MCNLETTERS on Cross-Training
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"Do you think cross-training is good for patients? " "Are you cross-trained?"
In our March/April issue, we asked readers to respond to Mary Ellen Strohbach's column, "Clinical Excellence and Cross-Training," by answering yes or no to two questions: "Do you think cross-training is good for patients?" and "Are you cross-trained?" Readers obviously feel strongly about this issue as practically all respondents, ivhether through phone calls or letters, were compelled to go beyond yes or no answers. (Even those who tried to answer simply wrote notes in the margins of our survey box.) Here are some letters typical of the comments we have received. Enhancing "Employability" In "Clinical Excellence and CrossTraining" (March/April 1992), Mary Ellen Strohbach poses an excellent challenge to contemporary crosstraining issues in maternal-child nursing. My favorite commentary for years has been that if my 42year-old nulliparous sister, who has failed IVF/GIFT six times, finally becomes pregnant and develops preeclampsia, I would want her cared for by a specialist, not a generalist. From the consulting side, when cross-training is not done well, we have seen resistance to the practice cause extensive damage to nurses, physicians, patients, and to the reputation of excellent contemporary program models, such as LDRP and mother-baby nursing. As in most areas of life, the answer to whether to cross-train is not clearly yes or no. In high vol252
ume and/or high acuity services, our experience has been that extensive cross-training may do little—if anything—to improve efficiency or morale. The reverse is also true: in low volume/low acuity settings, cross-training may be the key to whether the unit survives at all, and certainly can improve efficiency and often the overall quality of care. Whether or not well-executed cross-training improves morale has not yet been scientifically explored with maternal-child nursing. There is no doubt that different nurses are attracted to different types of nursing, and trying to force one outside the preferred mode often works poorly at best. However, the science of organizational development has long acknowledged that variety of tasks plays a key role in job satisfaction as well as the prevention of isolation and burnout. One also wonders why, in nursing, we adhere so carefully to rewarding only vertical integration of skills (specialization) rather than horizontal integration. Career ladders, for instance, typically reward only new skills within a specialty, rather than the development of a breadth of skills. Yet in medicine, family practice seems to not only attract numerous practitioners—who seem to enjoy it—but is also the most highly demanded physician discipline in outpatient services today. The certified nurse-midwife is also a generalist in maternal-child, with expertise throughout the spectrum
of maternity and newborn care. There clearly is a very valued role for the traditional specialist in obstetrical or newborn/neonatal nursing. But do those nurses who desire to provide care over a continuum for patients and their families really have to become nurse or family practitioners to practice as they wish? For the staff nurse, however, the final argument may be related to neither efficiency nor morale. Rosabeth Moss Kanter, PHD, editor of the Harvard Business Review and author of numerous landmark organizational development texts, talks about the concept of "employability" in When Giants Learn to Dance. In the 1990s, she argues, "security no longer comes from being employed...but from being employable." Any time the breadth of a practitioner's knowledge is increased, she/he becomes much more valuable to the organization—a key issue for nurses looking forward to future employment in the changing economic milieu of health care. Mary Anne L. Graf, MSN President, Health Care Innovations Salt Lake City Office, UT For Those Who Enjoy Variety I wonder if Mary Ellen Strohbach is suggesting that obstetric/gynecologic physicians should also separate into subspecialties: antenatal, intrapartum, postpartum, surgical, and gynecologic. Our hospital currently is crosstraining for labor, delivery, antenatal, and postpartum. These are performed in two units on the same floor. There is a great deal of camaraderie as we understand each others' roles. We ask and give each other help freely. More importantly, the patient receives care from a nurse who understands all aspects of the hospital stay. Frequently, the nurse who one day took care of the laboring
MCN Volume 17 September/October 1992
Continued from page 252
