The programme, known locally as the Quality Safety Culture Framework (QSCF), was built on practice development—a participatory approach to workforce transformation that uses facilitation, active work-based learning, and critical inquiry to change workplace cultures from within. Unlike conventional quality improvement, which typically targets individual units or specific safety problems, the QSCF aimed at something far more ambitious: building the capability of frontline teams to generate, lead, and sustain improvement from the point of care across an entire hospital. It was explicitly designed as what organisational researchers call “help it happen” rather than “make it happen”—practitioner-led and participatory, with organisational leaders playing an enabling rather than directive role. Its components included daily safety huddles in every setting, quality and safety boards in every work unit, a Clinical Leads facilitation programme supporting roughly 185 clinicians across eight high-risk domains, audits aligned to national safety standards, and an annual hospital-wide Safety Attitudes Questionnaire with facilitated unit-level feedback.

The research team, led by Jacqueline Peet of the University of the Sunshine Coast and Clint Douglas of Queensland University of Technology, conducted 27 interviews with nursing, medical, allied health, and executive staff, six half-day workshops with 49 frontline staff, a multidisciplinary focus group, and approximately 20 hours of observation, all during the programme’s sixth year. Their analytical approach was deliberately abductive: rather than testing predetermined assumptions, they treated the fieldwork as a critical dialogue partner designed to generate theoretical surprise. Four tentative programme theories—formulated as if-then propositions about evaluation, engagement, facilitation, and leadership—were developed before analysis and then challenged, extended, or reframed by the evidence. The central analytical question that emerged was stark: why does the same programme, under the same governance conditions, produce sustained participatory improvement in some settings and mere directive compliance in others?

The answer, distilled into five refined programme theories, begins with data. The researchers found that the evaluation infrastructure itself—huddles, boards, audits, surveys—was not the active ingredient. What mattered was how data connected to a learning-oriented culture. When experiential data such as patient stories and qualitative feedback sat alongside quantitative metrics, transparency enabled collaborative learning. When performance numbers dominated, the same transparency became surveillance. One clinical leader who discovered that only 1.3 percent of discharged patients had an advance care plan spent two months asking “why, why, why?” rather than jumping to a solution, traced the problem back into residential aged care facilities, and built an interdisciplinary collaboration that raised completion rates to 21 percent within six months. On another ward, staff noticed falls clustering around 7 a.m., connected this to morning medication timing, changed the schedule, and triggered a hospital-wide change to the medication system’s default settings—insights that no standardised falls-prevention protocol could have prescribed.

The second theory concerns communicative space, and here the evaluation produced one of its most striking findings: such space must already exist before facilitated reflection can produce its theorised outcomes. In a large procedural department with 200 full-time staff, values clarification sessions prompted colleagues who had worked side by side for years to finally discuss why they chose their professions and what mattered to them—leaving an emotional impact still vivid two years later. When pressure to maximise procedural volume later threatened safety, staff drew directly on their shared vision statement: “we come to work to provide the best quality and safe care, not the numbers.” By contrast, in settings where trust and relational safety had not been established, safety huddles devolved into one-directional information transfer. “Is it truly a safe space, or are we (just) saying it?” one participant asked, noting that sometimes only department heads speak out because “you don’t want to rock the boat.” Power hierarchies, the researchers concluded, are not flattened by facilitated forums alone.

The third theory exposed the study’s most consequential finding: systematic implementation drift concentrated in the programme’s facilitation pipeline. The educators, mentors, and clinical leads who translate programme intent into ward-level practice were trained primarily in quality improvement methods—audit, Plan-Do-Study-Act cycles, pre-post surveys, education-as-intervention—and transmitted what they knew. Observed clinical leads workshops focused on templates and “showing an effect” rather than collaborative reflection. A patient safety representative noted clinical leads’ “strong desire to jump to solutions rather than to sit and brainstorm.” Crucially, the researchers argue this drift was not a design failure or a matter of individual choice but a fidelity problem driven by organisational logic: quality improvement produces measurable outputs that governance systems demand, while practice development produces relational and cultural outcomes that are harder to quantify and easier to defer. The educators were transmitting what the system rewards.

