Alshahrani, Nouf
(2025)
Understanding adherence to international and national surgical site infection prevention guidelines in Saudi Arabia: A qualitative study.
PhD thesis, University of Nottingham.
Abstract
Background: The most common healthcare-associated infections are surgical site infections (SSIs). Worldwide, their incidence rate is approximately 20% to 38%, with rates in Saudi Arabia ranging from 10% to 86%. SSIs result in increased mortality and morbidity rates, increased healthcare costs and extended hospital stays. International and national SSI guidelines were developed to improve the quality of care and outcomes for surgical patients by providing standardized practices to prevent SSIs based on evidence. However, studies show that there is poor adherence to the SSI guidelines during the pre-and intraoperative periods among surgical team members worldwide. Moreover, there is a paucity of evidence concerning this topic in Saudi Arabia where there is a high incidence of SSIs.
Aim: The aim of this study is to explore adherence to international and national SSI prevention guidelines by surgical team members during the pre-and intraoperative periods in Saudi Arabia.
Method: The researcher conducted a detailed review of relevant literature on the adherence to SSI guidelines to identify existing knowledge and gaps in the literature. This was followed by a focused ethnographic study using the following methods: observations of routine practice recorded with field notes describing behaviours, interactions between members of the surgical team and surgical patients during the pre and intraoperative periods, supported by a review of patients’ notes and semi-structured interviews. The research was conducted in two operating rooms (ORs) units of two hospitals in Saudi Arabia. Nineteen members of the surgical teams were observed for a total of 160 hours. Observations were followed by interviews with 18 surgical team members who had been observed. Observations and interviews data were analysed using thematic analysis inductively to investigate the reasons influencing adherence. The analysis was followed by a deductive ‘abductive’ approach in which themes were presented and organised where possible within the Consolidated Framework for Implementation Research (CFIR).
Findings: Adherence to SSI guidelines at both hospitals and among surgeons and nurses was poor. Different reasons influenced adherence to the SSI guidelines, and the results illustrated that 19 CFIR constructs/themes impacted adherence across all five domains. Some reasons for adherence and non-adherence were specific to Saudi Arabia, including language barriers, culture and gender. Other reasons were more universal and included personal beliefs and behaviours, the nursing role, leadership, and organisational planning.
Conclusion: Language, the culture of power and the influence of hierarchy, gender, beliefs, patients, behaviours, the OR nurses’ role, the influence of surgeons and leadership, and organisational influences are key reasons that influence the adherence to SSI guidelines. Some facilitators were suggested to assure best practice and encourage adherence, such as education and training on SSI guidelines for all members in the ORs, communication and cooperation between surgical team members and staff in other units, that SSI practices should be introduced by staff who speak Arabic to ensure patients understand, strong friendships among female nurses, the availability of up-to-date checklists for SSI practices, and the influence of heads and surgeons could all improve adherence. This study offers a unique contribution to expand CFIR. In addition, it has relevance for OR units in the southern region of Saudi Arabia, although, they might contribute further to bolstering understanding of the reasons influencing adherence to SSI guidelines among similar cultural groups of surgical team members in OR units in other Saudi Arabia regions or Arab countries.
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