Operating room nurses’ experiences of maintaining sterile technique: a qualitative study

Abstract

Background

Operating room nurses play a crucial role in maintaining sterile technique to prevent surgical site infections and ensure patient safety. Despite guidelines in place, challenges persist in maintaining sterility due to systemic issues and interpersonal dynamics. This study aims to explore the experiences of OR nurses in maintaining sterile technique, focusing on the challenges they face, the emotional burden they experience, the dynamics of teamwork, and recommendations for improving practice.

Methods

A qualitative descriptive study using semi-structured interviews was conducted with twelve OR nurses from a university hospital in Turkey. Data were collected between May 5 and 9, 2023, through in-depth, face-to-face interviews, which were transcribed verbatim and analysed using a content analysis approach.

Findings

Analysis of interviews with 12 operating room (OR) nurses produced four main themes and eleven subthemes. General Chaos and Systemic Challenges reflected barriers such as rushed scheduling, excessive OR traffic, technical limitations, and staff shortages, all of which compromised sterility. Teamwork Challenges and Interpersonal Dynamics highlighted protocol non-compliance, inadequate training of novice staff, communication breakdowns, and a lack of respect from some surgeons. The Emotional Burden theme described nurses’ experiences of persistent stress, anxiety, helplessness, and a strong sense of moral responsibility for patient safety. Finally, Training and Staff Selection captured participants’ recommendations.

Conclusion

OR nurses face significant challenges in maintaining sterile technique, influenced by organisational inefficiencies, interpersonal conflicts, and emotional stress. To enhance practice, support systems, communication protocols, and structured training programs must be improved. Recommendations include implementing structured training programs, enhancing communication protocols, and selecting appropriate personnel to ensure effective sterile technique maintenance in the OR.

Introduction

Operating room (OR) nurses play a pivotal role in maintaining the sterility of the surgical environment, which is essential to patient safety and surgical success [1, 2]. Globally, lapses in sterile technique are associated with increased morbidity, mortality, and healthcare costs due to preventable infections and complications. According to the World Health Organization (WHO), surgical site infections (SSIs) are among the most common healthcare-associated infections, contributing to prolonged hospital stays, readmissions, and a significant economic burden (3.4). Sterile technique refers to a set of evidence-based practices designed to minimize microbial contamination during surgical and invasive procedures. All perioperative team members are responsible for upholding these standards; however, OR nurses are uniquely positioned to oversee, implement, and monitor sterile practices across all stages of surgery. Their responsibilities include preparing the sterile field, ensuring proper hand hygiene, gowning and gloving, managing surgical instruments, and responding immediately to any breaches of contamination. Given their central role, OR nurses are also expected to intervene when sterile technique violations occur and to educate others on best practices.

Common breaches in sterile technique occur during various phases of surgery, ranging from instrument sterilisation and draping the patient to gowning, gloving, and maintaining a sterile field [1, 3]. These errors, often subtle or procedural, may result in serious postoperative infections if not promptly corrected. Despite the existence of international guidelines, variability in compliance and training across institutions remains a significant barrier, especially in countries like Turkey, where standardized OR nursing education and protocols may differ across public and private healthcare institutions.

Importantly, SSIs account for approximately 20% of all healthcare-associated infections worldwide and are linked to a 2- to 11-fold increased risk of mortality. Alarmingly, 75% of the deaths associated with SSIs are directly attributed to the infection itself. These statistics underscore the need for continuous evaluation and reinforcement of sterile technique, particularly among OR nurses who are at the frontline of infection prevention [2–4].

Although several studies have examined general infection control measures, there remains a gap in the literature concerning the practical implementation of sterile techniques by OR nurses. OR nursing responsibilities may vary significantly depending on hospital type, regional resources, and staff training, yet national data on the impact of these factors is sparse.

This study aims to evaluate the experiences of operating room nurses regarding sterile technique in surgical procedures in Turkey. By identifying common challenges and areas for improvement, the findings are expected to inform future training initiatives and contribute to the development of OR nursing practice.

Method

Research design

This study adopted a qualitative descriptive phenomenological approach to explore the lived experiences and perceptions of operating room (OR) nurses regarding the use of sterile technique in surgical settings. This design was selected to capture the essence of participants’ experiences through their narratives and reflections [5]. The study followed the Standards for Reporting Qualitative Research (SRQR) guidelines to ensure methodological rigor and transparency.

Setting and participants

The study was conducted in a university hospital in Turkey. A homogeneous purposive sampling method was used to recruit participants who shared similar professional experiences relevant to the study phenomenon.

