needed in such specialized topics as work redesign, knowledge management, error prevention and detection (Spear and Bowen, 1999), and change management itself (Strebel, 1996). In a 1995 survey of nurse leaders in VHA Inc. HCOs and nurse executives and managers belonging to the American Organization of Nurse Executives (AONE), expertise in change management was one of five learning needs reported by the nurse leaders (Gelinas and Manthey, 1997).

Few changes in complex organizations work perfectly when first introduced. Virtually all changes require modification over time to achieve optimum results. It is not unusual for organizations, departments, or plants that have implemented innovations most recently to perform worse than those that implemented comparable innovations a year or two before (Macduffie and Pil, 1996). New practices often initially undermine existing routines and competencies and require ongoing learning adjustment, redesign of the change, and supportive efforts to capture the intended benefits of the innovation. Ongoing monitoring, feedback, and redesign are needed to create and sustain effective change (Goodman, 2001; Walston and Kimberly, 1997).

Effective organizational transformations require long periods of time and constant effort. Macduffie and Pil (1996) point out that in the auto industry, plants in the first year following adoption of a new work system struggle with the right mix of incentives, managerial supports, and training needs, and experience coordination difficulties with other units. Those that sustain the change into the second year begin to see cost and quality improvements. The above-cited study of 14 U.S. hospitals implementing reengineering initiatives in the 1990s found that 2 to 3 years into their reengineering efforts, many had yet to implement a number of their initial plans. Although difficulties arose during the long implementations, the transition from implementation to a sustained, institutionalized process was even more problematic. While most study participants perceived reengineering to be an ongoing change process, and managers realized that continual effort was needed to move reengineering forward, many ended their efforts or decreased them after initial implementation. Without continued attention, the change was not sustained. The hospitals that were able to sustain a change were those that embedded the new initiative within ongoing operations, such as a continuous quality improvement or total quality management process, or established specific, measurable goals and mechanisms to