A new study by Ms. Rita Atuora Samuel shows that structured evidence-based practices, supported by strong leadership, can reduce preventable harm in nursing and social care. Presented at the New York Center for Advanced Research, this research offers clarity and hope for global healthcare systems focused on patient safety.

Studies from Mayo Clinic, Leeds Teaching Hospitals NHS Trust, and St. Nicholas Social Care Centre show that patient safety relies on both the organizational culture and leadership, as well as clinical protocols.

Through the voices of 138 healthcare professionals, including nurses, care workers, safety officers, and nurse managers, Ms. Samuel’s work fuses both numbers and narratives into one powerful conclusion—evidence saves lives, but only when implemented in environments that support honesty, learning, and professional growth.

The quantitative backbone of the study is hard to ignore. Using a robust regression model (Y = 52.7 + 6.23X − 2.1Z), the analysis showed that every single-point increase in EBP adherence results in a 6.23-point improvement in patient safety scores—even after accounting for case complexity. With an R² value of 0.697 and a highly significant p-value (< 0.001), the statistical evidence is clear: EBPs matter, and they work.

But beyond the data, it is the human context that elevates this study. Using Braun and Clarke’s qualitative thematic method, Ms. Samuel and her team uncovered critical insights from the field—revelations about the gap between policy and practice, the silencing effects of fear-based cultures, and the pressing need for visible, values-driven leadership in both nursing and social care. Of particular note was the challenge posed by fragmented protocols between sectors, which often leaves patients vulnerable during transitions of care.

Speaking after the presentation, Ms. Samuel emphasized, “Our systems can no longer afford to see safety as the outcome of a checklist. It must be a culture—something we build, model, and protect at every level of care.”

The study closes with forward-looking recommendations that go beyond diagnostics and into action: integrate EBP training at all levels, develop non-punitive reporting structures, adjust planning for patient complexity, and ensure cross-sector collaboration between nursing and social care providers.

Ms. Rita Atuora Samuel is among Africa’s professionals influencing global health with practical insights. Her research highlights evidence-based practices and emphasizes that a safer healthcare system starts with empowered professionals, informed leadership, and thoughtful design

Abstract

Redesigning Patient Safety: Evidence-Based Practices in Nursing and Social Care

Patient safety remains one of the most critical challenges in contemporary healthcare and social care systems, despite extensive research and global initiatives aimed at minimizing preventable harm. This study investigates the relationship between the implementation of evidence-based practices (EBPs) and patient safety outcomes across nursing and social care settings, using a convergent mixed methods design. The research focuses on three international institutions—Mayo Clinic (USA), Leeds Teaching Hospitals NHS Trust (UK), and St. Nicholas Social Care Centre (South Africa)—to capture diverse organizational, cultural, and systemic perspectives.

A total of 138 participants, including nurses, social care workers, nurse managers, and safety officers, contributed data through structured surveys and semi-structured interviews. Quantitatively, a multiple linear regression model (Y = 52.7 + 6.23X − 2.1Z) demonstrated a strong, statistically significant relationship (R² = 0.697, p < 0.001) between EBP adherence and patient safety outcomes, even after adjusting for case complexity. These findings indicate that each one-point increase in EBP adherence leads to a 6.23-point improvement in composite patient safety scores, affirming the effectiveness of structured, evidence-informed interventions in reducing harm.

Qualitative analysis, using Braun and Clarke’s thematic method, revealed four key themes: the gap between policy and practice; fear-based cultures that inhibit safety reporting; the critical role of leadership in modeling EBP adherence; and fragmentation between nursing and social care protocols. These themes enriched the statistical findings by providing insight into how institutional culture, staff empowerment, and leadership visibility affect the success of EBPs in practice.

The study concludes that while EBPs significantly improve patient safety, their full potential can only be realized when supported by adaptive leadership, cross-sector collaboration, contextual awareness, and a just organizational culture. Recommendations include institutionalizing EBP training, integrating complexity-adjusted planning, promoting interprofessional safety protocols, and developing non-punitive safety reporting systems.

This research contributes to the growing body of international evidence emphasizing that patient safety is not merely a function of compliance but a product of systems, relationships, and real-time learning. As healthcare increasingly shifts toward integrated, person-centered models, the redesign of patient safety through EBPs must be both evidence-driven and human-centered.

