on the delivery of care. If I’m getting handed 4 tipsheets this week on changes in the EHR that impact me, or if I get handed a few tipsheets, and by the way, there’s this online module I need to complete, and I have 8 patients this shift — that’s more burden on them.
Back in the day, we had more informatics support. We had people assigned to units who would go to the morning huddle and talk things through with them. They might say, for example, here’s what’s coming in Epic. That ability to ask questions, interact, and know who you can call, is a different environment than just pushing something out through email. Having someone they can relate to and let them know when it’s not working correctly.
“Nurses will find a workaround”
When you just push out tipsheets, if it doesn’t work correctly, you know as well as I do that nurses will find a work around. They are not going to take the time to pick up the phone and call the help desk, and I don’t blame them one bit. I wouldn’t either. It’ll be months before we find out it’s not working correctly because something will happen.
And so, just having that personal touch to help with the change management part is so important, especially with all of the features and upgrades. We have to figure out a better way to get that personal touch to education training versus putting the onus all on the clinicians.
Gamble: Getting away from that personal connection and relying on the tip sheets is something that I’m sure can save time or money but can be detrimental in the long run.
Gallagher: Right. Honestly, I think the biggest thing that we lost in the informatics space is that with every organization I’ve been with, we’ve aligned informatics with service lines. If you’re in charge of cardiovascular, you own the education and communication for that. And then the managers and directors know which IS person to go to. It works very well, and I think we get a much better dyad in terms of getting things adopted than we do without that.
During Covid, resources got cut and never added back in. People thought we could do more with less, but the reality is, we can’t do more with less, because your EHR is not going to be utilized. You can push out every little feature you want, but just because you push it out, it doesn’t mean people are using it. That’s the wrong assumption. Ninety percent of them probably don’t know about it.
Gamble: What type of advice can you offer to CIOs, chief digital and information officers and other leaders as to how can avoid situations where nurses are getting increasingly frustrated, and leaders are walking away?
Gallagher: Help get your CNIO to the strategic table. And if the organization doesn’t see an opportunity to have them there, I encourage CIOs to be part of showing the value of having that person there. Don’t just kind of accept the culture the way it is; help drive the change to get them at the table. It should be relatively easy, but I think it depends on the organization.
Gamble: When you think about your next steps, what are some of the biggest lessons you’re going to take with you?
Gallagher: I started my new role at the end of February with a consulting company that works with health systems at the strategic level. I wanted to avoid doing project work again, because I would be repeating the same things. In this role, I want to help drive change.
Showing the need for CNIOs
The company is getting more and more requests to work with organizations that don’t necessarily have a CNIO but want to hire one and need help justifying the need or need help mentoring some of their internal people for that role. Part of it will be working with nursing leadership across the country as well as CNIOs to say, how can we do this together? How can we do it better? Why does your organization need a CNIO? What does the CNIO do? And even virtual nursing and making sure we’re at the table for that.
I think it will be interesting to build that momentum across multiple health systems. I’m hoping that this will allow me to have that strategic role I was looking for and work with leaders to help make a bigger change.
Gamble: Right. Another thing I wanted to touch on was your LinkedIn post, when you talked about walking away from a ‘dream job’ and how you want to make sure the same mistakes aren’t being made again and again. You also talked about burnout, which really struck a chord. Were you surprised by the number of people who responded and said they had similar experiences?
Gallagher: It actually made me feel somewhat better, because part of me kept wondering if I had overreacted and might regret walking away. I also got a lot of private messages from people who said they did the same thing and shared some of the things they learned. I think it helped. It also highlighted the fact that this is a bigger problem than we all know about.
I will also say that I was able to walk away from it partly because of where I am in my career. My husband was supportive. In 30 years, I had never left a job without having another one lined up. It was an extremely uncomfortable feeling.
But I worked with a group of very devoted, dedicated analysts who were feeling the same way as me and could not walk away. It told me that we’ve got a bigger problem; it’s just that not everybody is able to do what I did. How do we fix the culture of technology inside these health systems? It is not the holy grail to all your problems. We’ve got much bigger problems.
Gamble: And it shows that burnout, exhaustion, or whatever you call it is something that can happen at any level. It’s so pervasive.
Gallagher: It is. I don’t think we’re providing the right resources, but honestly, I don’t know what they are. We keep hearing about building up resilience in people. I don’t think that’s what we need to do. Our people are very resilient. I think they’ve been through a lot, and I think we need to just be more cognizant of what we’re doing to them.
Gamble: I agree. Well, I want to thank you so much for sharing your story. It’s been really interesting, and I think it’s such an important message to get out.
Gallagher: My heart goes out to nurses right now. It really does. We’ve been here before where we keep saying we’re going to have a nursing shortage. But we don’t have a nursing shortage; we have a nursing shortage of people who want to work at the bedside because of the environment. There are nurses out there, but it’s scary right now.
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