Strengthening Surgical Safety in Somalia: The Role of Scrub Nurses in Infection Prevention and Team Communication in Resource-Limited Operating Theatres

Abstract

Surgical safety in resource-limited health systems is undermined by workforce shortages, limited equipment, inconsistent sterilisation systems, incomplete use of standardised safety tools, and hierarchical team cultures. In Somali operating theatres, scrub nurses are close to the sterile field and procedural workflow, yet their safety role is often treated as technical support rather than recognised clinical leadership. This commentary addresses the gap between scrub nurses’ substantial responsibility for infection prevention, counts, equipment readiness, and checklist communication and their limited authority to shape systems or halt unsafe practice. It argues that improving surgical safety requires hospitals to recognise scrub nurses as patient-safety leaders and to address three linked tensions: responsibility without authority, safety expectations amid resource scarcity, and professional accountability within hierarchical teams. The commentary interprets global guidance and published Somali evidence through these tensions and proposes practical responses, including locally adapted checklist use, standardised counts, escalation pathways for sterility and equipment concerns, structured briefings and debriefings, nurse participation in procurement and quality governance, and locally relevant professional development. These measures can convert scrub nurses’ proximity to risk into formal influence over prevention and learning. The distinctive contribution of this commentary is therefore not simply to restate scrub nursing duties, but to show that safer surgery in Somalia depends on aligning nurses’ safety responsibilities with the authority, resources, and organisational support needed to fulfil them.

Introduction

Surgery saves lives, but unsafe surgical care causes avoidable morbidity, mortality, prolonged hospitalisation, and financial burden for patients and families. Safe surgery depends on an organised system in which patient identification, consent, surgical-site confirmation, anaesthesia safety, sterility, instrument readiness, antibiotic timing, preparation for blood loss, specimen labelling, and postoperative handover are performed reliably. The World Health Organization (WHO) Surgical Safety Checklist supports these tasks at three critical moments: before induction of anaesthesia, before skin incision, and before the patient leaves the operating room.^1,2

The burden of surgical-site infection is particularly important in low- and middle-income settings. WHO guidance identifies surgical-site infection as a serious but preventable complication and recommends evidence-based measures throughout the perioperative pathway.^3,4 In resource-limited operating theatres, limited sterilisation capacity, shortages of consumables, emergency caseloads, inconsistent environmental cleaning, overcrowding, and communication gaps can interact rather than occur as isolated problems. A sterility breach, for example, becomes harder to manage when replacement supplies are unavailable and a junior nurse does not feel authorised to delay a senior surgeon.

Somalia is rebuilding its health system after prolonged fragility. Operating theatres may function with limited instruments, shortages of sterile supplies, variable access to perioperative training, and inconsistent written protocols. Evidence from Mogadishu indicates that checklist implementation is feasible and that education, audit, visual reminders, and leadership support can improve adherence.^5–7 Nevertheless, discussion of surgical safety often concentrates on whether a checklist or protocol exists rather than on who has the authority and resources to make it work.

This commentary focuses on the under-recognised position of scrub nurses within that implementation gap. Its central argument is that scrub nurses cannot be held responsible for sterility, counts, and timely communication while being excluded from decisions about supplies, workflow, escalation, and team behaviour. The analysis is organised around three tensions that are especially relevant to resource-constrained theatres: responsibility versus authority, safety expectations versus resource scarcity, and professional accountability versus hierarchical constraint. By examining these tensions, the commentary aims to move beyond a descriptive list of duties and identify organisational changes that can turn scrub nurses’ proximity to risk into effective patient-safety leadership.

Commentary Scope and Approach

This article is a focused commentary and does not present original empirical findings or a systematic review. It draws on WHO surgical-safety and infection-prevention guidance, peer-reviewed literature on operating-room nursing and team communication, and published studies and audits from Mogadishu identified for their direct relevance to checklist implementation and the Somali surgical context.^1–15 The literature is interpreted through practical experience of resource-limited operating theatres to develop an argument about scrub-nurse agency, authority, and organisational support. The cited evidence is illustrative rather than exhaustive; no formal search strategy, quality appraisal, or pooled analysis was undertaken.