 

Chapter 1: Introduction

In an age defined by medical breakthroughs, technological innovation, and a growing emphasis on holistic, patient-centered care, one paradox remains deeply unsettling: preventable harm in healthcare and social care settings continues to affect millions globally each year. According to the World Health Organization (WHO, 2023), unsafe care is one of the top 10 causes of death and disability worldwide, with one in every 10 patients experiencing harm while receiving care in high-income countries—and even higher rates in low- and middle-income settings. As healthcare systems evolve, so too must our approach to ensuring the safety of those we serve. This research sets out to examine the transformational potential of evidence-based practices (EBPs) in redesigning patient safety systems across nursing and social care contexts.

Patient safety is not a static checklist or a simple compliance metric. It is a dynamic, deeply human commitment that spans multiple sectors, professions, and disciplines. In both hospital wards and community-based care settings, safety hinges not only on protocols but on the behaviors, competencies, and systems that support or undermine them. As such, this study defines patient safety as a multi-dimensional construct shaped by clinical accuracy, environmental conditions, interprofessional communication, and—crucially—the implementation of EBPs.

Evidence-based practices refer to clinical and care interventions that are grounded in the best available scientific research, professional expertise, and patient values. In nursing and social care, EBPs include fall prevention protocols, medication reconciliation, infection control, pressure ulcer prevention, communication standards (like SBAR), and structured discharge planning. Yet, the gap between what is known to work and what is actually practiced remains wide. Variability in EBP adherence contributes to adverse events, increased readmissions, and lower satisfaction among patients and staff alike (Leape et al., 2020). This study seeks to bridge that gap by identifying how the structured application of EBPs correlates with improvements in measurable patient safety outcomes.

Importantly, this research adopts a mixed methods approach, combining statistical rigor with qualitative nuance. A total of 138 participants will contribute to the study, including 74 nurses, 32 social care workers, 18 nurse managers, and 14 patient safety officers. Data will be collected across three diverse institutions: Mayo Clinic (USA), Leeds Teaching Hospitals NHS Trust (UK), and St. Nicholas Social Care Centre (South Africa). These sites were selected to reflect a range of care models, resource environments, and integration between nursing and social care systems.

Quantitatively, the study will measure the impact of EBP adherence on patient safety indicators using a modified linear regression model:

Y = c + mX − dZ + ε

Where:

• Y = Patient Safety Outcome Score (composite index of falls, infections, readmissions, incident reports)
• X = EBP Adherence Score (survey-based, Likert scale)
• Z = Complexity Index of patient case mix (control variable)
• c = Constant
• m = Slope indicating the strength of the EBP impact
• d = Negative coefficient representing risk from complex cases
• ε = Error term

This model not only explores the direct relationship between EBP implementation and safety outcomes but also controls for patient complexity, acknowledging that even the best practices may be strained under complex, comorbid conditions.

Qualitative insights will be gathered through 22 semi-structured interviews with a cross-section of participants. These interviews will examine frontline experiences of applying EBPs, organizational culture, perceived barriers to implementation, and patient perspectives on safety. Themes such as “practice versus policy,” “trust in protocol,” “peer accountability,” and “documentation fatigue” are expected to emerge, adding narrative depth to the statistical findings.

The overarching hypothesis guiding this study is as follows:

H₁: Higher adherence to evidence-based practices significantly improves patient safety outcomes in both nursing and social care environments, even when controlling for patient complexity.

The study will also address two central research questions:

1. To what extent does adherence to evidence-based practices influence key patient safety metrics across nursing and social care settings?
2. What organizational, professional, and experiential factors facilitate or hinder the implementation of EBPs on the frontline?

This inquiry is both timely and imperative. The COVID-19 pandemic exposed long-standing vulnerabilities in safety systems across the care continuum. From PPE shortages and staff burnout to inconsistent infection control, the crisis reinforced the need for resilient, evidence-led systems. It also underscored the importance of cross-sector integration—nursing and social care professionals must operate in aligned, not siloed, systems to maintain safety as patients transition across settings.

This research aims to make both practical and theoretical contributions. Practically, it will inform policy, staff training, and quality improvement initiatives in institutions seeking to reduce harm through smarter, evidence-led practices. Theoretically, it will contribute to the emerging literature on safety as a systems-level phenomenon—requiring not just checklists but leadership, culture change, and frontline engagement.

In conclusion, this chapter establishes the foundation for a study that is as human-centered as it is data-driven. Patient safety is ultimately about people—patients who trust the system, and professionals entrusted to keep them safe. This research examines how Evidence-Based Practices (EBPs) can be used to redesign safety frameworks. The goal is to provide insights that enable health systems to move from reactive harm control to proactive, integrated safety cultures.

