The Impact of COVID-19 on Healthcare Services, Risk Management, and Infection Prevention in Surgical Settings: A Qualitative Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for providing me with the opportunity to read this interesting paper. Below, I have listed my comments:

1) The paragraph on 'Compliance with evidence-based procedures in surgical environments' could flow better. Instead of jumping straight from the general topic to evidence-based procedures, you might add a connecting sentence.

2) In the methods section, the point about data saturation is important, but the explanation can be slightly clearer. It’s mentioned that 'data saturation was reached during the 19th interview' but then refers to the last two interviews signaling the end of data collection. This could be confusing as it’s unclear if these last two interviews were redundant.

3) You could further explain how Colaizzi’s method relates to your analysis and why it's suitable for your study.

4) In the discussion, while it mentions hierarchical barriers in the operating room, it could be helpful to explore potential solutions or strategies to overcome these challenges. For example, what could be done to reduce the power distance between nurses and surgeons in practice? It would also be valuable to link this back to the organizational culture and leadership styles.

5) The limitations section could provide more specific suggestions for future research. While the impact of COVID-19 is mentioned, it would be useful to explore how this pandemic might have specifically changed the roles of nurses or affected the operating room dynamics, and how future studies could investigate these changes in a more focused way.

I hope this feedback is helpful.

Author Response

Comments 1: Are the methods adequately described (x) can be improved

 

Response 1: Thank you for pointing this out. We agree with this comment, Therefore, we have revised the results presentation in page 4 line 156 to 161, line 165 to 176.

 

Comments 2: Are the conclusions supported by the results (x) can be improved

 

Response 2: Thank you for pointing this out. We agree with this comment, Therefore, we have revised the results presentation in page 13 line 580 to page 14 line 591.

“This qualitative study explored HK caregivers’ perspectives on long-term planning for relatives with ID during the later period of COVID-19 pandemic. Interviews revealed key triggers raising awareness of future planning needs, but barriers like painful emotional distress and exhaustion hindered progress; open communication and family involvement helped. The pandemic exacerbated challenges and fragile support networks. Healthcare providers must offer individualized psychosocial support, practical assistance and skill-building workshops, increased respite care, improved care coordination. Policymakers must prioritize gradual implementation of supportive policies, increased investment in services, facilitated discussions about resident care, and a comprehensive, integrated care plan. Addressing caregiver needs requires a collaborative effort to build more resilient support systems improving quality of life for both caregivers and their family members with ID.”

 

Comments 3: The paragraph on 'Compliance with evidence-based procedures in surgical environments' could flow better. Instead of jumping straight from the general topic to evidence-based procedures, you might add a connecting sentence.

 

Response 3: Thank you for pointing this out. We agree with this comment. Therefore, we modified the introduction section in page 2 line 53 to 65:

“The reduction of bacterial burden within surgical settings is most important to minimizing the occurrence of surgical site infections during intra-operative procedures. Compliance with evidence-based procedures plays a significant role in achieving this objective. To that end, implementing strict protocols, such as ensuring adherence to hygiene practices by all surgical team members and correct sterilization of operating rooms between procedures, represents a direct approach to lessening the bacterial load [6,14]. While these measures are theoretically effective, maintaining consistent compliance within clinical practice presents an ongoing challenge for healthcare providers. Furthermore, a stronger body of evidence is needed to comprehensively illuminate the impact of surgical site infections on patient outcomes and to further refine preventative strategies [2,15]. Given increasing bacterial antibiotic resistance, preventing surgical site infections is a complex undertaking. It is crucial to reduce operating room microbial contamination of the absolute minimum.”

 

Comments 4: In the methods section, the point about data saturation is important, but the explanation can be slightly clearer. It’s mentioned that 'data saturation was reached during the 19th interview' but then refers to the last two interviews signaling the end of data collection. This could be confusing as it’s unclear if these last two interviews were redundant.

 

Response 4: Thank you for your insightful comment. Therefore, we modified the methods section in page 4 line 156 to 161:

“Data saturation, the point at which further data collection ceased to yield new insights relevant to the research question, was achieved in this study. Specifically, after the 19th interview, analysis of the subsequent interviews confirmed the absence of novel concepts, themes, or perspectives related to the study’s aims. This redundancy of in-formation validated the achievement of data saturation and justified the conclusion of data collection.”

 

Comments 5: You could further explain how Colaizzi’s method relates to your analysis and why it's suitable for your study.

