What large systems can learn from rural hospitals about cross-training

With no float pools or nearby backup systems to rely on, many rural hospitals have developed cross-training programs because they had to. Those efforts have produced lessons about confidence, sequencing and workplace culture that are becoming more relevant to health systems of all sizes.

As workforce vacancies and agency spending continue to strain hospitals across the country, rural providers offer a model that many larger systems have not yet needed to build in the same way. The approach is not new, but it gained more attention during the COVID-19 pandemic, when organizations had to do more with fewer resources and greater staffing pressure.

At Reeves Regional Health in Pecos, Texas, the impact of that investment can be seen in workforce results. Chief Nursing Officer JohnRich Levine, DNP, said the hospital’s RN vacancy rate has fallen to about 7%, while retention has risen to roughly 75%. Levine said those results reflect several efforts happening at once, with cross-training serving as a central driver.

But the first change he pointed to was not a number. It was a shift in the way staff think about each patient encounter.

“Rural healthcare is broader healthcare,” Levine told Becker’s. “For us, every nurse, nurse leader and department carries a broader scope of responsibility because patient needs arrive without regard to specialty, staffing plans, or departmental boundaries. Cross-training prepares our teams to act with confidence wherever the need arises.”

He said cross-training has also influenced the hospital’s culture by changing the questions employees ask. Rather than focusing first on role boundaries, the conversation begins with, “How do we help our patient?”

According to Levine, that mindset has made the workforce more adaptable and has strengthened collaboration across departments. It has also helped the organization prepare for the realities of rural healthcare, where readiness affects every patient encounter.

That shift, however, required a look at the program itself. In the early stages, Reeves Regional structured its cross-training around documentation of skills. Competencies were assessed and checklists were completed. Over time, leaders recognized that competence and confidence do not develop in exactly the same way. Competency grows through education, while confidence grows through experience.

The program was redesigned with readiness in mind. Reeves Regional added simulation, mentoring, hands-on practice and interdisciplinary collaboration so each experience could be reinforced before the next one. Levine said that approach helps prepare staff for the uncommon situations that are common in rural care.

“In our healthcare, every day brings a different set of patient needs. But readiness gives our teams the confidence to respond effectively, regardless of what comes through the emergency department doors,” he said.

Freeman Health System in Joplin, Mo., has taken a similarly intentional approach, President and CEO Matt Fry told Becker’s. The system has cross-trained colleagues where it makes sense, including nurses who work across different nursing units, environmental services staff who cover multiple areas in the hospital and system support staff who manage functions across service lines.

Fry said the results have been operational, creating a more adaptable workforce, lowering labor expenses and reducing service disruptions.

Still, he said the lesson is as much about scope as it is about training. Programs that attempt to do too much too quickly can undermine the very outcomes they are meant to deliver.

“It is really important that you don’t try and boil the ocean with your cross-training strategy,” Fry said. “I would recommend cross-training colleagues across similar services. I would limit the cross-training for any one colleague to one additional department at a time, only introducing additional training opportunities when they’ve demonstrated mastery with their current scope of work.”

He added that the goal is to develop cross-trained colleagues who are high-functioning, which takes time, patience, a willingness to learn and tactical leadership.

For rural hospitals, cross-training has been a practical response to staffing limits. For larger systems, the examples from Reeves Regional and Freeman suggest that success depends not just on expanding coverage, but on building confidence, pacing the training carefully and creating a culture that supports collaboration.