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Yes they have to actively work until that unlocks, you can view their progress in the staff window, there will be a little circle around the star, when this fills the next one will unlock (with promotion).
Make sure they have been promoted, select the staff member and in the window to the right you will see the option to send on break etc, one of them is for promotion, if can click that then you will be able to train them, if you can't, they aren't ready yet.
This. All levels above 2 need to be researched, for 1000, 2000, and 4000 points (I think).
1) A staff member of the appropriate career type with an available training slot (so if you only have nurses and janitors with an open slot, the Surgery skill will not appear on your list of training options)
2) The staff member also has to have all the prerequisites. Can't get Treatment 2 if you don't already have Treatment 1, etc.
2) A qualified trainer. It seems in my experience that there is one hire-able healing trainer, one hire-able diagnostics trainer, etc. So if your hired trainer is teaching Treatment 1 in a classroom, you won't be able to hire a Treatment 2 trainer from the outside until she is finished with the level 1 class
turns out my personel didn't have another slot
(suffice to say, leveling up fixed it)