Where the participatory intent was realised, the pattern was recognisable. In a dialysis unit, a clinical lead tackled advance care directive conversations—a challenge no protocol could resolve—through months of inclusive, collaborative inquiry, with staff released from the floor to attend workshops. In community health, a lead formed a working group across dispersed teams and deliberately chose not to delegate: “I want the staff to feel well supported when they raise issues or concerns, so they got listened to.” Staff designed their own educational resources and visual cues, cutting unnecessary glove costs by 40 to 50 percent and embedding the project into the service’s business plan. Notably, some advanced practice nurses were surprised to discover that facilitation skills mattered more than their subject knowledge when mentoring—confirming that the active ingredient is the facilitative relationship, not the clinical content.

Leadership emerged as the fourth condition, but with a caveat that should concern hospital executives everywhere. What sustained the programme was not person-centred leadership in the abstract but mutual trust and vulnerability between leaders and teams—honestly sharing constraints, being transparent about what is and isn’t possible. A nursing co-director who spotted a shared pattern of rising falls and pressure injuries across two very different wards brought the teams together, presented the data, and then stepped back: “the ideas came from them.” Yet the researchers found these conditions were consistently person-dependent rather than system-embedded. Culture maps had to be restarted when staff turnover made original visions irrelevant, and one nursing unit manager admitted starkly: “none of this is done by the RNs … it’s mostly me.” The programme was vulnerable at every leadership transition.

The fifth theory, new to this evaluation, addressed a quieter threat: project proliferation and improvement fatigue. Participants described running four different projects on a ward simultaneously, completing surveys out of hours, and receiving duplicate templates to tick monthly. “Push, push, push, no-one engages because they don’t understand how it all works together,” one participant explained. Against this backdrop, an acute aged care unit caring for long-stay patients with dementia initiated a “Rise and Shine Breakfast Club”—staff sitting down to eat with patients three times a week, with real cutlery and soft music. Patients who had refused to leave their rooms were among the first at the table; some began eating independently for the first time in years; falls reduced. The initiative used quality improvement tools, but its purpose was irreducibly person-centred, and it spread to a neighbouring ward organically. Collaborative prioritisation, the researchers argue, is not merely a recommendation to do fewer projects—it is itself a participatory act: when teams decide together what matters most, practice development is enacted in the very act of prioritising.

The study’s conclusion is sobering and practical in equal measure. Organisational enablement—naming, backing, resourcing, and connecting local improvement—is necessary but insufficient to sustain participatory practice. Even with genuine participatory design intent, governance infrastructure built to reward measurable outputs can systematically displace the relational and cultural processes that make improvement durable. Huddles can become checklists, boards can become wallpaper, and clinical leads can become auditors, all while satisfying accreditation. For hospital leadership teams, the five refined programme theories offer a diagnostic: attend to what facilitation actually transmits, value experiential alongside quantitative evidence, actively prioritise and sequence improvement demands, build dialogue spaces as a way of being rather than an intervention, and embed participatory principles in systems rather than individuals. The Director of Nursing’s founding question—how do you know the care in this hospital is safe and person-centred?—can now be answered. The harder lesson is that keeping the answer alive requires defending the conditions that produced it, year after year, against the gravitational pull of compliance.

Subject of Research: A qualitative process evaluation of a hospital-wide practice development programme for quality and safety improvement

Article Title: How is practitioner-led quality and safety improvement sustained across a whole hospital? A process evaluation of a practice development programme

Article References: Peet, J., Tuqiri, K., Smoother, R., Sheppard-Law, S., & Douglas, C. (2026). How is practitioner-led quality and safety improvement sustained across a whole hospital? A process evaluation of a practice development programme. Frontiers in Health Services, 6, Article 1932480. https://doi.org/10.3389/frhs.2026.1932480

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1932480

Keywords: practice development, quality improvement, patient safety, safety culture, nursing leadership, facilitation, process evaluation, hospital care, participatory approaches, health services research, organisational culture, workforce capability

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