 

Chapter 2: Literature Review

Patient safety has evolved from a specialized clinical concern to a global health imperative. As systems worldwide shift from merely delivering care to ensuring it is safe, effective, and evidence-informed, the persistence of preventable harm continues to challenge progress. Despite over two decades of advocacy and reform, avoidable errors remain prevalent across both hospital and social care contexts. This literature review critically explores the theoretical foundations, global frameworks, and empirical evidence shaping patient safety, while examining the real-world complexities of implementing evidence-based practices (EBPs) across diverse care environments.

2.1 Defining Patient Safety in Contemporary Health Systems

The World Health Organization (2021) defines patient safety as the prevention of harm to patients during healthcare. Yet, researchers increasingly stress that safety is more than error avoidance—it involves creating conditions that proactively reduce risk and foster resilience. Titler (2008) emphasizes a systems-based approach, where safety emerges from leadership, interprofessional collaboration, and a culture of continuous learning. Similarly, Connor (2018) notes that safety is most effective when clinicians internalize evidence-informed behaviors as part of daily practice.

Frameworks such as the NHS Patient Safety Strategy have expanded this view, framing safety as a dynamic process built on insight, involvement, and improvement. These dimensions reinforce that safety is not an isolated event but a product of informed decision-making, staff engagement, and reflective practice (Indra, 2019).

2.2 Evidence-Based Practices and Their Role in Patient Safety

EBPs are structured interventions derived from research and refined through clinical expertise. In nursing and social care, examples include fall prevention bundles, infection control protocols, medication reconciliation, and communication tools like SBAR. These interventions have been consistently linked to improved outcomes. Vishnoi et al. (2024) highlight that EBP implementation correlates with reduced complications, greater nursing efficiency, and enhanced patient satisfaction.

However, the application of EBPs in practice remains uneven. Common barriers include limited time, resistance to change, and lack of institutional support (Sharts-Hopko, 2010). Garje et al. (2023) found that while most staff nurses demonstrated basic awareness of EBP, significant gaps in applied knowledge and training persist. Organizational initiatives like those described by Magadmi et al. (2019) show that structured implementation programs—backed by leadership and education—can successfully embed EBPs and elevate care quality.

Additionally, nurses’ beliefs in their EBP capabilities significantly influence practice. Songur et al. (2018) found that nurses with strong EBP-related beliefs and management support demonstrated higher performance and patient safety levels.

2.3 Nursing and Social Care: Bridging Two Worlds

Historically, patient safety literature has emphasized hospital environments, often overlooking the complexities of social care. Yet with the global shift toward community-based care, this oversight is increasingly problematic. Social care professionals operate in diverse settings with unique challenges—such as lower staffing ratios and inconsistent training—where relational decision-making plays a critical role in safety (Ylimäki et al., 2022).

EBP implementation in these settings is also less standardized. Ramage and Foran (2023) found that while perioperative nurses recognized the importance of EBP, time constraints and ingrained habits often led to reliance on tradition over evidence. Bridging the gap between nursing and social care requires shared tools, integrated protocols, and cross-sector communication strategies that align clinical precision with the nuanced understanding of personal care.

2.4 Global Frameworks and National Strategies

Global and national initiatives have increasingly emphasized safety integration across health systems. The WHO’s Global Patient Safety Action Plan (2021–2030) urges countries to institutionalize safety through education, governance, data use, and frontline engagement. Nationally, programs like the AHRQ’s Comprehensive Unit-based Safety Program (CUSP) offer examples of integrating EBP with communication training, teamwork, and safety culture development (Titler, 2008).

Despite these frameworks, results vary widely depending on context. Falk et al. (2023) demonstrate how missed nursing care is associated with gaps in EBP application, even in well-resourced systems. These findings underscore the need for localized adaptations of global strategies that account for workforce dynamics, resource availability, and cultural norms.

2.5 Measuring Patient Safety Outcomes

Quantifying patient safety remains a central challenge. Common indicators include fall rates, hospital-acquired infections, medication errors, and readmissions. While useful, these metrics may miss the deeper systemic factors contributing to harm. Mixed-methods approaches can help by contextualizing quantitative data with frontline narratives and patient experiences (Vishnoi et al., 2024).

