Comparing Qualitative Study Approaches

Critical Appraisal of Research Studies: Surgical Site Infections (SSI)

Surgical site infections (SSIs) are a serious source of concern worldwide. They are not only a health risk to patients but also pose a significant risk in terms of an increase in antibiotic-resistant bacteria infections. Yet, there is a gap between theoretical knowledge of how to prevent such infections and how providers implement them. The issue of SSIs has been quantitatively identified as a serious issue and is especially disheartening, given it is a preventable one: an estimated 60% of all SSIs are preventable, if providers follow guidelines (Mengesha et al., 2020).

This failure of compliance, however, is not particularly to underserved or low-resource medical systems. Prevalence of SSIs is around 19.6% in Europe, 20% in the U.S., and in Africa as low as 12% in Algeria and as high as 31% in Nigeria (Mengesha et al., 2020). Within Ethiopia alone, infection rates in different regions vary widely from 10.9%-19.1% (Mengesha et al., 2020). In resource-poor countries, SSIs pose an even more considerable drain in terms of unnecessary costs. There is also the concern for increasing the spread of antibiotic-resistant bacteria, with multidrug resistance as high as 82.9%, in countries where antibiotic shortages are rife and options are limited (Mengesha et al., 2020). This article will review the prevalence of SSIs quantitatively and then review two qualitative studies that attempt to address the issue through meaningful approaches.

In one study conducted by Mengesha (et al., 2020) surveying nurses in Addis Ababa, Ethiopia, less than half of the 409 participants observed evidence-based guidelines (48.9%) to prevent SSIs. The study found that male nurses, greater education of providers, and more extensive work experience were all correlated with greater adherence to infection prevention guidelines (Mengesha et al., 2020). This suggested that greater education and setting higher educational standards for provider may result in lower rates of infection. A 25-item list of best practices, scored on a 1-4 Likert scale assessed compliance in a strictly quantitative fashion, spanning from questions about handwashing to the use of preoperative shaving and the use of appropriate antimicrobial agents (Mengesha et al., 2020).

Nurses were the focus of the study not to shift the focus away from physicians but because nurses often have the most significant roles in pre-and postoperative patient care after surgery, according to the study authors, and thus can have the greatest impact upon potential care improvement. Proper implementation of surgical safety checklists by nurses has been linked to reducing risk of infection; this also suggests that hospitals can have a significant role in creating standard operating procedures to make compliance the default, rather than something that nurses must consciously strive to fulfill. The study authors also note the importance of the surgical team in creating an environment to reduce the risk of infection, including minimizing people and conversations in the operating room, closed doors, appropriate ventilation, and adequate preparation of patient and the hands of the surgical team (Mengesha et al., 2020). Compliance, in short, is a team effort.

The study offered useful advice and a perspective upon Ethiopia in particular that was welcome, given the lack of research into SSI specific to the nation. But one weakness of the study was the fact that while it pointed to deficits in practice and, to a lesser extent, knowledge and training, it did not solicit input from practitioners why they did not comply. Providers are not necessarily willfully noncompliant, nor did they necessarily discount the need for appropriate hygiene. But a lack of time, lack of supplies, perceived pressures from physicians and supervisors to rush might all contribute to the fact that the desired surgical checklists are not always strictly followed. Unfortunately, given the study was quantitative in nature, providers did not have a chance to offer input into what was so difficult for them.

An important corrective to this, in short, is to review qualitative studies in conjunction with quantitative studies. While quantitative studies in specific areas may confirm the fact that practitioners are not always observing the necessary procedures and precautions to prevent infection, and certain demographic correlations with heightened or lower compliances, qualitative studies allow providers to offer experiential input in an open-ended fashion.

In a study by Qvistgaard, Lovebo, & Almerud-Österberg (2019), using the qualitative Reflective Lifeworld Research (RLR) phenomenological approach, 15 OR nurses were asked to constructively discuss how and why they took precautions regarding SSIs. Rather than simply being subjected to a questionnaire, nurses were asked questions like what SSI prevention meant to them personally, followed with open-ended questions like asking them to describe a typical workday and how they took precautions (and also how and why precautions were difficult to take).

The disadvantage of qualitative research can be is that it is highly subjective and personal. But it can also be one of its strengths. For example, one nurse noted that surgeons can be quite intimidating, rush them, which leads to errors and mistakes. Physicians, the study found, tended to go by medical professional standards while nurses were more inclined to wish to follow hospital guidelines (such as following institution-specific checklists). Nurses also expressed concerns about being understaffed in the operating room, which can lead to fatigue and burnout (Qvistgaard et al., 2019). These are the types of responses that might not be solicited from nurses in a quantitative study solely focused on outputs.

Overall, the study found that the hierarchical structure of operating rooms was particularly problematic, given that it could create ambiguity between following guidelines versus the lead surgeon, and preventing SSIs requires both head-based knowledge about procedures but also affective heart-based procedures regarding systematic institutional work to create better teamwork (Qvistgaard et al., 2019). Nurses wished to have a greater voice in leadership to ensure that they were not overworked, and also that they had the time and support to proceed according to guidelines.

Another study, this one specific to Ethiopia, used a qualitative approach to address noncompliance in some of the issues identified by Mengesha (et al., 2020). The Clean-Cut intervention strove to reduce SSI through handwashing and disinfecting, surgical gown and draping, antibiotics, sterilization, gauze counts, and using WHO checklists (Mattingly et al., 2019). Nurses were interviewed afterward to determine issues that prevented compliance, with responses focusing on a lack of resources, obstacles from hospital administration and staff, as well as their personal beliefs and education (Mattingly et al., 2019). Although in this instance only 20 participants were interviewed, the results suggested a more holistic approach to address noncompliance than focusing on education alone.