This paper reports on the evaluation of a teamwork intervention designed to introduce four evidence-based teamwork protocols. The aim of the intervention was to standardize and improve team communication and team leadership in care delivered in a residential aged care facility. The evaluation framework examined changes in understanding and practice of the new teamwork protocols, as well as evolution of leadership from hierarchical, command-and-control style of traditional nursing, to a preferred distributed leadership. Of the four teams involved in training, only one successfully transitioned to working with the new protocols. This outcome is analyzed in terms of whole of organization factors impacting on practice change at the care delivery interface.