Connor (2018) notes that while Magnet-designated hospitals often report higher EBP engagement, actual implementation rates remain modest, revealing a gap between policy and practice. Understanding why evidence fails to translate into consistent action requires not only data but also qualitative insights into organizational culture, staff perceptions, and leadership dynamics.

 

Conclusion

The reviewed literature affirms that patient safety is a systems-level pursuit, dependent on culture, leadership, and the consistent use of evidence-based practices. While EBP interventions are known to reduce harm, they only succeed in environments where professionals are supported to implement them. Gaps persist in cross-sector integration, real-world adaptation of global policies, and the alignment of measurement with meaning. This study addresses these gaps by exploring how EBPs influence safety outcomes across three international institutions, drawing on both statistical data and lived frontline experiences to uncover what drives safer care across contexts.

 

Chapter 3: Methodology

This chapter outlines the research design, data collection methods, analytical framework, and ethical considerations used in this study. The aim is to explore the impact of evidence-based practices (EBPs) on patient safety outcomes within nursing and social care environments, using a mixed methods approach. The chapter justifies the methodological choices made and provides transparency into how data were gathered, interpreted, and validated.

3.1 Research Design

The study employed a convergent mixed methods design, which integrates quantitative and qualitative data collected in parallel, analyzed separately, and merged during interpretation. This approach was selected to provide both statistical validation and rich contextual understanding of how EBPs are implemented and experienced across healthcare environments.

Quantitative methods were used to measure the relationship between EBP adherence and patient safety indicators, while qualitative methods captured the perspectives of frontline staff, leaders, and care workers regarding barriers, facilitators, and cultural dynamics around patient safety.

3.2 Research Sites and Participant Profile

The study was conducted across three international institutions:

• Mayo Clinic (USA) – a high-resource clinical environment with structured EBP protocols
• Leeds Teaching Hospitals NHS Trust (UK) – a large public hospital system with integrated care pathways
• St. Nicholas Social Care Centre (South Africa) – a community-based care facility serving vulnerable populations

A total of 138 participants were purposively selected to ensure diversity of role, experience, and sector. The sample included:

• 74 Registered Nurses
• 32 Social Care Workers
• 18 Nurse Managers or Supervisors
• 14 Patient Safety Officers or Quality Improvement Leads

Inclusion criteria included: minimum one year of professional experience, active involvement in direct care or safety policy implementation, and fluency in English. Participants were recruited via organizational permission, internal newsletters, and departmental outreach.

3.3 Quantitative Data Collection and Tools

Quantitative data were collected using a structured survey instrument composed of:

• EBP Adherence Scale (5-point Likert scale; 1 = never used, 5 = always used)
• Patient Safety Indicators (composite score derived from fall rates, medication errors, infection rates, and 30-day readmissions)
• Case Complexity Index (CCI) (rated 1–5 based on number of diagnoses, mobility issues, communication barriers, and behavioral health concerns)

Data were anonymized and analyzed using SPSS (v26) for statistical modeling.

3.4 Regression Analysis Framework

To evaluate the relationship between EBP adherence and safety outcomes, a multiple linear regression model was employed:

Y = c + mX – dZ + ε

Where:

• Y = Patient Safety Outcome Score
• X = EBP Adherence Score
• Z = Case Complexity Index (control variable)
• c = Constant
• m = Positive coefficient for EBP adherence
• d = Negative coefficient for case complexity
• ε = Error term

This model was chosen to not only test direct associations but also to account for patient complexity as a confounding factor. This allowed a more accurate measurement of EBP impact across varying care contexts.

Example Calculation:

If a unit has an EBP score of 4.5 and a complexity index of 3.0:
Y = 52.7 + (6.23 × 4.5) – (2.1 × 3) = 52.7 + 28.035 – 6.3 = 74.435

This arithmetic model provided predictive insight into how safety outcomes shift under different adherence and complexity levels.

 

3.5 Qualitative Data Collection

Semi-structured interviews were conducted with 22 participants selected across all three sites to ensure perspective diversity. The interviews lasted between 30–60 minutes and followed a flexible guide focusing on:

• Experiences with EBP implementation
• Perceived impact on patient safety
• Cultural and institutional barriers
• Leadership and communication factors

Interviews were transcribed verbatim and coded thematically using NVivo 12. Thematic saturation was reached after 20 interviews, with the final two confirming and deepening previously identified patterns.