 

Response 5: Thank you for your comment. Therefore, we modified the methods section in page 4 line 165 to 176.

“A descriptive phenomenological approach, guided by Colazzi’s (1978) method, was employed to analyze the data pertaining to healthcare providers’ experiences with surgical site infection prevention in the operating room [27]. This methodological choice was predicted on its established efficacy in elucidating the nuanced meanings individual attribute to their lived experiences, a critical aspect of understanding the complexities intrinsic in surgical site infection prevention. Colazzi’s seven-step process provided a systematic framework for analyzing detailed descriptions and field notes, facilitating the identification of significant statements, the distillation of their intrinsic meanings, and the subsequent synthesis of a comprehensive understanding of the phenomenon [27]. This rigorous approach enabled the researchers to move beyond superficial interpretations and delve into the essence of healthcare providers’ lived expe-riences concerning surgical site infection within the dynamic and demanding context of the operating room.”

 

Comments 6: In the discussion, while it mentions hierarchical barriers in the operating room, it could be helpful to explore potential solutions or strategies to overcome these challenges. For example, what could be done to reduce the power distance between nurses and surgeons in practice? It would also be valuable to link this back to the organizational culture and leadership styles.

 

Response 6: Thank you for your comment. Therefore, we modified the discussion section in page 11 line 468 to 483:

“The findings of this study emphasize the crucial role of team collaboration in pre-venting surgical site infections while concurrently exposing hierarchical barriers within operating room teams, particularly impacting nurse-surgeon dynamics [38,56]. These power imbalances can inhibit crucial information sharing, potentially endanger patient safety. Alleviating these challenges requires a multifaceted approach confining organizational cultural and leadership [55,56]. Cultivating shared responsibility and mutual respect is most important, achievable through empowering nurses in surgical site infection prevention decision-making. Implementing structured communication protocols, such as checklists or briefings, facilitates clear information exchange [42-44]. Furthermore, fostering open communication, where nurses feel safe expressing concerns, is essential. Transformational leadership, characterized by open communication and shared decision-making, is crucial for dismantling hierarchical barriers. Promoting psychological safety, where all team members feel valued, further enhance communication. Finally, organizational initiatives like interprofessional training and simulation exercises provide opportunities for practicing collaborative skills, ultimately optimizing surgical site infection prevention and patient outcomes [38,56].”

 

Comments 7: The limitations section could provide more specific suggestions for future research. While the impact of COVID-19 is mentioned, it would be useful to explore how this pandemic might have specifically changed the roles of nurses or affected the operating room dynamics, and how future studies could investigate these changes in a more focused way. I hope this feedback is helpful.

 

Response 7: Agree. We have, accordingly, modified this point in page 11 line 505 to 517:

“This study has limitations. The Hong Kong-centric participant pool, drawn solely from acute care hospitals, limits generalizability to other settings like ambulatory surgical centers or rural hospitals. Future research should diversify participant recruitment to enhance external validity. Reliance on self-reported data introduces potential social desirability bias, influencing participant responses. Mitigating this requires incorporating observational data or validated instruments in future studies. While acknowledging heightened infection control awareness due to COVID-19, the study doesn’t fully explore its impact on operating room dynamics and nursing roles. Future research should investigate pandemic-induced changes in hierarchies, communication, and resource allocation, and their effects on surgical site infection prevention. This could involve comparative pre- and post-pandemic studies or exploring nurses’ expe-riences with altered roles during the pandemic. Despite these limitations, the study’s phenomenological approach provides valuable insights into Hong Kong nurses’ experiences, laying groundwork for future research.”

Reviewer 2 Report

Comments and Suggestions for Authors

The article investigates narratively through online interviews the daily practice of operating room nurses in relation to infection prevention activities and policy, in particular for the surgical site infection prevention. Although descriptive in nature, the sample is adequate and the results/considerations well discussed and supported. Supplementary material with methodology for data consistency.

