Implementing Change in Long-Term Care Toolkit

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For quite some time now, state and federal legislation have been targeted at improving the quality of care in U.S. nursing homes. Some examples include: 1) mandating quality assurance and performance improvement efforts; 2) linking reimbursement to nursing home performance; and 3) mandating training hours and content for some nursing home staff.

Long term care providers have also been searching for ways to enhance the quality of care and the quality of nursing home work. As a result, several initiatives have been implemented by individual nursing homes and by networks of homes working collaboratively. Some focus on the physical environment, some on improved worker training, some on developing new and more positive workplace climates, and some on creating more resident-responsive communities. Some initiatives focus on specific activities, such as dining, while others are much more sweeping and comprehensive. Many providers have found it difficult to sustain changes over time.

This toolkit was designed to assist organizations, and the staff who work there, to implement changes that will improve care quality and to sustain them. Whether you are contemplating a comprehensive, organization-wide culture change, or implementing a best-practice protocol in a single clinical area, knowing something about how to implement and manage change will help you achieve your goal. You will find suggestions about preparing your organization for change, assisting your staff to gain a sense of ownership over the changes, and sustaining the changes over time. Not all sections of this toolkit will be useful to everyone. Look for what you think is the most useful, and start there.

The Implementing Change in Long Term Care Toolkit is based largely on feedback from staff in long term care organizations who have implemented significant practice and/or organizational changes. Their experience, insights, and wisdom, as well as published research, guided the development of the toolkit and provide the examples of real change experiences.

Who should use this toolkit?

This toolkit is intended for managers and staff development departments in long term care organizations. It is intended to stimulate discussions and engage a wide range of staff, to foster sustainable change.

What does the toolkit contain?

In this toolkit you will find case studies, exercises, worksheets and tools. Topics covered include:

  • Person-centered care
  • Leadership
  • Developing teams
  • Staff education and development
  • Preparing for the change
  • Conducting organizational assessments
  • Sustaining proactive change and developing accountability systems

The toolkit also includes system-level questions, reading guides and case studies in five clinical practice areas that are often the focus of culture change efforts: elimination, skin, falls, nutrition and psychosocial well-being.

How should these tools be used?

The Implementing Change in Long Term Care Toolkit is not a recipe for change. Any significant change must reflect the particular mission, goals, culture, and internal relationships of individual organizations. Acknowledging that each organization has its own personality, history, commitments, and challenges, the toolkit is intended to guide you as you consider the changes you wish to implement by introducing you to what is known about change in general and about change in long-term care. It offers suggestions and includes exercises intended to bring this knowledge to your particular change process, maintaining what is precious and unique about your organization while considering changes that will improve some aspect of the care or work environment. You are encouraged to consider what it is you value in your organization and to consider how to maintain those things while engaging in change. Mostly, the Implementing Change in Long Term Care Toolkit is intended to stimulate discussions and engage a wide range of staff within your organization as you plan, implement, and embrace important new initiatives.

Development of this toolkit

The Implementing Change in Long Term Care Toolkit was developed by researchers and clinicians (Principal Investigator: Barb Bowers, PhD, RN, FAAN) at the University of Wisconsin-Madison School of Nursing Center for Aging Research and Education.

This project was supported by The Commonwealth Fund, a New York City-based private, independent foundation (grants #20020672 and 20070611). Additional support was provided by the University of Wisconsin School of Medicine and Public Health’s Health Innovation Program (HIP), the Wisconsin Partnership Program, and the Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR), grant 9 U54 TR000021 from the National Center for Advancing Translational Sciences (previously grant 1 UL1 RR025011 from the National Center for Research Resources). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funders.

Please send questions, comments and suggestions to


  1. Bowers B, Nolet K, Jacobson N; THRIVE Research Collaborative. Sustaining Culture Change: Experiences in the Green House Model. Health Serv Res. 2016 Feb;51 Suppl 1(Suppl 1):398-417.
  2. Bowers, B (2002). Organizational culture change in long-term care: Urban institute, assistant secretary for planning & evaluation. U.S. Dept. of Health & Social Services.
  3. Bowers B. Guest editorial: culture change – challenges, opportunities and questions. Int J Older People Nurs. 2011 Mar;6(1):3.

Toolkit Citation

Bowers B, Nolet K, Roberts T, Esmond S. Implementing Change in Long Term Care Toolkit. University of Wisconsin – Madison School of Nursing Center for Aging Research and Education and UW Health Innovation Program. Madison, WI; 2007. Available at


About the Author

Barbara Bowers, PhD, RN, FAAN is a Professor and Associate Dean for Research at the University of Wisconsin – Madison School of Nursing and the Founding Director of the Center for Aging Research and Education. In this dual capacity, Dr. Bowers has conducted research with frail, older adults in order to examine how nursing staff and long term care systems impact quality of life and quality of care, as well as worked with state and federal government bodies to develop, implement, and evaluate public policies affecting older adults.