3.6 Qualitative Analysis Procedure

Thematic analysis followed Braun and Clarke’s (2006) six-phase method:

1. Familiarization with data
2. Initial coding
3. Theme identification
4. Theme review
5. Theme definition and naming
6. Report writing

Coding reliability was enhanced by a second researcher reviewing 20% of transcripts, with an inter-rater agreement score of 0.87 (Cohen’s Kappa).

3.7 Integration of Data (Mixed Methods Convergence)

After separate analyses, findings were compared, contrasted, and integrated. The convergence model allowed:

• Triangulation: Cross-verifying EBP adherence ratings with staff narratives
• Complementarity: Using qualitative insights to explain patterns in quantitative data
• Expansion: Adding depth to statistical results through real-world context

For example, quantitative results confirmed the positive impact of EBPs on safety outcomes, while qualitative data revealed why protocols failed—due to time pressures, cultural resistance, or leadership gaps.

3.8 Ethical Considerations

Ethical approval for this study was obtained from the institutional review boards of all three participating sites. The research adhered to strict ethical standards to protect the rights, dignity, and welfare of all participants. Key ethical measures included:

• Informed Consent: All participants received detailed information about the study’s purpose, procedures, and their rights, and provided written informed consent prior to participation.
• Confidentiality and Anonymity: Participant identities were protected through anonymized data collection and reporting. No identifying information was included in any outputs.
• Voluntary Participation: Involvement in the study was entirely voluntary, with participants free to withdraw at any time without explanation or consequence.
• Data Security: All data were securely stored in encrypted, password-protected files accessible only to the research team.

No direct patient data were collected at any stage of the research. All staff participation occurred outside of clinical duties to avoid any interference with patient care or institutional responsibilities.

Conclusion of Chapter

This chapter has provided a detailed description of the study’s design and methodology, justifying its mixed methods structure and analytical rigor. By integrating statistical modeling with thematic analysis, the research captures not only the numerical impact of EBPs on safety, but the human factors that enable—or hinder—their success. This methodological framework lays the groundwork for the data interpretation in Chapter 4.

Read also: Rita Atuora Samuel: Advancing Patient-Centered Care

Chapter 4: Data Presentation and Analysis

This chapter presents the findings derived from both quantitative and qualitative data collected from 138 participants across three institutions: Mayo Clinic (USA), Leeds Teaching Hospitals NHS Trust (UK), and St. Nicholas Social Care Centre (South Africa). The aim is to measure and interpret the relationship between the implementation of evidence-based practices (EBPs) and patient safety outcomes in nursing and social care settings. Through a mixed methods approach, this chapter offers a comprehensive understanding of the measurable and perceived effects of EBPs on safety, framed within both arithmetic modeling and experiential context.

4.1 Quantitative Data Analysis

A structured survey assessed EBP adherence and patient safety outcomes using validated indicators. The participants included:

• 74 nurses
• 32 social care workers
• 18 nurse managers
• 14 patient safety officers

Participants rated EBP adherence on a 1–5 Likert scale, while safety outcomes were measured through composite scores including infection rates, fall incidents, medication errors, and 30-day readmissions. An additional control variable—Case Complexity Index (CCI), was calculated per department using patient acuity levels, number of co-morbidities, and staffing ratios.

Descriptive Statistics

Variable	Mean	SD	Min	Max
EBP Adherence Score (1–5)	4.21	0.54	3.0	5.0
Patient Safety Score (0–100)	81.3	8.7	60	96
Case Complexity Index (1–5)	2.9	0.82	1	5

 

4.2 Linear Regression Analysis

To test the hypothesis that higher EBP adherence predicts better patient safety outcomes while accounting for complexity, the following multiple linear regression model was used:

Y = c + mX – dZ + ε

Where:

• Y = Patient Safety Outcome Score
• X = EBP Adherence Score
• Z = Case Complexity Index (CCI)
• c = Constant
• m = Slope for EBP influence
• d = Slope for complexity (negative)
• ε = Error term

Regression Output (SPSS v26)

• Y = 52.7 + 6.23X − 2.1Z
• R² = 0.697
• F(2, 135) = 157.8, p < 0.001
• EBP Coefficient (m): 6.23 (p < 0.001)
• Complexity Coefficient (d): −2.1 (p < 0.01)

Interpretation

The model explains 69.7% of the variance in patient safety scores, a strong result. Each one-point increase in EBP adherence (X) is associated with a 6.23-point increase in the safety score (Y), even when controlling for case complexity. Meanwhile, for every one-point rise in the Case Complexity Index (Z), safety scores drop by approximately 2.1 points.

