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Building a Rural Nursing Workforce With Fisher-Titus Medical Center

Building a robust nursing workforce is hugely important in providing quality care to patients, but poses unique challenges in rural Ohio. In this conversation, Fisher-Titus’s Stacy Daniel, director of clinical programs, and Katie Chieda, chief nursing officer, share how their team concentrated on recruiting international nurses to ensure that they remained a strong, independent health system for years to come.

00;00;01;05 - 00;00;35;00Tom HaederleEnsuring a robust nursing workforce in rural Ohio poses unique challenges. Equipped with a broad plan to retain their current workforce and recruit additional team members, the team at Fisher Titus Health concentrated on recruiting international nurses to their community to ensure they remain a strong, independent hospital for years to come.

00;00;35;02 - 00;01;03;23Tom HaederleWelcome to Advancing Health, a podcast brought to you by the American Hospital Association. I'm Tom Haederle with AHA Communications. In today's episode, Elisa Arespacochaga , AHA’s vice president of Clinical Affairs and Workforce, sits down with Stacy Daniel, director of clinical programs with Fisher Titus Medical Center, and Katie Chieda, chief nursing officer with Fisher Titus, to discuss their approach to building and sustaining a rural health care workforce.

00;01;03;26 - 00;01;26;07Elisa ArespacochagaWelcome to another podcast in the AHA's ongoing series where they focus on important issues facing clinician leaders. I'm Elisa Arespacochaga, vice president of Clinical Affairs and Workforce. I'm joined today by Stacy Daniel, director of Clinical Programs, and Katie Chieda, chief nursing officer for Fisher Titus Medical Center. Today we're going to talk about their approach to building and sustaining a rural health care workforce.

00;01;26;09 - 00;01;35;18Elisa ArespacochagaSo, all right, to get us started and Stacey, I'll start with you here. Tell me a little bit about yourself and your organization and then I'll ask Katie to chime in as well.

00;01;35;21 - 00;02;02;18Stacy DanielSo I have served as the director of clinical programs at Fisher Titus since 2021. I earned my Bachelor's of Arts and Biology from Ohio State in 2008 and my Bachelor's of Science in Nursing from Ashland University in 2014. I began my nursing career at Fisher Titus in 2014 as a staff nurse. Since then, I've held various positions throughout the organization, including church nurse, hospital supervisor and manager of nursing operations.

00;02;02;21 - 00;02;25;24Stacy DanielAs director of clinical programs, I serve as a liaison between Fisher, Titus Health and the clinical education programs. Ensuring continued development and successful recruitment and retention of their clinical staff, as well as leading international recruitment efforts. I also lead their clinical education department in initial and continuing education requirements and opportunities throughout their health system.

00;02;25;27 - 00;02;37;27Elisa ArespacochagaGreat. So you really have a sense from the ground up of where how the nursing team works and how to support it. So, Stacey, a little bit about you and Fisher, Titus.

00;02;37;29 - 00;03;07;21Stacy DanielYes. So Fisher Titus Health is an independent rural community health system, and we're located in north central Ohio. They have a 99 of that acute care hospital, which includes a level three trauma center, level two cath lab and certified stroke center. And they also have a 69-bed skilled nursing facility, a 40-unit assisted living facility. They have a home health center employed ambulatory physician group that provides primary and specialty care across 18 different sites.

00;03;07;23 - 00;03;17;03Stacy DanielWe also have a diverse ancillary outpatient services, which includes lab imaging, and they have a robust adult and pediatric rehab services at their facility. And Katie,

00;03;17;05 - 00;03;22;13Elisa Arespacochagaa little bit about your your background and how you came to this position.

00;03;22;15 - 00;03;54;25Katie ChiedaThank you. I am Katie Chieda and I serve as the chief nursing officer for Fisher Titus Health. I have served in this position since 2016. I originally joined Fisher Titus in 2013, holding many different leadership roles. Prior to the role I'm in today. As Chief nursing officer, I oversee nursing, ancillary and post-acute services across the health system. I started my nursing career at the Cleveland Clinic, serving as a bedside nurse prior to taking on nursing leadership roles.

00;03;54;27 - 00;04;15;19Katie ChiedaI also play an active role in the Ohio Organization of Nursing Leaders, serving as the committee chair for the engagement committee, as well as a seat on the board of directors for OONO. In addition to the state level involvement. I'm also a member of the American Organization of Nurse Leaders and serve on the Huron County Mental Health and Addiction Services Board.

00;04;15;21 - 00;04;28;26Elisa ArespacochagaGreat. Thank you. So, Katie, let's talk a little bit about how the pandemic and the nursing shortage really impacted your organization. Can you tell me a little bit about how that has gone for you?

00;04;28;29 - 00;04;58;14Katie ChiedaYeah. Before the pandemic, Fisher Tigers did not utilize contract labor. They were blessed that that wasn't something that they had to to turn to to staff their organization. Fortunately, they started the evaluation of international nursing in 2018-2019. As an independent community hospital surrounded by large tertiary centers. Their challenge with the nursing shortage was really just beginning at that point.