Participation was entirely voluntary. The nursing department management supported the research but did not influence the selection or participation of staff. Recruitment was facilitated through posters and in-person invitations by a researcher not in a supervisory role, aiming to reduce power dynamics and potential coercion.

Data collection

Data were collected between May 5 and 9, 2023, using semi-structured, face-to-face interviews. The term “in-depth” was used to reflect the open-ended, participant-led nature of the discussions, despite using a semi-structured guide. The interviews were conducted by the researchers (NT, DYT) in a room suitable for audio recording in the OR. Interviews with OR nurses were planned to continue until data saturation was achieved, and depending on the number of individuals. Each interview lasted approximately 30 min and was conducted in a quiet and private space within the hospital. No incentives or compensation were provided to participants. Field notes were taken during and after each session.

A pilot interview was conducted with one nurse who met the eligibility criteria but was not included in the final sample. The pilot interview confirmed that the questions were clear, relevant, and technically feasible, requiring no revisions.

The interview guide (Table 1) was developed based on a literature review and refined through expert feedback. It included open-ended questions focused on personal experiences with sterile technique, perceived challenges, institutional practices, and professional responsibilities.

Table 1.

Semi-structured interview questions

1. Can you describe your practices in establishing and, maintaining a sterile field? (Do you have a procedure?)

2. Do you have problems in establishing and, maintaining the sterile field?

(Explains the situations that negatively affect the sterile field while establishing and maintaining the sterile field)

3. When the sterile field is disrupted, how do you overcome this situation, the problems you experience?

(Can you tell us about the problems you have experienced? Can you explain through examples?)

4. What are your responses to the problems you have experienced in the process of establishing and maintaining a sterile field? (What are your feelings?)

5. Do you have any suggestions on how to maintain a sterile field?

All interviews were audio-recorded with permission. Audio files were stored on a secure, password-protected device accessible only to the research team. Transcripts were anonymized, and participants were assigned codes (e.g., P1, P2) to ensure confidentiality.

The final sample comprised 12 registered OR nurses who met the following inclusion criteria: they were of Turkish nationality; proficient in the Turkish language; employed full-time as OR nurses; had a minimum of one year’s experience in the operating room; were willing to share their professional experiences and perceptions; and had provided informed written and verbal consent to participate. The exclusion criteria were as follows: refusal to participate in audio recording; failure to complete the interview; and currently undergoing OR nurse training or orientation.

Data analysis

Thematic content analysis was employed to examine the interview data. Recordings were transcribed verbatim and reviewed multiple times by the researchers. Codes were generated based on repeated phrases and meaningful statements, and grouped into sub-themes and main themes. Memos and field notes were used to support contextual interpretation. An audit trail was maintained to document coding decisions. Peer debriefing and expert consultation were employed to validate the development of themes.

Data collection continued until data saturation was reached, defined as the point where no new insights emerged from additional interviews. Credibility was enhanced through member checking and triangulation of data sources (e.g., interview transcripts, field notes). Audit trails, memo writing, and inter-coder agreement discussions among the research team supported confirmability and dependability. Reflexivity was maintained through reflective journaling to monitor potential researcher biases.

Ethical considerations

Ethical approvalwas obtained from the the Human Research Ethics Committees (HRECs) of University Institutional permission was obtained from the hospital administration. All participants received verbal and written information about the study and signed informed consent forms. Confidentiality, autonomy, and voluntary participation were fully respected throughout the study. Interview recordings and data were securely stored and anonymized before analysis.

Findings

The study aimed to evaluate the experiences of operating room nurses regarding sterile technique in surgical procedures. Data analysis generated 96 codes, which were grouped into four main themes and eleven subthemes.

Participant demographics

The study included 12 participants: 10 female and 2 male nurses. Their professional experiences ranged from 1 to 20 years in the OR. All participants had at least a bachelor’s degree in nursing. Demographic data are presented descriptively rather than statistically, in line with qualitative methodology (Table 2).

Table 2.

Participant characteristics

Characteristic	Description
Gender	12 female, 4 male
Age range	38–43 years; mean 40.5 years
Education	9 bachelor’s degree, 5 diploma, 2 master’s degree
Experience in OR	All had > 6 years’ OR experience
Sterilization Training	All received in-service training; 10 attended certificate programs; 6 attended continuing education
Weekly Working Hours	13 worked 41–48 h/week (day and night shifts)
Role	8 scrub nurses, 8 scrub and circulating nurses

Main themes and subthemes

Main Theme 1: General Chaos and Systemic Challenges – operational, technical, and staffing barriers to maintaining sterility.

