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: How is practitioner-led quality and safety improvement sustained across a whole hospital? A process evaluation of a practice development programme. (n.d.). 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