Cross-training your staff necessitates caution

It sounds like a good idea, and consultants are throwing it around all the time: Cross-train your staff so you get more out of the same people. But how exactly do you cross-train the staff?

Very carefully, says Emory Petrack, MD, FAAP, FACEP, president of Petrack Consulting in Shaker Heights, OH. Cross-training won’t solve all of your problems, but it can help ease many common difficulties faced in the ED, such as overcrowding, short staffing, and tight budgets, he says. But do it wrong, and you may end up with seriously disgruntled staff and lower productivity than you started out with. Do it right, and you could see great improvements, Petrack says.

Petrack has been involved with cross-training ED staff many times, and he says the most dramatic improvements came from cross-training pediatric emergency nurses and adult emergency nurses.

He has seen EDs cross-train secretaries and medical assistants, and he has seen cross-training of transport staff and emergency technicians.

The first step in cross-training ED staff is simply acknowledging that you need to do it, Petrack says. There usually is an automatic resistance to cross-training because people don’t like to be told they will have additional duties, and managers often are reluctant to broach the topic, he says. "As much as people don’t want to hear it, EDs are under tremendous financial constraints now, and cross-training can be appropriate," Petrack explains. "To have one area where people are sort of sitting around and another where people are going crazy because they’re so busy just doesn’t make sense. It’s important to acknowledge that as a reality."

Once you decide that cross-training staff is appropriate, Petrack says you must go about it with a carefully organized plan. He offers these tips:

Clarify to staff the need for cross-training. Establish a partnership of understanding about the financial constraints the hospital and the department are under, and why those difficulties directly affect the staff. Promote the idea that you’re all in this together and the cross-training is a necessary step, as opposed to it being something onerous handed down from administration.

"This is where I’ve seen some difficulty," Petrack says. "When people start talking about cross-training, staff get very anxious. They’re being asked to put themselves very much outside their comfort zones, knowledge base, and even their professional expertise."

Avoid sending the message that staff aren’t working hard already. Any time you suggest cross-training, there is the danger of sending the message that "we think you have too much free time on your hands." That may be true, actually; but it’s not the way to bring up the idea of cross-training, Petrack says. Use data to show that though the staff are busy much of the time — and stress that you appreciate that hard work — there are some times when they’re not that busy.

"Most staff in the ED know that there are some busy times and some not-so-busy times," he adds. "Just be careful how you say that."

Listen to the staff’s concerns, and respond to them. Even if you succeed in getting the staff on board with your cross-training plan, they will have concerns about how it is implemented. Encourage staff to air their misgivings, and then structure the plan to accommodate those concerns.

"With nurses, pediatric nurses think of themselves as only pediatric nurses, and they’re not so comfortable with adults, and vice versa," he says. "You have to respect that. Some, however, are comfortable with both roles, and those are the ones you might want to target for leadership positions when rolling this out. They can model the behavior you want, and their confidence can be an example for others."

Petrack says it is crucial to respect the staff’s concerns. It is normal for staff to resist the idea at first, but how you respond can determine the future of your cross-training.

"How that resistance is handled will absolutely determine the ultimate success of the program. If that resistance is handled in a respectful way in which staff are heard and concerns are addressed as much as they can be, the plan is likely to be accepted," he says. "But if the administration just plows ahead without creating a sense of security with appropriate training and support, it’s probably going to fail."

Reassure staff that you won’t ask them to go beyond their abilities. Contrary to common belief, resistance to cross-training staff is not based on a reluctance to work harder. It’s based on the fear that they will be asked to do things they’re not capable of, Petrack says.

Provide appropriate training before the plan is implemented. Don’t just do it on the fly. Cross-training plans can be doomed to failure if you just tell staff to go over to the other department and "someone will show you what to do," Petrack says.

You must implement formal training for any skills that are new or substantially different, and at a minimum, you should provide orientation to the new area. Even if a nurse from one department is capable of handling the clinical duties in another, don’t throw that nurse into your ED without providing orientation to the everyday procedures and where supplies are located, he adds. Partnering is one solution, Petrack says. In some instances, it can be useful to have a pediatric nurse partner with a nurse in the adult ED to overcome any trepidation. After the pediatric nurse becomes comfortable, the partnering probably won’t be necessary.

Remember that some necessary skills are not clinical. An adult ED nurse, for instance, might need pointers on how to talk with children and parents.

Document that staff have been trained and achieved the skills necessary. To ensure that training is provided to each person and that staff are comfortable with their new roles, Petrack advises using a short didactic test.

Limit the cross-training roles to the necessary hours. Just because you need to cross-train staff doesn’t mean you have to make those staff available at all times. If one department is slammed only during the evening hours, for instance, you may want to make your cross-trained staff available to that department only during those hours.

Limiting the hours in which they might be assigned makes people more comfortable, Petrack says.

Confirm that staff members have the time. Don’t just add to their workload. If you have clerical staff members who are busy all the time, you can’t insist that they take on patient care duties just because that’s what you need. You can end up losing your secretarial staff, and that will cause a different set of problems, with phones ringing all the time and labs not sent off. Don’t trade one problem for another.

Don’t use cross-training as a substitute for proper staffing. Cross-training can help you make the most of your current staff, but it won’t help you avoid hiring the necessary staff. If volume surges aren’t the problem and you really need more pediatric emergency nurses, cross-training your adult nurses only will be a temporary fix.

"Look to see if redistribution of staff would be a better answer," Petrack says. "If one area is always more busy, it might be better to move staff permanently instead of cross-training them." n

For more information, contact:

Emory Petrack, MD, FAAP, FACEP, President, Petrack Consulting, 16781 Chagrin Blvd., No. 249, Shaker Heights, OH 44120. Phone: (216) 371-8755. E-mail: Web: