The need to train nurse managers in delegation and management skills, strategies for dealing with role change, and the economic and policy factors that contribute to changes has been documented in other studies as well (Ingersoll et al., 2001).

Walston and Kimberly (1997) also found that many hospitals that employed cross-training of non-nursing staff to perform patient care activities underestimated the amount of initial training and retraining that was needed. Researchers were told that often after initial, brief training periods (some as short as 3 days), new workers were assigned patient responsibilities, such as the performance of electrocardiograms and phlebotomies, only to function very inadequately. Much of the rework fell back on nursing staff. The researchers note that training costs are high when comprehensively addressed. One 500-bed hospital spent $700,000 on its training in the first 2 years of its reengineering initiative. This hospital also performed a gap analysis to identify those roles not being performed adequately and to evaluate what additional training was needed. The reviewers concluded that such continual evaluation of training needs is important to the effective implementation of new roles and responsibilities.

Walston and Kimberly (1997) observed a lack of measurement and feedback to staff on the progress of reengineering efforts. In many situations, feedback either was not provided at all or if provided, was not well understood. Both managers and employees frequently reported that they rarely heard about the results of reengineering efforts. Although every hospital developed some type of data tracking mechanism, employees typically either lacked access to the data or felt that the availability of the data was inadequate. This inability to record and display the progress of reengineering frequently caused a perception that the outcomes would not be sustained and resulted in diminished efforts to sustain the process.

Walston and Kimberly (1997:153) further found that effective organizational reengineering initiatives require long periods of time and constant effort. “Many hospitals that were two to three years into their engineering effort had yet to implement all of their initial plans. The most simplified plan of any of the hospitals demanded at least a year to analyze, plan, and implement.” During this time, employees expressed concern that the engineering initiative “drifted” and lacked consistency. The transition from initial implementation to sustained operation of the reengineered processes