Responsibility Without Authority at the Sterile Field

The scrub nurse is positioned at the centre of the operative field. Before incision, the nurse prepares instrument trays, checks sterility indicators, arranges drapes and sutures, confirms essential items, and anticipates procedural needs. During the operation, the nurse maintains the sterile field, passes instruments, protects sharps safety, monitors for contamination, and participates in sponge, needle, and instrument counts. The WHO checklist includes nursing contributions such as confirming sterility, reporting equipment issues, confirming counts, reading specimen labels aloud, and communicating recovery concerns.^1,2 These are clinical safety functions, not merely technical assistance.

The difficulty is that responsibility does not automatically confer authority. A scrub nurse may be expected to prevent contamination but lack authority to postpone a case when an indicator is questionable. The nurse may be accountable for a complete count but face pressure to close quickly or accept an unresolved discrepancy. Where written escalation rules are absent, the decision to speak up becomes a personal confrontation rather than a routine safety process. This gap places the nurse in an ethically difficult position: remain silent and risk patient harm, or challenge established hierarchy without assurance of support.

Hospitals should therefore convert individual vigilance into formal authority. Written policy should state that any team member may call a safety pause for an incorrect count, sterility concern, patient-identification discrepancy, or critical equipment failure. The pause should trigger a defined escalation pathway rather than depend on negotiation at the table This approach protects the patient and makes the organisation, rather than the most junior individual, responsible for resolving risk.

Infection Prevention Under Resource Scarcity

Scrub nurses influence infection prevention through surgical hand antisepsis, gowning and gloving, sterile draping, safe handling of instruments, monitoring of the sterile field, and immediate management of contamination. Operating-room nursing research describes maintenance of sterile technique as a demanding responsibility shaped by teamwork, system pressure, and professional confidence.^8,9 In Somalia, those pressures may be intensified by shortages, interruptions, crowding, delayed sterilisation turnaround, or unreliable utilities.

Resource scarcity creates a tension between expected standards and what is immediately available. If a sterile item is contaminated but no replacement exists, proceeding may expose the patient to infection, while cancellation or delay may also carry harm, particularly in an emergency. The scrub nurse should not be left to absorb this conflict alone. A safe response requires an explicit team decision that considers urgency, available alternatives, and the least harmful course, with the deviation and rationale documented. Repeated shortages should then enter a quality-improvement process rather than becoming normalised workarounds.

Infection prevention must therefore be treated as a system property. Hospital leaders are responsible for functional decontamination and sterilisation processes, appropriate packaging and storage, monitoring of indicators, adequate instrument sets, environmental cleaning, and contingency plans for water, electricity, and supply disruption. Scrub nurses should participate in sterilisation monitoring, procurement discussions, and investigation of breaches because they can identify recurring failures across cases. Their observations can transform a vague complaint about “shortages” into actionable information about which tray, item, shift, or process repeatedly fails.

Simple logs can support this learning, but recording alone is insufficient. A shortage log that receives no management review merely transfers administrative work to nurses. Logs should identify the item or failure, effect on the case, immediate action, responsible service, and date of resolution. Theatre leaders should review trends at least monthly and report what was corrected. The meaningful indicator is not the number of problems recorded, but the proportion reviewed and resolved.

