I've found that cross-training is a great way to stretch a thin staff and make ends meet. As you can imagine, it's a lot easier to cross-train everyone at once in a brand new center. In established facilities, it's wise to start with one or two employees at a time, especially those who demonstrate the motivation to learn new skills. Here are steps you can take to ensure the process goes as smoothly as possible.

• Hire receptive employees. Search for employees who are willing to be flexible and who seem enthusiastic about learning new skills. Fear of the unknown can be a powerful force, especially when it comes to people without prior OR training learning the responsibilities of an area they consider "foreign turf."
• Create a structured orientation. Involve staff members in the process right at the outset. Have them help form teams by area (such as pre-admission and PACU). The pre-admission team, for example, is responsible for creating a checklist of skills for which competency is required to function successfully. They should then develop protocols for instructing the PACU nurses.
• Set and communicate realistic goals. You shouldn't expect to transform a non-OR nurse into the best OR nurse on staff. But there is no reason that a receptive, diligent employee can't become functional and competent in the OR setting.

• The Four Keys to Successful Cross-Training - Set realistic goals - Choose preceptors with care - Spell out the tasks to be learned and monitor progress - Don't wait for a rainy day - regularly put cross-trained employees to work where they've been trained

  Select your preceptors with care. Some of the most proficient practitioners are the weakest teachers. They may like to do everything themselves or they may be impatient with those who don't immediately grasp what they're showing them. Your preceptors should have as much patience as they do knowledge.
• Don't cramp your preceptors' style. Some preceptors may prefer to move cautiously towards significant hands-on training, and others may favor the "immersion" method under their supervision. Within reason, leave this choice up to the preceptors. As long as you're satisfied that actual teaching will take place, don't be too concerned if a preceptor from one area of the practice plans to assimilate employees more ambitiously or cautiously than another preceptor.
• Where to begin? Decide in which area the cross-training should begin and where it should end. The OR may actually be the best place to start. The OR provides a controlled learning environment, and I've found that it's best to demystify the OR early on.
• Inform the surgeons and staff. Tell surgeons about the cross-training, how it works and why it's good for the organization. They need to be on the same page to help facilitate OR training. You also need to inform other staff, because they may frequently be asked to cover an area while a preceptor works with an orientee.
• Put the ball in their court. Make it clear to the employees that the responsibility for learning is theirs. They should seek out every available opportunity to reinforce the skills they've been taught. If they feel they're not learning, they must notify the manager or else it will be assumed they can cover the area of the practice for which they've been cross-trained. For example, if someone from the admissions area still feels "lost" in the PACU, you shouldn't find this out when your PACU nurse is tending to a patient with unanticipated PONV and you need someone from the pre-op staff to assist because another patient is about to transferred from the OR.
• Meet regularly. Set up regular meetings between the manager, the preceptor and the orientee. The person in training can offer valuable information to the manager, if allowed to do so. Discuss what's working, what's not and whether needs are being met.
• Assign tasks intelligently. Skills need to be reinforced through repetition. If an employee completes training and then is never or seldom assigned to cover the area, especially the OR, the employee's skills and self-confidence erode and the center will have wasted time and money.

Expect bumps in the road
Critics of cross-training argue that the program drains resources while leading to mediocre nursing care, as you rely on employees who know a little about several areas rather than employees who are expert in one or two areas. Let's look at five problems that can arise and how you can solve them.

• Convincing the organization to spend the money. Realize that there will be a significant short-term investment of money, as well as time, involved before you can successfully train the staff. During cross-training, the facility must pay two staff people to do basically the same assignments. Your staffing costs may well increase in the short term to address the increased need for per diem nurses and overtime pay to cover the facility during training. Training in the OR in particular can take weeks or months, depending on the number of specialties you serve and the trainee's learning curve. Some new skills, such as starting an IV, may need to be taught on the job.

Management must be committed to the concept that they are expending more resources now in order to have more flexibility later. One way you can assist this process is to give those who control the purse strings realistic time frames for each facet of cross-training you plan and then monitor the time for maximum efficiency.

• Identifying good - and available - preceptors. Half of the challenge is finding the best preceptors at your facility. You need to identify preceptors who are not only proficient and experienced in a given area of the practice but also are able to impart hands-on knowledge. The other half of the problem is finding ways to relieve enough of their existing workload to enable them to truly teach a trainee.

Have a plan to "cover" both teacher and orientee. Do you have other previously cross-trained employees who can shift to cover an area while the training occurs? Can per diem staff be brought in to cover the work load? If so, are they available to work flexible shifts?

• Addressing surgeon and staff concerns. Do not move forward with cross-training until you've had a chance to discuss it with everyone at the facility. Never surprise surgeons by announcing one day that you've decided to conduct cross-training in their OR. That's an invitation for angry, uncooperative surgeons and a tense OR environment that reinforces existing fears and doubts about assimilating a novice into the environment. Discuss your plan for cross-training ahead of time with the surgeons and explain why you are doing it. This is even more important when you plan to train non-OR staffers than when you are training nurses and techs who have OR experience to work in the OR, but in a different specialty. Ultimately, even if the surgeons are not thrilled by the inconvenience, they'll accept that cross-training is beneficial to everyone.

Meanwhile, you may also find less-than-enthusiastic buy-in from the staff, both those scheduled to be cross-trained and those who have to cover in the interim. Stress to reluctant trainees that they will be allowed to learn at their own pace and the new skills they'll learn will improve their upward mobility within the organization and make them more marketable should they choose to leave. In particular, you need to address the widespread fear of entering the "taboo" area of the OR. While OR training will be demanding, the skills gained will be highly rewarding- both professionally and personally.

Employees with seniority may resent the additional responsibilities imposed by cross-training others, such as the obligation to rotate assignments or precept based on need. Especially with older nurses, there may be fear of displacement by younger staff. They may also refuse to learn new skills themselves, feeling they've earned the right to work in their one area of expertise. With these employees, it is important to emphasize that their role in the facility is not being diminished in any way. In fact, their involvement and support is indispensable in making the facility a better, more efficient place to work.

• Avoiding overwork. One of the hardest sells in cross-training is convincing employees that they won't be overworked. A cross-trained employee is the first one chosen to float during another staffer's vacation day and, on a more regular basis, to be called on to relieve other staff. There may be a feeling that there will never be a break or a slow period because the expectation is that this employee can do it all.

You can't tell cross-trained employees that you won't look first to them to move around and cover elsewhere as needed - that is, after all, the idea of cross-training. The extra training does not mean, however, that cross-trained employees are not entitled to all the privileges enjoyed by all employees, including breaks granted on the same basis as every one else's. Emphasize that you will rely on them but you won't rely on them too much.

Striking a balance can be difficult. Employees need to keep their new skills sharp or the benefits of the training are diminished. Thus, you can't wait until dire need arises to give "outside" assignments to a cross-trained employee. Rotation needs to be made part of the employee's regular schedule but so, too, do their relief and breaks. This is simpler to accomplish when there is widespread or staff-wide cross-training in place.

• Ensuring expertise. One good strategy for reducing the risk of turning an employee into a "jack of all trades, master of none" is to designate two areas where the cross-trained employees focus most of their time (PACU and the OR, for example). Routinely assign a rotation in a third area to maintain competency. Therefore, the employee becomes a specialist in a chosen area, yet remains at least competent in three different areas.

It's only natural
Change does not occur overnight, but you can cross-train your staff. As surgery center employees work so closely together anyway, cross-training can improve morale, increase communication and further promote teamwork.