I have a few minor suggestions

First: the title is neither relevant nor oriented to what is actually discussed. “Innovation” is not relevant, nor is “clinical”, as the comments are limited to the operating area. Covid is also a contextual aspect, but apart from the need for an online survey, it has no influence on an analysis that looks broadly at the activities/perceptions/modalities of these operators, with an average experience in OR of 8.3 years. Moreover, 12.2021-05.2022 is a pandemic period, but not an emergency one like the early stages with direct limitation on clinico-surgical performances. infection prevention in the operating theatre moreover is focused on infectious risk through contact, than droplets or air. For this reason it does not even seem relevant to the topical issue “The Impact of COVID-19 on Healthcare Services”, but it is a personal opinion, dealing with aspects of risk management, infection prevention in the operating theatre, teamwork, resources and personnel and not on Covid19 impact on healthcare services organisation and daily work. 

line 42-43 to be moved after line 61

line 67 probably to be briefly mentioned all the activities performed for SSI prevention as MRSA identification and cleaning, shaving, temperature and glycemia check, pre-surgical showers as 2018 Cochrane Database Syst Rev by Liu et al is mainly focused on prophylaxis. In fact those activities are widely managed by nurses. See doi: 10.3390/jcm13144197. 10.1016/j.cmi.2025.01.011 . 10.1371/journal.pone.0317887 

line 79 I suggest briefly mentioning all the activities undertaken by the nurses individually and as part of the surgical team to prevent surgical site infections (hand hygiene, asepsis procedures, prophylaxis, surgical clothing, personal protective equipment, door opening, ...) for which the whole team is responsible. In fact, the team itself verifies these activities before starting surgery, see the surgical checklist mentioned.

table 1 and discussion Meanwhile, Covid 19 specific questions were made so a focused discussion on disruption/change of activities and modalities/procedure could be significant. The issue of human capital deficit seems also to be relevant and ongoing, apart from covid 19 pandemic. 

table 2: mention in the method the education and training course for nurses in Hong Kong to allow comparisons and contextualisation ( a 18 years old individual could be a licensed nurse?) 

themes 1 and 3 are in many part (see first section of theme 1 dealing with team issues) overlapping. Perhaps it deserves to put the chapters side by side and to revise the text accordingly. 

line 233-235 very relevant. Please discuss further in the section discussion the presence of monitoring and verification procedures for minimum standard requirement compliance in OR. (as properly and previously referenced with reference 14).

line 355 relevant section. Please discuss further the issue of the team activities and shared responsibilities. This is relevant as it highlights the team cooperation issue. 

line 390 “essential evidence” please weigh this expression.

line 412 relevant. To be discussed with the worldwide issues of healthcare personnel lack and turnover that limits team cohesion and fellowship.

line 431 relevant. Considering nurses’ answers also the basic rules of theatre behaviours, equipment, clothing, … must be continuously monitored, evaluated and recalled.

chapter 4.2 please revise with previous consideration on covid 19 relevance on the investigation and with the mean activity experience (more than 8 years) reflecting broader attitudes and perceptions.  

Referencing brilliant: updated and focused on best literature. 

many thanks

Author Response

Comments 1: Does the introduction provide sufficient background and include all relevant references (x) can be improved

 

Response 1: Thank you for pointing this out. We agree with this comment, Therefore, we have revised the results presentation in page 2 line 53 to 96.

 

Comments 2: Are the conclusions supported by the results (x) can be improved

 

Response 2: Thank you for pointing this out. We agree with this comment, Therefore, we have revised the results presentation in page 12 line 530 to line 543.

“This study emphasizes the complex and multi-faceted role of nurses in preventing surgical site infections within the operating room. Establishing collaborative forums for quality improvement, recognizing, and valuing the expertise of nurses, and fostering stable team structures are essential for effective surgical site infection prevention. Continued caution in surgical site infection prevention is important for ensuring patient safety intra-operatively, particularly given the increasing threat of antibiotic resistance. Maintaining a high priority on operating room safety, including minimizing bacterial load throughout the surgical environment, is crucial. This research highlights the importance of reciprocal knowledge exchange and attentiveness among operating room team members, especially during critical periods like the COVID-19 pandemic. Furthermore, a reassessment of traditional hierarchical structures within the operating room is warranted to align with the evolving complexities of contemporary surgical practices. This will empower nurses and other team members to contribute their expertise effectively, ultimately enhancing patient safety and optimizing surgical outcomes.”

 

Comments 3: First: the title is neither relevant nor oriented to what is actually discussed. “Innovation” is not relevant, nor is “clinical”, as the comments are limited to the operating area. Covid is also a contextual aspect, but apart from the need for an online survey, it has no influence on an analysis that looks broadly at the activities/perceptions/modalities of these operators, with an average experience in OR of 8.3 years. Moreover, 12.2021-05.2022 is a pandemic period, but not an emergency one like the early stages with direct limitation on clinico-surgical performances. infection prevention in the operating theatre moreover is focused on infectious risk through contact, than droplets or air. For this reason, it does not even seem relevant to the topical issue. The Impact of COVID-19 on Healthcare Services”, but it is a personal opinion, dealing with aspects of risk management, infection prevention in the operating theatre, teamwork, resources and personnel and not on Covid19 impact on healthcare services organisation and daily work.