Checklist Communication, Not Checklist Completion

Operating theatres are high-risk environments in which surgeons, anaesthesia professionals, scrub and circulating nurses, and recovery staff must share accurate information at the correct time. Communication failures can contribute to wrong-site surgery, delayed antibiotics, missing equipment, specimen errors, retained items, or inadequate postoperative planning. The WHO checklist creates structured pauses for the team to confirm essential safety information.^1,2

The original multicentre checklist study reported reductions in postoperative complications and mortality, and subsequent reviews have generally found benefit, while also showing that implementation quality and team culture affect results.^10–12,15 The distinction between use and implementation is important. A form completed retrospectively or silently may produce high documentation compliance without a shared mental model. In contrast, a concise verbal exchange allows each discipline to contribute information and exposes concerns before they become harm.

Somali studies illustrate the same implementation challenge. Checklist introduction in selected Mogadishu hospitals was associated with improved safety practices; healthcare workers have shown good knowledge but mixed attitudes; and a tertiary-hospital audit reported improved compliance after education, reminders, and leadership-supported change.^5–7 Taken together, these findings suggest that knowledge is necessary but insufficient. The unresolved question is whether staff are invited, expected, and permitted to use the checklist as a conversation rather than a signature exercise.

Scrub nurses can help close that gap. Before incision, they should audibly confirm sterility indicators, counts, equipment readiness, implant or imaging needs, and anticipated constraints. Before the patient leaves the theatre, they should confirm final counts, specimen labelling, equipment problems, and information needed for recovery. Local adaptation may simplify wording or assign a named checklist coordinator, but it should preserve the moments at which all team members stop and listen. Audit should assess active participation and completion at the correct time, not only whether a box was marked.

Professional Accountability Within Hierarchical Teams

Hierarchy can coordinate expertise, but it becomes unsafe when status determines whose concern is heard. Scrub nurses may hesitate to challenge senior clinicians because of fear of blame, disrespect, or consequences for employment and training. Communication research identifies speaking up, closed-loop communication, situational awareness, and shared understanding as important non-technical skills, while research on surgical counts shows that power relationships between nurses and surgeons influence practice.^13,14

The tension is not solved by instructing nurses to “be confident”. That response individualises an organisational problem. A nurse who is encouraged in training to speak up but criticised in theatre receives a stronger lesson from the latter. Leaders must make safety voice predictable and legitimate through behaviour, policy, and follow-through. Surgeons and anaesthesia professionals can invite concerns by name during time-out; senior nurses can model graded assertiveness; and managers can review reported concerns without retaliation.

Teams should use standard phrases that separate the safety issue from personal challenge, such as “I have a sterility concern”, “The count is not correct”, or “I recommend a safety pause”. Closed-loop responses should confirm that the concern was heard and state the action taken. If disagreement persists, a clear escalation route should identify who makes the final risk decision and how it is documented. These practices give scrub nurses bounded authority: not unilateral control over the operation, but an enforceable right to stop, be heard, and obtain a reasoned response.

A Scrub Nurse-Led Model for Improvement

A scrub nurse-led model does not mean nurses work alone or assume responsibilities belonging to other professions. It means they are formally included in identifying recurrent risk, designing feasible safeguards, monitoring implementation, and learning from failures. Their continuous presence across procedures and shifts gives them a view of patterns that may be invisible to clinicians who attend only part of the pathway.

Four linked activities provide a practical starting point. First, scrub and circulating nurses can use procedure-specific readiness lists to confirm trays, indicators, sutures, implants, and identified alternatives before the patient enters the room. Second, hospitals can adopt a written count policy covering initial counts, cavity closure, skin closure, staff changes, discrepancies, and escalation. Third, scrub nurses can contribute to brief infection-prevention audits that assess hand preparation, gowning and gloving, indicator checks, theatre traffic, cleaning, and sharps disposal. Fourth, they can co-lead briefings and debriefings that identify anticipated risks and convert equipment or process failures into assigned actions.

These activities require protected time, feedback, and management response. Adding an audit or checklist without removing duplication or resolving reported problems can increase workload while weakening trust. Implementation should therefore begin with a small set of high-risk processes, test them in one theatre, collect staff feedback, and expand only after the process is workable. Measures should combine reliability, voice, and response: checklist participation, count discrepancies resolved before closure, sterility concerns acted upon, shortage reports closed, and staff perception that speaking up is safe.