Main Theme 2: Teamwork Challenges and Interpersonal Dynamics – protocol non-compliance, lack of training, poor communication, and lack of respect.

Main Theme 3: Emotional Burden – combined stress, anxiety, and helplessness into “Emotional Strain,” plus moral responsibility.

Main Theme 4: Training and Staff Selection –integrated recommendations for structured training, mentoring, and recruitment strategies (Table 3).

Table 3.

Main themes, subthemes, and quotes from OR nurses

Main Theme	Subtheme	Illustrative Quote
1. General Chaos and Systemic Challenges	1. Scheduling	“…I cannot concentrate on the ongoing operation because we have to be ready for the next one…” (P2)
	2. Operating Room Traffic	“…It is impossible to focus on the operation when people are constantly coming and going…” (P4)
	3. Technical Problems	“…Sometimes, there is no place to step in the room…” (P5)
	4. Staff Shortage	“…We worked non-stop on a night shift; I literally slept with my eyes open…” (P10)
2. Teamwork Challenges and Interpersonal Dynamics	1. Non-compliance of Team Members	“…They do not fully implement surgical hand washing…” (P4)
	2 Lack of Training	“…They don’t know surgical hand washing, gowning, and gloving…” (P9)
	3. Communication Problems	“…Sometimes the OR is so crowded that we cannot hear each other…” (P8)
	4 Lack of Respect from Surgeons	“…He embarrassed me so much that I couldn’t lift my face…” (P6)
3. Emotional Burden	1. Emotional Strain (Stress, Anxiety, Helplessness)	“…Every day I am tired of thinking about what we will experience today…” (P10)
	2. Moral Responsibility	“…We managed to keep the patient alive. This feeling was worth everything…” (P4)
4. Training and Staff Selection	1. Training	“…All employees should undergo specific training before starting in the OR…” (P2)
	2. Staff Selection	“…The person working in the OR must be calm, cool, and practical…” (P5)

Main Theme 1: General Chaos and Systemic Challenges.

Subtheme 1: Scheduling.

Nurses described rushed transitions between surgeries and inadequate scheduling as compromising sterility.

…I cannot concentrate on the ongoing operation because we have to be ready for the next one… (P2).

Subtheme 2: Operating Room Traffic.

Excessive movement in and out of the OR distracted staff and posed a sterility risk.

…It is impossible to focus on the operation when people are constantly coming and going… (P4)

Subtheme 3: Technical Problems.

Limited space and inadequate ventilation systems disrupted workflow and safety.

…Sometimes, there is no place to step in the room…(P5).

Subtheme 4: Staff Shortage.

Shortages of trained staff increased workload, fatigue, and error rates.

…We worked non-stop on a night shift; I literally slept with my eyes open… (P10)

Main Theme 2: Teamwork Challenges and Interpersonal Dynamics.

Subtheme 1: Non-compliance of Team Members.

Some surgeons and assistants ignored sterilisation protocols.

…They do not fully implement surgical hand washing… (P4)

Subtheme 2: Lack of Training.

Inexperienced staff and students frequently breached sterility due to inadequate preparation.

…They do not know surgical hand washing, gowning, and gloving… (P9)

Subtheme 3: Communication Problems.

Crowded ORs and multitasking reduced communication effectiveness.

…Sometimes the OR is so crowded that we cannot hear each other… (P8).

Subtheme 4: Lack of Respect from Surgeons.

Nurses experienced verbal humiliation, which in turn lowered their morale.

…He embarrassed me so much that I could not lift my face… (P6)

Main Theme 3: Emotional Burden.

Subtheme 1: Emotional Strain (Stress, Anxiety, Helplessness)

Nurses reported experiencing persistent stress due to high responsibility, inadequate support, and a fear of errors.

…Every day I am tired of thinking about what we will experience today… (P10).

Subtheme 2: Moral Responsibility.

Despite challenges, participants valued the opportunity to save lives.

…We managed to keep the patient alive. This feeling was worth everything… (P4)

Main Theme 4: Training and Staff Selection.

Subtheme 1: Training.

Participants recommended structured orientation, simulation-based learning, and standardised mentorship.

…All employees should undergo specific training before starting in the OR… (P2).

…The OR is not taught at school; there should be separate training and even internship…(P12)

Subtheme 2: Staff Selection.

