Building a Rural Nursing Workforce With Fisher-Titus Medical Center

00;00;01;05 - 00;00;35;00
Tom Haederle
Ensuring 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;23
Tom Haederle
Welcome 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;07
Elisa Arespacochaga
Welcome to another podcast in the AHA's ongoing series where we 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;18
Elisa Arespacochaga
So, 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;18
Stacy Daniel
So 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;24
Stacy Daniel
As 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 our clinical staff, as well as leading international recruitment efforts. I also lead our clinical education department in initial and continuing education requirements and opportunities throughout our health system.

00;02;25;27 - 00;02;37;27
Elisa Arespacochaga
Great. 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;21
Stacy Daniel
Yes. So Fisher Titus Health is an independent rural community health system, and we're located in north central Ohio. We have a 99 of that acute care hospital, which includes a level three trauma center, level two cath lab and certified stroke center. And we also have a 69-bed skilled nursing facility, a 40-unit assisted living facility. We 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;03
Stacy Daniel
We also have a diverse ancillary outpatient services, which includes lab imaging, and we have a robust adult and pediatric rehab services at our facility. And Katie,

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

00;03;22;15 - 00;03;54;25
Katie Chieda
Thank 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;19
Katie Chieda
I 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;26
Elisa Arespacochaga
Great. 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;14
Katie Chieda
Yeah. Before the pandemic, Fisher Tigers did not utilize contract labor. We were blessed that that wasn't something that we had to to turn to to staff our organization. Fortunately, we started the evaluation of international nursing in 2018-2019. As an independent community hospital surrounded by large tertiary centers. Our challenge with the nursing shortage was really just beginning at that point.

00;04;58;16 - 00;05;25;11
Katie Chieda
Our team examined the market, our current ability to recruit and retain optimal staffing along with state and national trends, to identify strategies for recruitment and retention. Our findings indicated the growing nursing shortage, even before the pandemic. So we knew we 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;20
Katie Chieda
We expanded our med search bed capability as well as doubled the size of our 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 our focus on really how do we maintain patient care here in the community, knowing that we may not be able to get those patients out. 

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

00;06;15;22 - 00;06;40;15
Elisa Arespacochaga
Yeah, 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;04
Katie Chieda
Recruitment retention was a strategic priority before the pandemic, and of course it continues to be today. Our goal is to continue as an independent community hospital. So now myself and our chief of h.r. As well as Stacy and a few other members of the team, we meet on a monthly basis to review new opportunities for consideration for recruitment and retention.

00;07;04;07 - 00;07;23;29
Katie Chieda
In the past, it definitely held a place on our strategic plan, but it didn't get monthly attention to shift. But some of the things that we do or we've identified as opportunities, we 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;04
Katie Chieda
We also did focused educational assistance to ensure that we were spending the dollars allocated organizationally on our biggest challenge areas from a workforce standpoint. We identified and strengthened our clinical school partnerships. We expanded our clinical ladder program and that program is truly to keep the experts at the bedside. And we looked and we 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;28
Katie Chieda
We also looked at nontraditional nursing hours and international recruitment in addition to those other items.

00;08;05;00 - 00;08;29;12
Elisa Arespacochaga
Great. 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;11
Stacy Daniel
Yes. So when we decided we were going to begin down the road with international recruitment, one very important consideration we had was identifying a partner and then also determining whether we wanted to do direct to hire or contract staff. So we wanted to make sure the nurses were part of the Fisher Titus family and that they feel like they're part of our community.

00;08;51;11 - 00;09;17;19
Stacy Daniel
So we did opt for the direct-to-hire nurses. We identified our partner in late 2019, which was PRC Global, and then we began our road to recruitment. At the time, we 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;18
Stacy Daniel
So we strongly believed in finding the right individuals and building the right onboarding structure and felt like that was very critical to our success. So we 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, we not only identified the right person by skill and fit, we also shared the support system we had built to ensure our mutual success.

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

00;10;02;28 - 00;10;24;01
Elisa Arespacochaga
That 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;05
Elisa Arespacochaga
Katie, 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;20
Katie Chieda
I would say the biggest challenge was getting our 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;14
Katie Chieda
So we 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 we 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;10
Katie Chieda
And Stacey did a really great job of ensuring that that connection happened. That was probably the biggest challenge in the beginning. Once we did have an arrival date for those nurses that were joining us, then it was working with our 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;09
Katie Chieda
It's within one week. So all that pre hire paperwork and any prep that we could do in advance of them arriving, we needed to do so we could meet that deadline of a week. The second challenge that we identified were the minor differences in the general nursing practice. And although we had discussions with our nurses when we hired them in discussions with our partner PRS Global, some of those things weren't identified until our nurses arrived.

00;12;12;09 - 00;12;47;07
Katie Chieda
And we really relied heavily on our preceptors and our 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 our first nurse arrived to where we are today, incorporating monthly education and just listening to every member of the team, the preceptor, the nurse who joined us and our clinical education team to ensure that we were providing them the best education.

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

00;12;53;15 - 00;13;11;10
Elisa Arespacochaga
That'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;05
Stacy Daniel
Yeah, so we have open communication with the nurses and we've developed additional education to support the differences that we have noted in practice between the United States and the Philippines. We have team building events that are scheduled. We 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;26
Stacy Daniel
We really want them to have that tie to the community and feel like they're part of Norwalk. So we 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 we hope that the environment we 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;02
Elisa Arespacochaga
Great. 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;07
Katie Chieda
I 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 our program stand out for the international nurses. That includes the frontline staff. We did get our buy in from our board of directors and our community members.

00;14;50;09 - 00;15;14;16
Katie Chieda
And truly, I would tell you, our community members made this experience for our nurses. Many of our nurses came with their spouses or their families, and they've been hired by companies in our community that are providing them just as much support as we 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;29
Katie Chieda
We 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 our first nurse arrived, I can tell you our staff was super excited for them to be here as were our community mentors.

00;15;37;01 - 00;16;09;16
Katie Chieda
It'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 we did our matching with the community mentors, we identified key hobbies...or church attendance or families with children ages.

00;16;09;18 - 00;16;31;28
Katie Chieda
And we made sure that the people that we 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;22
Katie Chieda
And 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 our nurses that much better.

00;16;44;25 - 00;17;11;09
Elisa Arespacochaga
I'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 our Rural Leadership Conference, but also with our broader audience on this podcast.

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

Thanks for joining me.