IntroductionNetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals.Methods and analysisOur primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews.Ethics and disseminationWe believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143).Trial registration numberAustralian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.

Developing professional identity is a vital part of health professionals' education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.

Aim NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff – including the challenges they faced – in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation. Method We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning. Results Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs. Conclusion Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

Patient Safety is central to the New Zealand (NZ) health strategy. However international experience shows that safety improvement work frequently fails to meet its objectives. This article provides a qualitative account of the challenges of safety improvement from the perspective of nurses, doctors, and managers in three departments in two NZ public hospitals. These staff described significant tensions in relation to engagement and organisational capacity. An analysis of their perspectives through the Organising for Quality model [Bate et al. 2008, Organising for quality: The improvement journeys of leading hospitals in Europe and the United States, Oxford & New York, Radcliffe Publishing] highlights the significance of failures at the level of structure, culture, politics, motivation and infrastructure.

Hospital care is unavoidably associated with the risk of preventable harm due to human error. The problem is pervasive, damaging and expensive - globally, and in New Zealand (NZ). But while many of the processes through which patients are harmed have been described, there is a lack of published research about the perspectives of staff in public hospitals in NZ on patient risk. This article reports on a qualitative investigation of how nurses, doctors, and managers in NZ understood patient harm. Their perspectives, analysed here through theory about risk in complex systems, emphasised economically-driven pressure as an important risk factor that dominated safety.

In this thesis I explore the challenges for staff working to reduce harm and implement safety improvement in New Zealand (NZ) hospitals. Their views are contextualised in four stages. First, medical harm is outlined as a persistent and expensive threat to public health. While new practices make decisive action possible, implementation remains problematic. Second, policy in America, England, and NZ is analysed through Light???s (1995, 2010) theory of countervailing powers, and a shift from medical to managerial dominance. In NZ safety entered policy rhetoric around 2000, but it was compromised by resource shortages, a lack of evaluation, insufficient centralised support and coordination, and disengagement between managers and clinicians. While efforts intensified post-2008, resourcing remained problematic. Third, theories of organisational accidents (Reason 1990, 2000, 2001, 2004), normal accidents (Perrow 1984), sensemaking (Weick and Sutcliffe 2007), and the empirical literature about in-hospital risks, are reviewed. The review follows Vaughan???s (1999) discussion of organisational failure as emergent from the complex interconnection of organisational environments, organisations, and cognition and action. Pressure, organisational systems, hierarchy, communication, and organisational culture are identified as key risks. Fourth, the safety improvement literature is reviewed, implementation challenges are identified, and safety is theorised as emergent from unique organisational solutions to universal challenges of structure, culture, politics, learning, motivation, and infrastructure (Bate, Mendel et al. 2008). Staff perspectives from NZ are provided by n=37 qualitative interviews with doctors, nurses, and managers in three departments in two hospitals. Interviews explored the challenges of risk control and safety improvement, and are theorised as naturalistic accounts of real experiences. The dominant generalised risk was short staffing, which drove pressure, and contributed to poor communication and breakdowns in teamwork. These and other factors meant that some clinical risks were poorly controlled. Some denial of generalised and clinical risks was also evident. Improvement activities showed a number of gains, but many processes were failing from insufficient time, a lack of expertise in using systemic data and sensing problems, staff disengagement, poor ownership of processes, and inadequate IT infrastructure. In conclusion, tensions between productivity and safety pressured clinical work and contributed to ongoing harm. These failures drive up costs and threaten the fiscal sustainability of healthcare in NZ.