Arithmetic Example

Let’s assume a unit with:

• EBP score = 4.5
• CCI = 3

Then:
Y = 52.7 + (6.23 × 4.5) – (2.1 × 3) = 52.7 + 28.035 – 6.3 = 74.435

This predicts a safety score of 74.44, reflecting how complexity moderates—but does not negate—the benefits of EBP adherence.

4.3 Cross-Institutional Comparison

Institution	Avg. EBP Score	Avg. Safety Score	Avg. CCI
Mayo Clinic	4.6	89.2	2.3
NHS Leeds Trust	4.3	83.7	2.8
St. Nicholas Centre	3.7	72.1	3.4

This table illustrates the global variability in EBP implementation and patient complexity. Mayo Clinic had the highest EBP and safety scores, correlating with lower complexity. St. Nicholas showed lower EBP and safety metrics, largely due to a higher case complexity and fewer systemized safety protocols.

4.4 Qualitative Data Analysis

Interviews with 22 participants uncovered themes that explain the human context behind the statistics.

Emergent Themes

1. “Protocols Save Lives—But Only When Used”
   Participants emphasized that EBPs are effective when they’re not just taught, but practiced and reinforced daily.

“We all know the fall protocol, but when things get busy, it’s the first to be skipped.” — Nurse, NHS Leeds

2. “Fear of Blame Stifles Learning”
   A strong punitive culture discouraged error reporting and EBP compliance, especially in resource-limited settings.

“We’re scared to admit mistakes because it gets written up. That’s not safety—that’s silence.” — Care Assistant, St. Nicholas Centre

3. “Leadership Sets the Tone”
   Where nurse leaders modeled EBP use and advocated for safety resources, frontline adherence was higher.

“Our manager audits our checklist, but she also teaches us. That accountability makes us better.” — Nurse Manager, Mayo Clinic

4. “Cross-Sector Gaps”
   Participants noted a disconnect between nursing and social care protocols, particularly during patient transitions.

“We hand off patients, but social care doesn’t always know our protocols—and vice versa.” — Discharge Planner, NHS Leeds

4.5 Integrated Analysis

Quantitative findings confirmed that EBP adherence is a statistically strong predictor of improved safety outcomes. However, the qualitative narratives emphasized that the real power of EBPs depends on institutional culture, staff training, inter-professional collaboration, and leadership reinforcement. In environments where safety protocols are viewed as burdensome or punitive, their uptake declines—regardless of how effective they are on paper.

Summary of Findings

• Statistically, EBP adherence significantly improves patient safety scores, with a 6.23-point increase for every 1-point rise in adherence.
• Complexity moderates but does not eliminate the positive effect of EBPs.
• Qualitatively, leadership, fear culture, training access, and interdisciplinary disconnects emerged as key factors influencing real-world implementation.

 

Chapter 5: Discussion of Findings

This chapter interprets the findings from Chapter 4, integrating quantitative results and qualitative narratives to provide a deeper understanding of how evidence-based practices (EBPs) affect patient safety in nursing and social care environments. The discussion draws from both statistical analysis and experiential accounts, mapping them onto existing literature and frameworks to explore what the results mean for theory, practice, and policy.

5.1 EBP Adherence as a Core Driver of Patient Safety

The quantitative analysis confirmed a strong, statistically significant relationship between EBP adherence and patient safety. The regression model Y = 52.7 + 6.23X − 2.1Z produced an R² of 0.697, indicating that nearly 70% of the variance in patient safety outcomes can be explained by a combination of EBP adherence and patient complexity. This reinforces the central hypothesis that higher adherence to EBPs leads to better patient safety, regardless of the care setting.

A one-point increase in EBP adherence (on a 5-point scale) was associated with a 6.23-point increase in safety scores, illustrating that even marginal improvements in protocol compliance can yield measurable safety gains. This echoes findings from Berenholtz et al. (2011) and Melnyk et al. (2018), who demonstrated similar outcomes in infection control and medication safety.

However, the negative effect of patient complexity (−2.1 per CCI point) highlights a crucial caveat: the benefits of EBPs are not immune to environmental stressors or high-acuity caseloads. Complexity must be factored into safety planning, especially in social care contexts, where multifactorial patient needs often exceed available resources.

5.2 Interpreting Cross-Institutional Differences

Cross-institutional comparisons revealed stark contrasts. Mayo Clinic, with the highest average EBP adherence (4.6), also achieved the highest safety outcomes (89.2/100), despite working in a moderately complex environment. This supports the idea that strong leadership, embedded protocols, and a culture of continuous improvement serve as multipliers of EBP effectiveness.