00;04;58;16 - 00;05;25;11Katie ChiedaOur team examined the market, their current ability to recruit and retain optimal staffing along with state and national trends, to identify strategies for recruitment and retention. Their findings indicated the growing nursing shortage, even before the pandemic. So they knew they had to start to find different solutions with that growing shortage. With the pandemic, of course, those nursing needs intensified quickly.

00;05;25;13 - 00;05;49;20Katie ChiedaWe expanded their med search bed capability as well as doubled the size of their ICU facilities across the state. We're nearing maximum capacity, which often meant that patients could not be transferred to other facilities. And that made their focus on really how do they maintain patient care here in the community, knowing that they may not be able to get those patients out. 

00;05;49;22 - 00;06;15;20Katie ChiedaWe did look at contract labor premium pay, of course, for their internal staff, but they were tired as well. So they wanted to ensure that they had the staff that they needed for the long term and they were able to, of course, as many hospitals across the nation did, decrease or hold elective services. They reallocate allocated resources from across the organization, ensuring that they were still providing the best care to their patients.

00;06;15;22 - 00;06;40;15Elisa ArespacochagaYeah, I know you took a look at a number of different approaches. You mentioned several of them to support your own workforce. In addition to looking to see how you could bring additional workforce in which in a rural area where you have a little more challenge doing that. Can you talk a little bit about some of those additional approaches that you looked at in addition to looking at bringing in international nurses?

00;06;40;17 - 00;07;04;04Katie ChiedaRecruitment retention was a strategic priority before the pandemic, and of course it continues to be today. Their goal is to continue as an independent community hospital. So now myself and their chief of h.r. As well as Stacy and a few other members of the team, they meet on a monthly basis to review new opportunities for consideration for recruitment and retention.

00;07;04;07 - 00;07;23;29Katie ChiedaIn the past, it definitely held a place on their strategic plan, but it didn't get monthly attention to shift. But some of the things that they do or we've identified as opportunities, they looked at an updated nursing compensation structure, which as soon as you look at it and make a change, you probably need to look at it again.

00;07;24;01 - 00;07;57;04Katie ChiedaWe also did focused educational assistance to ensure that they were spending the dollars allocated organizationally on their biggest challenge areas from a workforce standpoint. They identified and strengthened their clinical school partnerships. They expanded their clinical ladder program and that program is truly to keep the experts at the bedside. And they looked and they developed and then expanded a nursing residency program continually to look at the nursing compensation structure, as I mentioned at the beginning.

00;07;57;06 - 00;08;04;28Katie ChiedaWe also looked at nontraditional nursing hours and international recruitment in addition to those other items.

00;08;05;00 - 00;08;29;12Elisa ArespacochagaGreat. Yeah, I think it's going to take a lot of different approaches to really make this effective. And it sounds like you've had a full suite of activities. Stacy, let me turn to you now to talk a little bit about how you sort of rethought some of the nursing programs and focused on some of the international opportunities and some of those education and support activities that you lead.

00;08;29;14 - 00;08;51;11Stacy DanielYes. So when they decided they were going to begin down the road with international recruitment, one very important consideration they had was identifying a partner and then also determining whether they wanted to do direct to hire or contract staff. So they wanted to make sure the nurses were part of the Fisher Titus family and that they feel like they're part of their community.

00;08;51;11 - 00;09;17;19Stacy DanielSo they did opt for the direct-to-hire nurses. They identified their partner in late 2019, which was PRC Global, and then they began their road to recruitment. At the time, they recognized that it would take a minimum of about a year for them to come on. But with complications with immigration and the pandemic slowing down the process, it really extended it to about 18 months some times.

00;09;17;22 - 00;09;44;18Stacy DanielSo they strongly believed in finding the right individuals and building the right onboarding structure and felt like that was very critical to their success. So they developed a comprehensive interview process so that involved frontline leaders, frontline staff, and then they had a final interview with Katie, the chief nursing officer. Throughout this process, they not only identified the right person by skill and fit, they also shared the support system they had built to ensure their mutual success.

00;09;44;25 - 00;10;02;25Stacy DanielSo this included community mentor program, peer mentor, preceptor program, their general onboarding, and then also cultural diversity classes that they had for existing staff as well as their new international nurses and teambuilding events that they would have with the nurses when they arrived.

00;10;02;28 - 00;10;24;01Elisa ArespacochagaThat sounds great. Really important to make them feel like they they have come to a community that's really welcoming of them. I know when you shared this with me, you've shared some pictures of some of the different activities and welcoming them, which I just think is a great idea, even to meeting them at the airport too, to make sure they feel connected to your organization.

00;10;24;03 - 00;10;31;05Elisa ArespacochagaKatie, let me ask you, what are some of the challenges that came along with this as you started getting it off the ground?

00;10;31;07 - 00;10;52;20Katie ChiedaI would say the biggest challenge was getting their clinical leaders comfortable with the fact that they were identifying an individual that was going to join their team 12 to 18 months from now. Generally speaking, when you talk about recruitment of a nurse, we're filling a position that's open today and you're looking for the skillset to meet that need.