Recommendations for Hospitals and Policy Leaders

Table 1 links recommended actions to the tensions that may obstruct them. The purpose is to make implementation barriers visible rather than present safety practices as context-free instructions.

Table 1.

Practical Recommendations Foramc Strengthening Scrub Nurse Contributions to Surgical Safety

Area	Recommended Action	Expected Safety Benefit
Infection prevention	Provide regular practical training on surgical hand preparation, sterile field management, sterilization indicators, and contamination response.	Reduced breaks in asepsis and lower surgical site infection risk.
Checklist use	Adapt the WHO Surgical Safety Checklist to local workflow and perform it verbally at sign-in, time-out, and sign-out.	Improved communication, fewer omissions, and stronger shared responsibility.
Instrument safety	Use procedure-specific instrument lists and standard count policies for sponges, needles, and instruments.	Fewer missing items, reduced retained-item risk, and smoother surgical flow.
Team culture	Empower scrub nurses to speak up about sterility, counts, equipment, and checklist concerns.	Earlier detection of preventable harm and better team accountability.
Leadership support	Conduct monthly operating theater safety meetings with nurses, surgeons, anesthetists, and managers.	Continuous improvement and shared ownership of safety problems.
Resource management	Track shortages, sterilization delays, and equipment failures using a simple logbook.	Better planning, procurement, and risk anticipation.

At hospital level, scrub nurses should participate in theatre policy, procurement, infection-prevention committees, and morbidity and mortality reviews when relevant. At national and professional levels, nursing curricula and continuing professional development should include perioperative competencies, checklist leadership, infection prevention, non-technical skills, and escalation practice. These reforms recognise that competence without organisational authority cannot reliably protect patients.

Implications for Research

The argument advanced here requires local empirical testing. Multicentre studies should describe surgical-site infection, checklist use, count practice, sterilisation reliability, and perioperative training needs across public, private, and teaching hospitals. Qualitative work should examine how scrub nurses experience authority, hierarchy, professional identity, and ethical decisions when resources are unavailable. Implementation studies should test whether nurse co-leadership, escalation protocols, and feedback on reported shortages improve both process reliability and staff willingness to speak up. Outcomes should extend beyond checklist completion to include timely participation, resolution of concerns, infection indicators, and team climate.

Limitations

This commentary does not present primary data or a systematic review, and the selected literature is not an exhaustive representation of Somali practice. Published evidence from Somalia remains limited, and conditions may vary across hospitals. The recommendations therefore require local adaptation and evaluation. Practical interpretation is used to connect available evidence with organisational tensions; it should generate debate and testable improvement strategies rather than be read as proof of effectiveness in every setting.

Conclusion

Scrub nurses occupy a critical but structurally constrained position in Somali operating theatres. They are expected to protect sterility, maintain accurate counts, identify equipment problems, and contribute to checklist communication, yet they may lack the supplies, decision-making access, and authority required to fulfil those expectations. This mismatch helps explain why accepted safety principles may not translate into reliable practice.

The distinctive implication is that training nurses or introducing checklists will be insufficient unless responsibility is matched by authority and organisational response. Hospitals should give scrub nurses an enforceable voice in safety pauses, escalation, procurement, audit, and team learning while strengthening sterilisation and supply systems. Policy leaders and educators should develop perioperative nursing competence alongside leadership and non-technical skills. Aligning scrub nurses’ responsibility, resources, and authority offers a context-sensitive route to safer surgery and challenges the assumption that they are only technical assistants rather than patient-safety leaders.

Funding Statement

The authors received institutional support from SIMAD University.

Ethics Approval and Consent to Participate

Not applicable. This commentary does not involve human participants, patient records, or identifiable clinical data.

Consent for Publication

This was deemed not applicable.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.