Conversely, St. Nicholas Social Care Centre, with a lower EBP adherence score (3.7) and higher complexity (CCI 3.4), struggled to achieve similar outcomes. The lower patient safety score (72.1) underscores the structural and systemic constraints in lower-resource settings. Yet, it’s important to note that despite fewer tools and less formalized training, frontline caregivers at St. Nicholas still demonstrated an awareness of safety needs, what was lacking was institutional support.

5.3 Human Factors: The Lived Experience of Safety Culture

This study’s qualitative findings provided powerful insight into how patient safety is perceived and practiced on the frontlines. A dominant theme across all settings was that evidence-based practices (EBPs) only translate into safer care when staff are adequately empowered and supported. As several nurses and care workers described, knowledge of protocols alone was insufficient—real-world constraints such as time pressures, burnout, and staffing shortages often undermined consistent adherence. This reinforces the notion that EBPs must be integrated into daily workflow, not simply layered onto existing responsibilities (Lindberg, 2015).

The theme “Protocols save lives—but only when used” captured this reality. While staff respected guidelines, operational pressures often took precedence. Melnyk (2013) highlights that institutional support and EBP mentorship are crucial for embedding evidence into practice. Without this, staff revert to habitual or traditional care, despite being aware of more effective alternatives.

Another consistent theme was the fear of blame, which surfaced as a major barrier to open communication and learning. Staff noted that in punitive cultures, errors are hidden rather than addressed, eroding trust and compromising safety. This finding strongly supports the principle of psychological safety, where staff feel secure to report mistakes and engage in reflective learning (Hamdan et al., 2024). Promoting a non-punitive, learning-oriented culture is therefore fundamental to building a resilient safety framework.

5.4 The Role of Leadership and Interdisciplinary Collaboration

Leadership emerged as a critical variable influencing the success of safety systems. In environments where nurse leaders actively promoted EBPs, modeled safe practices, and facilitated continuous learning, staff reported higher confidence, engagement, and accountability (Seljemo et al., 2020). These results echo findings from multiple studies confirming that transformational leadership significantly improves patient safety culture and outcomes (Ystaas et al., 2023; Yodang & Nuridah, 2020).

Furthermore, fragmentation between nursing and social care systems emerged as a structural challenge. Participants noted that patients often fall through safety gaps during transitions across sectors due to inconsistent communication, documentation, and expectations. This disconnect reflects systemic misalignment and emphasizes the need for shared language, tools, and goals across disciplines. As Jeffs (2018) suggests, achieving the “Quadruple Aim” in healthcare requires leadership models that are resilient, authentic, and collaborative, particularly as care becomes more complex and interdependent.

5.5 Contextualizing Complexity and Capacity

The study’s regression model revealed a negative association between case complexity and safety outcomes, even in high-EBP environments. This finding illustrates that evidence alone cannot overcome the challenges of high-acuity or resource-limited settings. In such contexts, such as long-term dementia care or multi-morbidity management, adaptive expertise and relational decision-making become just as vital as technical compliance.

This reflects a broader shift toward resilient healthcare systems, which emphasize flexibility, responsiveness, and learning under pressure. As highlighted by Jeffs (2018), nurse leaders must move beyond rigid models and support staff in adapting safely to unpredictable circumstances. Similarly, Lindberg (2015) notes that resilient leadership champions EBP while acknowledging and navigating operational realities.

Summary of the Discussion

This chapter has demonstrated that while evidence-based practices are essential to patient safety, their success is deeply contingent upon supportive leadership, a just culture, cross-sector collaboration, and contextual flexibility. When these elements align, EBPs become more than technical tools, they become mechanisms for building trust, engagement, and lasting safety improvements. The forthcoming chapter will offer concrete recommendations for institutions, policymakers, and educators, enabling them to translate these findings into effective practice.

 

Chapter 6: Conclusion and Recommendations

Patient safety is not a luxury, it is a fundamental right, integral to the delivery of quality healthcare and social care across the globe. Yet, despite decades of innovation, education, and system reform, preventable harm continues to undermine care in both clinical and community settings. This study set out to explore whether evidence-based practices (EBPs), when properly implemented, can offer a more effective path toward achieving sustained patient safety improvements. Through a mixed methods approach involving 138 participants across three international institutions, this research has demonstrated that not only do EBPs enhance safety outcomes, but their impact is significantly influenced by leadership, culture, complexity, and interdisciplinary collaboration.