00;10;52;22 - 00;11;17;14Katie ChiedaSo they we had to shift their thinking on that. Some just that you're identifying somebody that fits with your team, that brings the skillset that you need for the team, but you're not necessarily identifying someone for a specific position. That was interesting. I think they had to keep them connected with the nurses throughout the time frame from when they identified and hired that individual through the date of arrival.

00;11;17;14 - 00;11;43;10Katie ChiedaAnd Stacey did a really great job of ensuring that that connection happened. That was probably the biggest challenge in the beginning. Once they did have an arrival date for those nurses that were joining us, then it was working with their h.r. Team to ensure a seamless onboarding process. There is a quick turnaround from the date that the nurse arrives to the date that the nurse has to start.

00;11;43;10 - 00;12;12;09Katie ChiedaIt's within one week. So all that pre hire paperwork and any prep that they could do in advance of them arriving, they needed to do so they could meet that deadline of a week. The second challenge that they identified were the minor differences in the general nursing practice. And although they had discussions with their nurses when they hired them in discussions with their partner PRS Global, some of those things weren't identified until their nurses arrived.

00;12;12;09 - 00;12;47;07Katie ChiedaAnd they really relied heavily on their preceptors and their clinical education teams to work collaboratively and identify and addressing those differences as the nurses joined us. And really they we, we've we've grown since their first nurse arrived to where they are today, incorporating monthly education and just listening to every member of the team, the preceptor, the nurse who joined us and their clinical education team to ensure that they were providing them the best education.

00;12;47;08 - 00;12;53;12Katie ChiedaSo at the end of their orientation, they could be a successful member of the nursing team.

00;12;53;15 - 00;13;11;10Elisa ArespacochagaThat's great. It sounds like you've really created a an ongoing welcome, if you will. Stacey, let me ask you, what are you working on to sustain this effort to keep those connections beyond what Katie already covered? And how do you see your process going forward?

00;13;11;13 - 00;13;33;05Stacy DanielYeah, so they have open communication with the nurses and we've developed additional education to support the differences that they have noted in practice between the United States and the Philippines. They have team building events that are scheduled. They try to do them quarterly and encourage that the nurses build relationships with their mentors, both within the hospital and also within the community.

00;13;33;11 - 00;13;59;26Stacy DanielWe really want them to have that tie to the community and feel like they're part of Norwalk. So they truly believe that the key to success is ensuring that the nurses feel like they're that part of the community and the Fisher Titus family. These nurses are signing a three year agreement with us. So they hope that the environment they create here within the hospital and within the Norwalk community encourages them to remain here for many years to come.

00;13;59;28 - 00;14;20;02Elisa ArespacochagaGreat. Let me ask you, Katie. Now, looking back on the last I guess it's been for almost five years, what advice would you share with others who might be thinking about either bringing in international nurses or taking a look at some of the the ways that they're supporting their nursing teams?

00;14;20;05 - 00;14;50;07Katie ChiedaI definitely would say ensuring that you have a comprehensive program to support the nurses joining, but then also the nurses supporting them and the community members that step forward. For us, it was the support of those key stakeholders that truly created our, I believe, made their program stand out for the international nurses. That includes the frontline staff. They did get their buy in from their board of directors and their community members.

00;14;50;09 - 00;15;14;16Katie ChiedaAnd truly, I would tell you, their community members made this experience for their nurses. Many of their nurses came with their spouses or their families, and they've been hired by companies in their community that are providing them just as much support as they are. In addition, I would tell people the more work you can complete in advance of their arrival, the better.

00;15;14;18 - 00;15;36;29Katie ChiedaWe had the opportunity with the pandemic and the immigration process to have 18 months to prepare. That created a challenge of keeping connected with those individuals. But it also gave us plenty of time to tell the story. So by the time their first nurse arrived, I can tell you their staff was super excited for them to be here as were their community mentors.

00;15;37;01 - 00;16;09;16Katie ChiedaIt's important to remember that these individuals are leaving everything that they knew and helping them understand what they can expect when they arrive. It's very important for their transition. And then you want to get those nurses, those individuals integrated into the community as much as you can as well. So when they did their matching with the community mentors, they identified key hobbies...or church attendance or families with children ages.

00;16;09;18 - 00;16;31;28Katie ChiedaAnd they made sure that the people that they connected that with them with could provide them the support that they needed outside of working hours. Sometimes those three 12-hour shifts as a nurse, seems like you spend most of your time at the hospital. But for somebody who left there, their family and the community that they were used to, there's a lot of hours to fill outside of that.

00;16;31;28 - 00;16;44;22Katie ChiedaAnd having that community mentor to go to the grocery store with or attend a family event with or celebrate the holidays with, really made the experience for their nurses that much better.

00;16;44;25 - 00;17;11;09Elisa ArespacochagaI'm sure and just even all the little things that you don't think of that just are a little bit different in a new country. Having that support to really help you, you know, make those connections, I think it's got to be a huge part of this. Well, Katie, Stacy, I want to thank you for your time and for sharing your story, not only at their Rural Leadership Conference, but also with their broader audience on this podcast.

00;17;11;12 - 00;17;23;13Elisa Arespacochaga

Thanks for joining me.