 

Response 3: Thank you for pointing this out. We agree with this comment. Therefore, we modified the title of this manuscript in page 1 line 2 to 3:

“The Impact of COVID-19 on healthcare services, risk management, and infection prevention in surgical practices: A qualitative study”

           

Comments 4: line 42-43 to be moved after line 61.

 

Response 4: We agree with this comment. Therefore, we modified the introduction section in page 2 line 60 to 62:

“Given increasing bacterial antibiotic resistance, preventing surgical site infections is a complex undertaking. It is crucial to reduce operating room microbial contamination of the absolute minimum.”

 

Comments 5: line 67 probably to be briefly mentioned all the activities performed for SSI prevention as MRSA identification and cleaning, shaving, temperature and glycemia check, pre-surgical showers as 2018 Cochrane Database Syst Rev by Liu et al is mainly focused on prophylaxis. In fact those activities are widely managed by nurses. See doi: 10.3390/jcm13144197. 10.1016/j.cmi.2025.01.011 . 10.1371/journal.pone.0317887

 

Response 5: Agree. We have, accordingly, modified this point in page 2 line 69 to 75:

“Several pre-operative interventions contribute significantly to surgical site infection prevention. These include measures like MRSA screening and decolonization, hair removal (clipping rather than shaving), maintaining normothermia, optimizing glycemic control, pre-surgical showers, and skin antisepsis with agents like chlorhexidine-gluconate [6]. The impact of each of these practices, including topical chlorhexidine-gluconate application, on surgical site infection rates warrants further investigation.”

 

Comments 6: line 79 I suggest briefly mentioning all the activities undertaken by the nurses individually and as part of the surgical team to prevent surgical site infections (hand hygiene, asepsis procedures, prophylaxis, surgical clothing, personal protective equipment, door opening, ...) for which the whole team is responsible. In fact, the team itself verifies these activities before starting surgery, see the surgical checklist mentioned.

 

Response 6: Thank you for pointing this out. We agree with this comment. Therefore, we have revised contents in the introduction section in line 79, in page 2 line 85 to 96:

“Operating room nurses contribute significantly to surgical site infection prevention through both individual and collaborative practices. Their individual responsibilities include rigorous adherence to hand hygiene protocols, meticulous application of aseptic techniques during surgical procedures, administering prescribed prophylactic antibiotics, and correct donning of sterile surgical attire and personal protective equipment [22]. Furthermore, they contribute to maintaining a controlled operating room environment by minimizing unnecessary traffic and door openings. These individual practices are reinforced by collaborative efforts within the surgical team, including the utilization of surgical safety checklists to verify critical aspects of surgical site infection prevention prior to incision. This comprehensive, team-based approach ensures the maintenance of a sterile field and minimizes the risk of microbial transmission, ultimately contributing to patient safety.”

 

Comments 7: table 1 and discussion Meanwhile, Covid 19 specific questions were made so a focused discussion on disruption/change of activities and modalities/procedure could be significant. The issue of human capital deficit seems also to be relevant and ongoing, apart from covid 19 pandemic.

 

Response 7: Thank you for pointing this out. We revised the content of interview quide in page 4 line 163 in Table 1 of No. 6 probing question:

“No. 6: How have the COVID-19 pandemic and the ongoing human capital deficit impacted your thoughts, feelings, and practices related to surgical site infection prevention in the operating room, specifically regarding changes in

procedures, modalities, and challenges in maintaining best practices?.”

 

 

Comments 8: table 2: mention in the method the education and training course for nurses in Hong Kong to allow comparisons and contextualisation (a 18 years old individual could be a licensed nurse?)

 

Response 8: Nursing training programs in Hong Kong allow entry before age 18, with a minimum 3-year duration, and guarantee licensure by age 20. This means student enter between ages 17 and some younger age, and program length varies to ensure graduation by 20.

 

Comments 9: themes 1 and 3 are in many part (see first section of theme 1 dealing with team issues) overlapping. Perhaps it deserves to put the chapters side by side and to revise the text accordingly.

 

Response 9: We agree with this comment. Therefore, we modified the results section in page 7 line 259 to page 8 line 352.

 

Comments 10: themes 1 and 3 are in many part (see first section of theme 1 dealing with team issues) overlapping. Perhaps it deserves to put the chapters side by side and to revise the text accordingly.