mother will care for her the next day in the postpartum setting. It is obvious the nurse has a special, personal knowledge of these mothers, and mothers are delighted to recognize their caregivers. Fragmentation and specialization are not suited for those people who enjoy stimulation, variety, and commitment to years in one field. Georgette Bartell, RN Philadelphia, PA Expertise for Quality Care Having been a neonatal nurse for 20-plus years before branching out and adding postpartum care to my "repertoire," I can say that I function very well within postpartum care, but I am also an excellent, intuitive baby nurse. I would much prefer my grandchild be cared for by someone with my level of expertise than the experienced labor and delivery nurse who is cross-trained to newborn. I would want an experienced—not just competent—intrapartum nurse caring for my kin's labor. I don't think it hurts to have some knowledge of all three areas as it prevents tunnel vision, but you cannot be an expert in all three. And an expert is what is needed to provide quality care. Daisy Eickhoff, RNC Midlands Community Hospital Papillion, NE A Necessity in Smaller Hospitals Clinical expertise in only one area of obstetrics may be very legitimate in larger hospitals that do more than 1,500 to 2,000 deliveries a year. We in smaller hospitals have to be cross-oriented to be able to meet the sudden fluctuations in patient census and acuity with a minimal number of nurses. Hospitals cannot afford to keep multiple staff on for the sake of keeping staff expert in only one area. It is taking us time to gain the expertise in the other areas but I
MCN Volume 17 September/October 1992
know I am a better nurse to my is not a luxury but a necessity. patients because I can meet all I was cross-trained on my arrival aspects of their care without hav- to my first hospital—it was autoing to deal with multiple nurses. matic. If one worked labor and Those who said mother-baby care delivery, postpartum and anteparwouldn't work are those who are tum were also covered. If one now saying cross-orientation with worked nursery, and the labor and single-room maternity care won't delivery nurses were busy, you either. In busy obstetric units with a watched postpartum and sent the high enough census to have multiple babies to their moms. Cross-trainstaffs for level 3 nurseries and LDR ing, admittedly, was then based on units, cross-orientation between your preceptor's skill and knowlthose units is not necessary. Howev- edge, and I was blessed with expeer, LDRP cross-orientation for labor rienced preceptors. In a setting and delivery and other baby-care working with first-year residents, I staffs makes sense for better conti- had to know as much or more than nuity and comprehensive patient they to keep them out of trouble. care, especially in the small com- So the books and journals were munity hospital. read to keep ahead of them. Karen MacDonald, RN It would have been nice to have Nurse Manager had more formal instruction, but Maternity/Nursery really much is already covered in Wentworth-Douglass Hospital nursing school. Fortunately, my Dover, NH cross-training put me at great advantage when I was in midWho Cares for the Patients wifery school. Most of my cohorts When the "Expert" Is Gone? had much less experience than I. I don't believe Strohbach's article And the transition to one-room discusses how to deal with the maternity care almost makes problem of when an "excellent" cross-training a necessity, since nurse calls in sick, wants vacation, you must be labor and delivery or a leave of absence. Who does nurse, recovery room nurse, nursthis leave to care for her patients? ery/transitional newborn nurse, There is not a major resource of and postpartum nurse—not to competent nurses to care for mention high-risk obstetric nurse patients under these circumstances when things go wrong or the in many communities in this coun- patient goes bad. try. The availability of staff in the I do not think my cross-training city is not indicative of staff in oth- has made me "master of none" er areas. Cross-training provides (although, admittedly, neonatal the ability to care for patients intensive care units and very highwhen that expert nurse isn't there. risk obstetric patients are probably Linda Mascarinas, RNC best staffed by specialists). It is just Farmington, NM an area for individual growth and relief from burnout—one cannot Around Before the Term Was Coined work in these high-stress areas forI certainly think cross-training is ever without hating to come to good for patients, and I have been work some days. Thanks for the interesting opincross-trained for approximately 13 years in maternity nursing, before ion, but remember those of us in the term was ever around! I think I the nontertiary centers doing speak for many nurses in small, 36-60 deliveries per month. Linda Haeger, CNM rural, or level I facilities (even levSumter, SC el II) when I say that cross-training 253
* >
"Do you think cross-training is good for patients? " "Are you cross-trained?"
