Patient safety culture refers to the shared attitudes, beliefs and behaviors that determine how an organization prevents, reports and learns from errors and adverse events. It is the invisible architecture of a hospital: whether a nurse feels able to speak up about a near miss, whether staff believe management will respond constructively to a reported incident, whether error is treated as a personal failing or a systems problem. Decades of research have shown that this culture is one of the strongest predictors of patient outcomes, yet changing it has proven stubbornly difficult. Checklists, posters and mandatory e-learning modules often fail to shift deeply held norms, because they transmit information without engaging the emotional and social machinery that actually drives behavior.

The study took place at Firouzgar Hospital in Tehran in 2023. From a population of 515 nurses, the researchers randomly selected 64 participants using a computer-generated random number sequence and allocated them into two groups of 32. The intervention group took part in six storytelling sessions, each lasting one and a half hours, spread over a three-month period. The sessions were led by a nurse manager, and crucially, the stories were not invented parables or imported case studies. They were drawn from the hospital’s own root cause analyses, the formal investigations conducted after patient safety incidents, and focused on specific events that had actually occurred within those walls.

This grounding in real institutional experience is what distinguishes the approach from conventional safety training. Root cause analysis documents are typically dry, procedural and read by only a handful of quality officers. By converting those documents into narratives, complete with context, human decisions and consequences, the intervention made abstract safety principles concrete and memorable. The control group, meanwhile, received only the routine patient safety education the hospital already provided, creating a clean comparison between standard practice and narrative-based learning.

To measure the effect, the researchers used the Hospital Survey on Patient Safety Culture questionnaire, version 1, a widely validated instrument that assesses multiple dimensions of safety culture, including management support, communication openness, non-punitive responses to error, staffing adequacy and training. Both groups were surveyed at three timepoints: before the intervention began, immediately after the final storytelling session, and one month later. This design allowed the team to track not just whether the intervention worked, but whether its effects persisted after the novelty wore off. Data were analyzed using SPSS software, version 16, with independent t-tests, analysis of variance and Fisher statistical tests used to compare the groups over time.

The results were striking. Patient safety culture scores in the storytelling group rose significantly above those of the control group, with a P value below 0.001, indicating that the probability of the difference arising by chance was less than one in a thousand. The effect size of the intervention was 0.159, which the researchers describe as substantial, since it exceeds the 0.08 threshold conventionally used to distinguish meaningful effects in this type of analysis. In practical terms, nurses who had heard and discussed stories drawn from their own hospital’s incident investigations came to see safety not as a compliance exercise but as a shared professional commitment.

The breakdown across dimensions is particularly revealing. The greatest impact appeared in the training and skills dimension, with an effect size of 0.185, suggesting that narrative learning is especially powerful for building practical competencies. When nurses hear a story about how a communication gap led to a medication error, they do not simply memorize a rule; they rehearse, mentally and emotionally, the situation in which that rule matters. The lowest impact was observed in the staff dimension, with an effect size of 0.049, which makes intuitive sense. Storytelling can change attitudes and skills, but it cannot hire more personnel or fix chronic understaffing, structural problems that require administrative rather than educational solutions.

The study’s design deserves scrutiny, as quasi-experimental studies cannot match the rigor of randomized controlled trials. Participants were randomly allocated to groups, which strengthens the inference, but the intervention was delivered at a single hospital, and the sample of 64 nurses, while adequate for detecting the observed effect, is modest. The researchers also note that the article was published as an early, citable version subject to further editorial refinement. Nevertheless, the three-timepoint measurement, the use of a validated instrument and the random allocation collectively provide what the authors describe as robust evidence that narrative-based learning can complement, and perhaps amplify, routine patient safety education.

The implications reach well beyond one Tehran hospital. Healthcare systems worldwide invest enormous resources in safety training, yet preventable medical errors remain a leading cause of harm. If a low-cost intervention, six ninety-minute sessions led by an existing nurse manager using material the hospital already generates, can produce a measurable and lasting shift in safety culture, the return on investment is extraordinary. The approach also honors a truth that cognitive science has long affirmed: humans encode and recall information far more effectively when it is embedded in narrative than when it is presented as abstract instruction. Stories provide causal structure, emotional salience and social meaning, the very ingredients that checklists lack.

There are also cultural considerations specific to healthcare hierarchies. In many institutions, junior nurses hesitate to question senior colleagues or report incidents involving physicians, fearing blame or career consequences. Storytelling sessions facilitated by a nurse manager create a sanctioned space where error can be discussed openly, where the protagonist of a difficult story is not a villain but a professional navigating a flawed system. By repeatedly modeling this kind of discussion, the intervention may gradually normalize speaking up, which is precisely the behavior that safety culture frameworks identify as foundational. The study, approved by the ethics committee of Iran University of Medical Sciences with informed consent from all participants, offers a template that other institutions could adapt: mine your own incident reports, transform them into honest narratives, and let your staff talk about what really happens when systems fail. The evidence suggests that in the space between the facts of an error and the feelings it provokes, a safer hospital culture can take root.

Subject of Research: The effect of storytelling training based on root cause analyses on patient safety culture among hospital nurses

Article Title: Storytelling for fostering a culture of safety in healthcare: a quasi-experimental study

Article References: Mehraban, M. A., Gharehbaghi-NoveinFar, M., Salehi, T., Haghani, S., & Abbariki, E. (2026). Storytelling for fostering a culture of safety in healthcare: a quasi-experimental study. Health Research Policy and Systems. https://doi.org/10.1186/s12961-026-01508-y

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01508-y

Keywords: patient safety, storytelling, nursing education, safety culture, root cause analysis, quasi-experimental study, HSOPSC, knowledge transfer, hospital quality, narrative learning, Iran University of Medical Sciences, health systems