Review Maps the Forces That Shape Infection Control in Operating Rooms

A systematic review of thirteen studies has brought together the fragmented evidence on why operating room teams do, or do not, consistently follow infection prevention and control practices for transmissible infections. The review, conducted according to the Joanna Briggs Institute methodology for mixed-methods systematic reviews and registered with PROSPERO, synthesised quantitative, qualitative and mixed-methods research published from 2010 onwards. Its central conclusion is that adherence in the operating room is not simply a matter of individual knowledge or willingness. Instead, it emerges from an interplay of organisational support, professional and team dynamics, education and training, and the very practical difficulties of wearing protective equipment while performing surgery and anaesthesia.

The stakes are considerable. The World Health Organization estimates that around 7 percent of hospitalised patients in high-income countries and 15 percent in low- and middle-income countries acquire at least one healthcare-associated infection, and on average one in ten affected patients dies as a result. Australia alone records an estimated 170,000 such infections and more than 7,500 associated deaths annually. Surgical patients sit near the top of the risk spectrum because surgery breaches the body’s natural defensive barriers and because the operating room offers multiple opportunities for pathogen transfer, from clinicians’ hands to anaesthesia equipment, monitors, operating tables and other high-touch surfaces. Studies of methicillin-resistant Staphylococcus aureus have shown that contamination of anaesthesia practitioners’ hands can lead to transmission between surgical cases within a single session.

The reviewers searched five major databases between March and April 2025, with updated searches in August 2026, and screened 2,765 database records plus additional citations. After removal of duplicates and full-text assessment, thirteen studies were included, published between 2012 and 2025 across settings including Australia’s international comparators in the United Kingdom, the United States, Tunisia, Türkiye, Iran, India, Singapore, Switzerland and China. Most were quantitative, with two qualitative studies and one mixed-methods study, and eight were conducted in the context of the COVID-19 pandemic. The synthesis produced four overarching themes: organisational support and resources; professional and team dynamics; knowledge and training; and practical challenges in implementing precautions.

Organisational conditions proved to be among the most powerful influences. A Turkish study of 203 operating room team members during the pandemic found that the absence of open-air or oxygen-rich rest areas and of opportunities to shower after surgery made it harder for staff to cope with prolonged personal protective equipment use, contributing to avoidance of PPE. Iranian research across teaching hospitals found that signage and restrictions on traffic were more commonly implemented than recommended ventilation or negative-pressure requirements. In Singapore, concerns about potential PPE shortages led junior anaesthetists to reuse disposable gowns and store goggles incorrectly; when an intervention improved storage facilities and access to disinfectant wipes, correct handling rose substantially over a nineteen-week period.

Oversight and feedback also mattered. A quasi-experimental study in the United States spanning 194 operating rooms showed that structured education and performance feedback raised cleaning thoroughness from 47 percent to 82 percent, with anaesthesia equipment cleaning jumping from 25 percent to 77 percent after cleaning duties were reassigned to the anaesthesia team itself. Although this did not translate into an overall reduction in environmental pathogens, a separate multi-component intraoperative programme was associated with a fall in Staphylococcus aureus transmission from 24 percent to 9 percent and in surgical site infections from 8 percent to 3 percent, effects sustained during six months of post-pandemic follow-up. The review’s authors caution, however, that the multicomponent designs of such studies make it difficult to determine which individual strategies drove the improvements.

Professional and team dynamics formed the second theme. In a Welsh mixed-methods study of 315 surgeons and scrub nurses, only 9.8 percent reported consistent adherence to all available standard precautions, and 58.1 percent agreed that staff took fewer precautions with patients considered low risk. Surgeons were markedly less likely than scrub nurses to use eye protection, with an odds ratio of 0.28, and often regarded sharps injuries as an expected part of the job. During the pandemic, an observational audit at an Indian cancer centre found high overall PPE compliance of 96.3 percent, yet the most frequent lapses involved eye protection among surgeons, largely due to discomfort and visor fogging. Iranian data similarly showed surgical residents with lower PPE adherence scores than nurses and attending surgeons.

Communication within the team emerged as both a facilitator and a casualty of precautions. International interviews with surgical teams during COVID-19 found that regular discussions, defined roles, buddy systems and simulation helped teams adapt as recommendations changed rapidly. Conversely, Turkish nurses described how protective equipment made it difficult to hear colleagues, feeding anxiety about making medical errors, while social distancing and staff rotation increased feelings of isolation. In the United States, friction between nurses, surgeons and environmental services staff over cleaning protocols for patients with multidrug-resistant organisms was eased by an interprofessional decision algorithm; afterwards, nurses reported less pushback from surgeons when terminal cleaning was required.

Knowledge and training, the third theme, told a more nuanced story. A Tunisian study found that fewer than half of operating room nurses had received training on blood exposure accidents, although 90.2 percent wanted to know more. Turkish research revealed that despite months of wearing multilayered pandemic PPE, over 85 percent of staff had never been trained on breathing with an N95 mask or on head movements to prevent vision and balance problems. Generally, staff relied more on colleagues and written guidelines than on formal workshops. Most strikingly, a Swiss randomised controlled trial with 85 physicians and anaesthetic nurses found that neither simulation-based nor video-based training significantly improved hygiene knowledge, although simulation was rated more positively and participants reported a greater willingness to speak up when a senior colleague breached precautions.

The fourth theme concerned the sheer practicality of protective measures. Across the pandemic-era studies, teams reported reduced respiratory quality in 91.6 percent of cases, visor fogging in 89.2 percent of those with visual problems, reduced hearing in 61.6 percent, and communication difficulties in 93.6 percent. Participants told international researchers that PPE occasionally impaired dexterity and equipment use, forcing them to prioritise operability over full protection. Junior anaesthetists worried that strict PPE practices could interfere with the care of unstable patients. The review frames these findings through a human-factors lens: protective equipment changes the interface between healthcare workers and their patients, instruments and colleagues, so compliance depends not only on knowing what is required but on whether protective gear can be integrated safely into clinical tasks.

The authors are careful about the limits of their synthesis. The evidence base was methodologically heterogeneous, dominated by single-centre, observational and self-reported designs, precluding meta-analysis and any firm conclusions about causal effects of specific interventions on infection outcomes. Eight of the thirteen studies were conducted under the exceptional conditions of the COVID-19 pandemic, which may limit transferability to routine practice. Language and publication bias are also possible, since only English-language published studies were included. Nevertheless, the review offers a conceptual map for improvement: organisational conditions such as staffing, infrastructure and leadership are potentially modifiable; interprofessional education can build shared understanding of transmission risks; and perioperative nurses, positioned at the centre of perioperative coordination, can review alerts, confirm precautions during team briefings, escalate unsafe practices and champion audit and feedback. Adherence, the review concludes, is a property of the whole system, not of individuals alone.

Subject of Research: Factors influencing infection prevention and control practices for transmissible infections among operating room team members

Article Title: Influences of Infection Prevention and Control Practices for Transmissible Infections Among Operating Room Team Members: A Systematic Review

Article References: Sriharan, K., Pillay, R., Glew, P., & Mutsonziwa, G. (2026). Influences of Infection Prevention and Control Practices for Transmissible Infections Among Operating Room Team Members: A Systematic Review. Nursing Open, 13(10), Article e70956. https://doi.org/10.1002/nop2.70956

Image Credits: AI Generated

DOI: 10.1002/nop2.70956

Keywords: infection prevention and control, operating room, systematic review, transmission-based precautions, personal protective equipment, healthcare-associated infections, perioperative nursing, COVID-19, hand hygiene, surgical team dynamics, training and education, multidrug-resistant organisms