Stabilizing Care Delivery: A Rural Health System’s Global Workforce Strategy

The Challenge

Since the early 2020’s, Fisher-Titus was already experiencing a persistent nursing shortage, especially in its medical-surgical and critical care units. With the arrival of COVID-19, the pressure continued to escalate: ICU capacity expanded, medical-surgical bed counts increased, patient volumes surged, and reliance on temporary or contract staffing became both financially and operationally challenging.

Key challenges included:

• Burnout & Burnout-Related Turnover: Nurses were reporting exhaustion, morale distress, and a very limited ability to cope with high patient loads and prolonged crisis conditions.
  
  
• Retirements & Workforce Exits: A significant portion of the national nursing workforce is nearing retirement, while many others are leaving the profession altogether. These exits exacerbate shortages because the pace of new graduates and other entries into the healthcare profession is not enough to keep up.
  
  
• Long Recruitment Timelines & Immigration Delays: Even with international recruitment under consideration, the process for credentialing, immigration, and onboarding can sometimes take from 12 to 18 months.
  
  
• Cultural & Practice Differences: Regardless of the required clinical skills, international nurses also face cultural and professional differences in nursing practice norms, workflows, and expectations—not all of which are evident until after arrival.
  
  
• Community Integration & Retention: Hiring is only part of the equation; retaining staff is more of a challenge. This is why international nurses and their families must feel welcomed and supported in both the workplace and the wider community. 

The Solution

As one workforce strategy to address some elements of the problem, Fisher-Titus turned to PRS Global for international nurse recruitment under the organization’s direct-hire model. The proven solution was multi-faceted and designed to mitigate known risks and challenges while supporting both recruitment and retention. Key components included:

1. Direct-Hire International Recruitment
   
   
   • Fisher-Titus invested in identifying international candidates (not just as temporary contract staff) to hire as part of the core nursing workforce.
     
     
   • Candidates were selected based on clinical skill and cultural fit (values, adaptability, communication, etc.), via a multi-stage interview process: front-line leaders, peer/staff, then a final interview with the chief nursing officer.
     
     
2. Robust Onboarding & Cultural Integration Support
   
   
   • Pre-arrival and pre-hire work included credentialing, immigration support, and as much preparation as possible.
     
     
   • A community mentor program was established to facilitate integration outside of work, alongside a peer mentor/preceptor program to support clinical transition, and educational sessions to navigate differences in practice.
     
     
   • Cultural and diversity training for existing staff, team-building events, and social gatherings were arranged once the nurses (and their families) arrived.
     
     
3. Community Engagement & Family Support
   
   
   • Since many nurses came with spouses and/or their families, Fisher-Titus worked with local community organizations and businesses to help spouses find employment.
     
     
   • Community mentors were selected to help nurses and their families acclimate to new cultural, social, and professional environments.
     
     
   • Housing assistance services were also provided to ensure affordable rentals were secured prior to the nurses’ arrivals and to foster a smooth transition.
     
     
4. Timeline Accuracy & Professional Commitment
   
   
   • As previously mentioned, the recruitment → immigration → arrival process can take 12-18 months, especially given delays from public health or immigration processes, and PRS Global accounted for all of this as part of the initial planning process to ensure accurate timelines.
     
     
   • As part of the onboarding process, the nurses agreed to a three-year contractual commitment with Fisher-Titus to ensure staffing stability and long-term planning.
     
     
5. Ongoing Education & Preceptorships
   
   
   • Once the nurses were onboarded, continuing education programs were offered to help address differences in nursing practice norms, workflows, policies, and other relevant areas.
     
     
   • Clinical preceptors were selected to provide hands-on guidance and support to each nurse. Evaluation and feedback systems were also established early on to ensure standards were aligned, consistent quality patient care was a priority, and professional growth opportunities were available.

“We want to make them feel at home, not just at work, but also in our community.”  - Katie Chieda Fisher-Titus Medical Center

The Results

Since partnering with PRS Global on its international nursing program, Fisher-Titus has observed:

• Improved Staffing Stability: Rather than relying heavily on contract or travel nursing, many positions that were difficult to fill locally have been filled by international hires who are committed long-term.
  
  
• Positive Culture Influences: Staff morale has improved; existing nurses report renewed energy and a sense of hope, seeing new colleagues committed, engaged, and bringing fresh perspectives.
  
  
• Retention Beyond Arrival: Thanks to the mentorship programs, community support, and preceptorships, many of the nurses have opted to stay in their positions beyond the minimal required time.
  
  
• Benefits to the Community: Beyond individual nurses, their spouses and families have integrated into the community and become active in local affairs and gatherings—they also help support the local economy, which benefits the entire community.
  
  
• Streamlined Onboarding: The entire process from physically arriving in the U.S. to being completely onboarded at work has been mapped out in detail, so once nurses arrive, they often start working within a week.
  
  

Lessons Learned & Best Practices

From Fisher-Titus’s experience, several lessons emerge:

• Realistic, proactive planning is key: clinical leaders must plan and hire against future needs (i.e., 12-18 months ahead), understanding projected supply/demand, understanding retirements and the impact, not just current vacancies.
  
  
• Early engagement is crucial: from the hiring process all the way through arrival, maintaining strong communication with candidates and helping set expectations about work, life, and housing provides comfort and stability.
  
  
• Connecting cultural differences: robust preceptor, mentor, and education programs are necessary to bridge gaps in clinical norms.
  
  
• Community support is necessary: what happens outside the hospital also matters greatly—social integration, housing, family support—all contribute to retention.
  
  
• Mutual trust and transparency: Long-term retention is enhanced when there is mutual agreement and commitment; Fisher-Titus commits ongoing support, while nurses often commit beyond their initial contract to stay and integrate.

Conclusion

Fisher-Titus Medical Center’s partnership with PRS Global represents a strong example of how a rural health system can proactively respond to nursing shortage, burnout, and workforce exit risks—not just by scrambling to fill vacancies, but by designing a sustainable recruitment, onboarding, and retention system anchored in both clinical and community support.

By blending international recruitment with robust cultural, community, and operational support, Fisher-Titus has been able to stabilize staffing, improve morale, and build a more resilient workforce. As national trends suggest that shortages, burnout, and retirements will continue to strain hospitals, this model offers strategic strategies that can be replicated in other rural and community health systems.