In our March/April issue, we asked readers to respond to Mary Ellen Strohbach's column, "Clinical Excellence and Cross-Training," by answering yes or no to two questions: "Do you think cross-training is good for patients?" and "Are you cross-trained?" Readers obviously feel strongly about this issue as practically all respondents, ivhether through phone calls or letters, were compelled to go beyond yes or no answers. (Even those who tried to answer simply wrote notes in the margins of our survey box.) Here are some letters typical of the comments we have received. Enhancing "Employability" In "Clinical Excellence and CrossTraining" (March/April 1992), Mary Ellen Strohbach poses an excellent challenge to contemporary crosstraining issues in maternal-child nursing. My favorite commentary for years has been that if my 42year-old nulliparous sister, who has failed IVF/GIFT six times, finally becomes pregnant and develops preeclampsia, I would want her cared for by a specialist, not a generalist. From the consulting side, when cross-training is not done well, we have seen resistance to the practice cause extensive damage to nurses, physicians, patients, and to the reputation of excellent contemporary program models, such as LDRP and mother-baby nursing. As in most areas of life, the answer to whether to cross-train is not clearly yes or no. In high vol252
ume and/or high acuity services, our experience has been that extensive cross-training may do little—if anything—to improve efficiency or morale. The reverse is also true: in low volume/low acuity settings, cross-training may be the key to whether the unit survives at all, and certainly can improve efficiency and often the overall quality of care. Whether or not well-executed cross-training improves morale has not yet been scientifically explored with maternal-child nursing. There is no doubt that different nurses are attracted to different types of nursing, and trying to force one outside the preferred mode often works poorly at best. However, the science of organizational development has long acknowledged that variety of tasks plays a key role in job satisfaction as well as the prevention of isolation and burnout. One also wonders why, in nursing, we adhere so carefully to rewarding only vertical integration of skills (specialization) rather than horizontal integration. Career ladders, for instance, typically reward only new skills within a specialty, rather than the development of a breadth of skills. Yet in medicine, family practice seems to not only attract numerous practitioners—who seem to enjoy it—but is also the most highly demanded physician discipline in outpatient services today. The certified nurse-midwife is also a generalist in maternal-child, with expertise throughout the spectrum
of maternity and newborn care. There clearly is a very valued role for the traditional specialist in obstetrical or newborn/neonatal nursing. But do those nurses who desire to provide care over a continuum for patients and their families really have to become nurse or family practitioners to practice as they wish? For the staff nurse, however, the final argument may be related to neither efficiency nor morale. Rosabeth Moss Kanter, PHD, editor of the Harvard Business Review and author of numerous landmark organizational development texts, talks about the concept of "employability" in When Giants Learn to Dance. In the 1990s, she argues, "security no longer comes from being employed...but from being employable." Any time the breadth of a practitioner's knowledge is increased, she/he becomes much more valuable to the organization—a key issue for nurses looking forward to future employment in the changing economic milieu of health care. Mary Anne L. Graf, MSN President, Health Care Innovations Salt Lake City Office, UT For Those Who Enjoy Variety I wonder if Mary Ellen Strohbach is suggesting that obstetric/gynecologic physicians should also separate into subspecialties: antenatal, intrapartum, postpartum, surgical, and gynecologic. Our hospital currently is crosstraining for labor, delivery, antenatal, and postpartum. These are performed in two units on the same floor. There is a great deal of camaraderie as we understand each others' roles. We ask and give each other help freely. More importantly, the patient receives care from a nurse who understands all aspects of the hospital stay. Frequently, the nurse who one day took care of the laboring
MCN Volume 17 September/October 1992
Continued from page 252