 

Response 10: We agree with this comment. Therefore, we modified the results section in page 7 line 259 to page 8 line 352.

 

Comments 11: line 233-235 very relevant. Please discuss further in the section discussion the presence of monitoring and verification procedures for minimum standard requirement compliance in OR. (as properly and previously referenced with reference 14).

 

Response 11: We agree with this comment. Therefore, we modified the results section in page 7 line 256 to 264:

“The cleaning of the entire operating room is the responsibility of the outsourced staff of ISS (Integrated Service Solutions Facility Services Limited), but they are generally older and less educated. In order to ensure a clean environment in the operating room, surgeons and nurses are usually present. I feel a strong responsibility to maintain a clean and safe operating room environment. I prioritize clear and accessible communication when guiding eternal cleaning staff, using visual aids like simplified Chinese characters, im-ages, and photos to ensure everyone understands the cleaning procedures, regardless of their educational background or language proficiency. This approach helps facilitate effective collaboration and ensures a consistently clean and safe surgical space.” (P07)

 

Comments 12: line 355 relevant section. Please discuss further the issue of the team activities and shared responsibilities. This is relevant as it highlights the team cooperation issue.

 

Response 12: We agree with this comment. Therefore, we modified the results section in page 9 line 389 to 394:

“Preventing surgical site infections requires a strong team approach. Success depends not only on overall team performance but also individual dedication and organizational support. A culture of shared responsibility and empowerment is essential. The finding of this study explores effective team activities and shared responsibilities, like communication and cross-training, to optimize team performance and improve patient outcomes.”

 

Comments 13: line 390 “essential evidence” please weigh this expression.

 

Response 13: We agree with this comment. Therefore, we modified the discussion section in page 10 line 426 to 432:

“Improved clinical practice, judgment, and specialized education for healthcare providers are linked to better patient outcomes [25,49]. This suggests that targeted training may reduce surgical site infections. However, strong evidence, like studies showing a direct link between specific training and lower surgical site infection rates, is significant. Further research should explore healthcare providers’ clinical judgement and weigh contributing factors to optimize surgical site infection prevention strategies and support healthcare providers effectively [25, 49].”

 

Comments 14: line 412 relevant. To be discussed with the worldwide issues of healthcare personnel lack and turnover that limits team cohesion and fellowship.

 

Response 14: Thanks for your suggestion. Therefore, we modified the results section in page 10 line 454 to 457:

“Global healthcare provider shortages and high turnover disrupt stable team development necessary for safe peri-operative care; constant onboarding hinders the cohesive teamwork and shared understanding gained through long-term collaboration, potentially compromising patient safety [55,56].”

 

Comments 15: line 431 relevant. Considering nurses’ answers also the basic rules of theatre behaviours, equipment, clothing, … must be continuously monitored, evaluated and recalled.

 

Response 15: Agrees for this suggestion. Therefore, we modified the discussion section in page 11 line 489 to 497:

“Moreover, they stressed the significance of staying current with cutting-edge innovations to adapt to the constantly shifting realm of surgical procedures [56,60]. The findings of this study highlighted that nurses believe basic rules regarding theatre behaviors, equipment, clothing, and procedural practices require continuous monitoring, evaluation, and reinforcement. This constant vigilance is essential not only for maintaining current standards but also for integrating new technologies and evolving best practices into daily routines. This emphasis on continuous learning and adaptation highlights the dynamic nature of the surgical environment and the nurses’ commitment to providing safe and effective patient care.”

 

Comments 16: chapter 4.2 please revise with previous consideration on covid 19 relevance on the investigation and with the mean activity experience (more than 8 years) reflecting broader attitudes and perceptions. 

 

Response 16: Agrees for this suggestion. Therefore, we modified the implications for practice section in page 12 line 518 to 528.

“Conducted during the COVID-19 pandemic, this study’s findings may reflect the exceptional circumstances and adaptations characterizing this period. The pandemic’s influence on staffing, protocols, and healthcare system capacity likely shaped participant experiences and perspectives. Subsequent research should address these limitations by investigating the enduring impact of the pandemic on theater nurses, including potential shifts in practices, attitudes, and perceptions, investigating how the pan-demic has reshaped these is significant for informing future training, resource allocation, and support systems. Specially, examining the pandemic’s influence on communication dynamics, teamwork efficacy, and occupational stress levels within peri-operative teams warrants further investigation.”