Cross-training staff provides flexibility to tailor care for individual patients

Clinicians reap its benefits within unit and across the continuum of care

Cross-training has always been a good way to improve flexibility in staffing, and that flexibility is a key component in two very different programs aimed at tailoring care for individual patients.

In Atlanta, a maternity unit uses cross-training to customize care for each mother and child and to give its facility more of a family focus. At a new multi-use facility under development in Marino Valley, CA, caregivers think cross-training will be the way to handle staff fluctuations among its hospital, long-term care, assisted living, physician, and home care units. There the effort is to provide elderly patients with a seamless continuum of care.

The Atlanta program began with the acknowledgement that labor, delivery, and getting to know a new infant are tough enough on new mothers, without adding a long parade of doctors, nurses, and aides to the mix.

"Among nurses and techs alone, a mother could see four people every eight hours," says Beth Allen, RNC, IBCLC, manager of the perinatal/family-centered care unit at Northside Hospital in Atlanta. "That’s 12 faces and 12 different teaching styles every day. That seems hard on a mother."

So when Northside began planning a new facility five years ago, one of the main goals was to create a maternity program that helped staff and families feel connected to each other. "We didn’t just want them to see that half the population in the room was staff. We wanted them to have individualized care."

The result was a cross-training program that allows fewer people to manage the care of mothers and babies. Staff members — even those resistant to the changes — have latched onto the program as a work-related benefit, and patients seem to like the new system better. The formal tracking of satisfaction has just begun, but Allen says anecdotal information looks positive. "Our premise is that this works," she says.

As the new building neared completion last year, cross-training kicked in for the nurses — providing pediatric nurses with knowledge and experience caring for new moms, and maternity nurses experience and learning to deal with infants. "There was some good incentive for them to take the training," Allen says. "Without it, they couldn’t work in the new building."

Committing to the new model was a hard thing for Northside. Allen says that starting a mother/baby program has failed three times in the hospital’s history. The last time was eight years ago. "I think that the one piece that was missing was an adequate amount of didactic and job training."

Cautioned to include adequate training, clinicians and specialists created a three-day intensive workshop that outlined mother and baby care, both low and high risk.

A benefit for the nurses

The class was required, but the time was paid and participants earned continuing education units for taking it. Nurses were also given the benefit of both parts of the training — if you were a baby nurse, you still got that pediatric refresher. And if you had experience in both areas, you still took the class. All of this helped even the most skeptical of nurses view the class as an advantage. "The way we presented it told the staff we were committed to them and wanted everyone to have the same foundation. Even some people who were resistant or felt they didn’t need them felt the classes had value," says Allen.

Once the class was completed, two weeks of on-the-job training in the opposite area of each nurse’s expertise ensued. "And in our facility — which has more than 13,000 deliveries per year — if you do two weeks, you get lots of that experience," Allen explains. The following week, nurses were teamed with a nurse who had already completed the training. They then saw how to care for a "couplet" of mother and baby. "This helped them see the learning fleshed out in reality," says Allen.

As time progressed, the trainee took over more and more care of the couplet. By the end of the week, the trainees provided all the care and were observed by the lead nurse. At the end, both student and preceptor were evaluated. Nurses who were still weak in particular areas were given a plan of action to facilitate improvement.

The nurses who took the training were regularly rotated into the new unit, explains Allen. "This keeps the enthusiasm and skills up."

Although the emphasis is on couplet care, Northside did have to provide for those mothers who either wanted a break from the baby, or didn’t want to room-in. To facilitate that, the hospital created an anchor nurse role for the nursery. This is the only nurse with no direct patient load. "They are stationed in the nursery and have a working knowledge of all nursery babies. If a couplet nurse has a question, problem, or something she isn’t experienced in, the anchor nurse has a minimum of five years nursery experience. She is the veteran, the resource to the couplet nurse," Allen says. The anchor nurse also acts as a physician liaison.

Since the family centered care unit opened, there have been some small changes. For instance, at 7 a.m., the mother, baby, nurse, supporting technician, pediatrician, and obstetrician are all on site. "Where is the nurse and who is she caring for at that time?" asks Allen. "We developed a process where the nurse starts by evaluating the baby, the techs take the mom’s vital signs, then they swap. The techs then go to the nursery to hold babies for pediatricians."

When the program started, there was also a nurse/tech combination taking care of five couplets. A better ratio was developed with two nurses and one tech taking care of eight couplets. The technicians now have an expanded role.

Both patients and staff seem to like the new program. Staff members who were extremely resistant have told Allen they like the program, that it makes sense, and that they were glad they didn’t quit when the new program was announced.

The biggest problem was conducting cross-training while still staffing a very busy hospital. At times, Northside had to use agency nurses to cover — especially since there were the usual illnesses, vacation, and requests for time off to consider at a time when four people were missing a shift for a full week.

Taking cross-training another step

Carl Rowe, PharmD, managing member of Integrated Care Communities, in Marino Valley, CA, is starting a project that could take cross-training to a new level: sharing staff among different parts of the continuum of care. Ground just broke on a facility in nearby Riverside that will include a hospital, a long-term care facility, an assisted living complex, physicians offices, and a home care agency (for more on the project, see article on p. 100).

Rowe believes the need to provide continuum of care for the growing tidal wave of elderly people will force the health care industry to look for new ways to provide that care.

In the public/private partnership in which he works, one of the main goals is to solve the problem of fluctuating staff needs at its various health care facilities. "Organizations that are going to survive are going to have to focus on efficiency and on increasing market share," he says. "They will have to increase their sphere of influence." One way to achieve that goal is form alliances and create partnerships that provide for their patients and their payers with a complete continuum of care.

By partnering to provide care across several types of facilities, Rowe adds, the alliance of partners can move both patients and staff seamlessly from one level of care to the next. If the patient census at the hospital is low, perhaps the outpatient rehabilitation facility could use the hospital’s therapist, or the home care agency could use its excess nurses. He is also toying with the idea that nurses can follow patients from one part of the continuum to the next — caring for the patient in the hospital, following to the rehab facility, and then into the home.

Rowe believes that there is a window of opportunity before the chronically ill swell the population. Facilities should start planning how they will serve that group effectively and efficiently now, he says, so that they can handle the demographic changes when they occur.