mother will care for her the next day in the postpartum setting. It is obvious the nurse has a special, personal knowledge of these mothers, and mothers are delighted to recognize their caregivers. Fragmentation and specialization are not suited for those people who enjoy stimulation, variety, and commitment to years in one field. Georgette Bartell, RN Philadelphia, PA Expertise for Quality Care Having been a neonatal nurse for 20-plus years before branching out and adding postpartum care to my "repertoire," I can say that I function very well within postpartum care, but I am also an excellent, intuitive baby nurse. I would much prefer my grandchild be cared for by someone with my level of expertise than the experienced labor and delivery nurse who is cross-trained to newborn. I would want an experienced—not just competent—intrapartum nurse caring for my kin's labor. I don't think it hurts to have some knowledge of all three areas as it prevents tunnel vision, but you cannot be an expert in all three. And an expert is what is needed to provide quality care. Daisy Eickhoff, RNC Midlands Community Hospital Papillion, NE A Necessity in Smaller Hospitals Clinical expertise in only one area of obstetrics may be very legitimate in larger hospitals that do more than 1,500 to 2,000 deliveries a year. We in smaller hospitals have to be cross-oriented to be able to meet the sudden fluctuations in patient census and acuity with a minimal number of nurses. Hospitals cannot afford to keep multiple staff on for the sake of keeping staff expert in only one area. It is taking us time to gain the expertise in the other areas but I
MCN Volume 17 September/October 1992
know I am a better nurse to my is not a luxury but a necessity. patients because I can meet all I was cross-trained on my arrival aspects of their care without hav- to my first hospital—it was autoing to deal with multiple nurses. matic. If one worked labor and Those who said mother-baby care delivery, postpartum and anteparwouldn't work are those who are tum were also covered. If one now saying cross-orientation with worked nursery, and the labor and single-room maternity care won't delivery nurses were busy, you either. In busy obstetric units with a watched postpartum and sent the high enough census to have multiple babies to their moms. Cross-trainstaffs for level 3 nurseries and LDR ing, admittedly, was then based on units, cross-orientation between your preceptor's skill and knowlthose units is not necessary. Howev- edge, and I was blessed with expeer, LDRP cross-orientation for labor rienced preceptors. In a setting and delivery and other baby-care working with first-year residents, I staffs makes sense for better conti- had to know as much or more than nuity and comprehensive patient they to keep them out of trouble. care, especially in the small com- So the books and journals were munity hospital. read to keep ahead of them. Karen MacDonald, RN It would have been nice to have Nurse Manager had more formal instruction, but Maternity/Nursery really much is already covered in Wentworth-Douglass Hospital nursing school. Fortunately, my Dover, NH cross-training put me at great advantage when I was in midWho Cares for the Patients wifery school. Most of my cohorts When the "Expert" Is Gone? had much less experience than I. I don't believe Strohbach's article And the transition to one-room discusses how to deal with the maternity care almost makes problem of when an "excellent" cross-training a necessity, since nurse calls in sick, wants vacation, you must be labor and delivery or a leave of absence. Who does nurse, recovery room nurse, nursthis leave to care for her patients? ery/transitional newborn nurse, There is not a major resource of and postpartum nurse—not to competent nurses to care for mention high-risk obstetric nurse patients under these circumstances when things go wrong or the in many communities in this coun- patient goes bad. try. The availability of staff in the I do not think my cross-training city is not indicative of staff in oth- has made me "master of none" er areas. Cross-training provides (although, admittedly, neonatal the ability to care for patients intensive care units and very highwhen that expert nurse isn't there. risk obstetric patients are probably Linda Mascarinas, RNC best staffed by specialists). It is just Farmington, NM an area for individual growth and relief from burnout—one cannot Around Before the Term Was Coined work in these high-stress areas forI certainly think cross-training is ever without hating to come to good for patients, and I have been work some days. Thanks for the interesting opincross-trained for approximately 13 years in maternity nursing, before ion, but remember those of us in the term was ever around! I think I the nontertiary centers doing speak for many nurses in small, 36-60 deliveries per month. Linda Haeger, CNM rural, or level I facilities (even levSumter, SC el II) when I say that cross-training 253