Recruitment should consider competence, personality, and physical suitability for OR work.

Discussion

This study explored operating room (OR) nurses’ experiences in maintaining a sterile field, identifying four interconnected themes: General Chaos and Systemic Challenges, Teamwork Challenges and Interpersonal Dynamics, Emotional Burden, and Training and Staff Selection. These findings highlight how structural, interpersonal, and individual factors interact to influence sterility maintenance in surgical environments.

General chaos and systemic challenges

Participants consistently linked compromised sterility to systemic issues such as inadequate scheduling, material shortages, excessive OR traffic, technical limitations, and staff shortages. Effective surgical scheduling is widely recognized as critical to minimizing delays, balancing workload, and preventing errors [6]. In line with our participants’ accounts, high turnover pressure and poorly coordinated cases increased fatigue and reduced concentration, echoing findings from Ghasemi et al. [7] that “pressure to work more quickly” is a major OR stressor. Such conditions can undermine both patient safety and staff well-being [8].

Material shortages were also a recurring challenge, sometimes leading to the use of flash sterilisation—a practice linked to higher infection risk. Similar to Hutzler et al. (2013), our findings suggest that preparation and resource allocation are essential to prevent last-minute sterilisation and procedural delays [9]. Participants also emphasized the negative impact of excessive OR traffic, which increases airborne particle counts and potential contamination This supports existing recommendations to restrict unnecessary entry and exit during procedures to minimize microbial spread [10].

Teamwork challenges and interpersonal dynamics

The maintenance of sterility relies heavily on teamwork, yet participants reported frequent non-compliance with protocols, particularly regarding surgical hand washing, mask use, and dressing technique. Our findings mirror prior research indicating that adherence to hand hygiene is inconsistent across OR roles, with nurses showing higher compliance than other team members [11, 12].

Mask use was another area of concern; incorrect wearing—especially failure to cover the nose—was widely observed, consistent with observational studies by Loison et al. (2017) and Dallolio et al. (2017) [13, 14]. Improper use not only poses infection risks but may also impair verbal communication in the noisy OR environment [15]. A lack of formal training for students and novice staff further compromised sterility, as documented in Khazayi et al. (2015). Combined with high OR traffic, this inexperience increased the likelihood of breaches [16]. Communication difficulties and perceived lack of respect from some surgeons were also prominent, supporting previous findings that poor interpersonal climate can reduce staff willingness to speak up and affect team functioning [17–19].

Emotional burden

Nurses described substantial psychological strain, combining stress, anxiety, and feelings of helplessness. The emotional weight of maintaining sterility under pressure aligns with previous literature on OR stressors and burnout risk [20–22]. While the OR can be a source of professional pride—especially when patient outcomes are positive—chronic stress without adequate support contributes to fatigue, diminished concentration, and reduced morale.

Training and staff selection

Participants proposed structured training programs, standardized mentorship, and periodic refreshers for all OR personnel. This result aligns with recommendations in international guidelines, emphasizing the importance of continuous education and competency assessment. Several nurses also emphasized the importance of selecting staff with the personal and physical attributes suited to the demands of OR work. This factor is less frequently discussed in the literature but is worth considering in workforce planning.

Limitations

While this qualitative study offers rich, contextual insights, its findings are limited to a single university hospital. Additionally, due to the researchers’ involvement in the workplace, potential bias resulting from prior relationships cannot be entirely ruled out. Self-reported data may introduce social desirability bias, which can affect how participants describe their experiences.

Conclusion

This study provides an in-depth account of the challenges OR nurses face in maintaining a sterile field, revealing a complex interplay of systemic, interpersonal, and individual factors. Alternatively, nurses face emotional, organisational, and educational barriers in maintaining sterile technique. Addressing these challenges through systemic reform and training can enhance patient safety and reduce the incidence of preventable surgical site infections. The findings underscore the need for integrated strategies that combine process optimization, comprehensive training, and cultural change. By addressing these areas, healthcare organisations can reduce infection risks, enhance patient safety, and improve the working conditions of OR staff.

Author contributions

NT designed study. NT and DYT analyzed the data. NT and DYT wrote, and revised the manuscript. All authors have read and approved the fnal version for submission.

Funding

Not applicable.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by the Human Research Ethics Committees (HRECs) University. Informed written consent, which was approved by the ethics committee, was obtained from all participants. The principles of anonymity and confidentiality regarding participants’ information were strictly upheld. This study was conducted under the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.