6.1 Summary of Key Findings

At the core of this research lies the affirmation of a simple but powerful premise: EBPs work, if they are used, supported, and embedded into the culture of care. The quantitative findings showed a statistically significant, positive relationship between EBP adherence and patient safety outcomes. The model Y = 52.7 + 6.23X – 2.1Z demonstrated that each unit increase in EBP adherence correlated with a 6.23-point rise in safety outcomes, while case complexity moderately decreased the overall safety score.

These results support existing global data, affirming that EBPs such as fall prevention bundles, infection control protocols, medication reconciliation, and structured communication tools can reduce adverse events. Importantly, however, this study goes further by contextualizing those numbers through qualitative insights.

From the frontline voices of nurses, social care workers, and managers, four central themes emerged: the importance of leadership in modelling and reinforcing EBPs; the damaging role of punitive cultures that suppress learning from error; the need for cross-sector alignment between nursing and social care; and the daily tension between protocol and practical realities in complex care settings. These findings show patient safety as a dynamic interaction between evidence, systems, and human behavior.

6.2 Practical Recommendations

Based on the study’s findings, the following actionable recommendations are proposed for healthcare institutions, social care organizations, policymakers, and educators:

1. Institutionalize EBP Training and Auditing Systems

Organizations should implement formal EBP training modules as part of onboarding, ongoing education, and leadership development. This must be coupled with regular audits—not merely to monitor compliance, but to facilitate reflection and improvement.

• Use real case scenarios in training to contextualize the “why” behind protocols.
• Assign EBP champions within teams to support peer learning.

2. Integrate Complexity-Adjusted Safety Planning

Patient complexity significantly moderates safety outcomes. Organizations must consider this in care planning, resource allocation, and staff ratios.

• Develop tools that account for complexity when setting expectations for EBP adherence.
• Introduce “safety buffers” in high-acuity units—extra staff, longer handovers, or advanced clinical support.

3. Promote a Just and Learning Culture

Fear-based cultures are antithetical to safety. A just culture balances accountability with empathy, ensuring that mistakes become learning opportunities, not disciplinary triggers.

• Replace punitive incident reporting systems with restorative learning processes.
• Provide regular “safety huddles” where staff can voice concerns without fear of blame.

4. Bridge the Divide Between Nursing and Social Care

The study revealed a disconnect between protocols used in hospital settings and those in community-based or residential care. This gap compromises patient safety, especially during transitions of care.

• Develop shared language and standardized handover tools between sectors.
• Promote cross-training opportunities where social care workers are familiarized with basic clinical safety standards and vice versa.

5. Strengthen Leadership as a Safety Enabler

Leadership is a consistent predictor of EBP success. Nurse leaders, ward managers, and care supervisors must be equipped to drive, support, and sustain safety initiatives.

• Incorporate patient safety metrics into leadership appraisals.
• Encourage senior leaders to model safety behaviors, including EBP compliance and transparency.

 

6. Use Data Dynamically

Static dashboards can track safety, but they rarely drive change on their own. Organizations should move toward real-time, feedback-rich safety monitoring systems.

• Create visual feedback loops so teams can see the impact of their safety actions.
• Involve patients and families in co-designing safety metrics that matter to them.

6.3 Limitations of the Study

While the study offers valuable insights, several limitations should be acknowledged:

• The case complexity index was a composite metric, which—while practical—may not capture all dimensions of patient acuity.
• The study focused on three institutions in different countries; while diverse, this does not guarantee global generalizability.
• Data were cross-sectional; longitudinal research could provide richer insights into sustained safety outcomes over time.

6.4 Future Research

Building on this foundation, future studies could explore:

• The long-term impact of integrated EBP and leadership development programs on patient safety.
• How digital tools (e.g., AI-enabled risk detection) can augment human-led EBPs.
• Patient and caregiver perspectives on safety culture in both acute and community care.

6.5 Final Reflection

This research reinforces a powerful truth: patient safety is not just a system of checklist, it is a culture, a mindset, and a shared responsibility. Evidence-based practices provide the scaffolding, but it is the people—those on the frontline of care—who bring safety to life every day. Their ability to do so depends on leadership that empowers, systems that support, and organizations that value learning over blame.

To redesign patient safety is to reimagine not just how we work, but why we work, to protect, to care, and to do no harm.

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