“They’re from another planet”: a reality check on the relational architecture of surgical site infection prevention — qualitative exploration for a social network analysis

Every surgery carries a hidden risk: the possibility that the wound left behind will become infected. These infections, known as surgical site infections, can turn a routine operation into a prolonged hospital stay, a costly burden, or even a life-threatening event. While doctors and nurses have long known the rules to prevent these infections—washing hands, sterilizing tools, timing antibiotics perfectly—these guidelines do not always translate into consistent action. The problem is not usually a lack of knowledge, but rather the complex human system in which that knowledge must be applied. Operating rooms are not just medical spaces; they are social environments where surgeons, anesthesiologists, nurses, and infection control specialists must coordinate under intense time pressure. When these groups do not connect well, the best guidelines can fail. Understanding how these teams talk, trust, and work together is now seen as just as critical as the medical protocols themselves.

Researchers at ETH Zurich and the University of Zurich set out to understand exactly how this coordination works in real life. They did not simply ask people if they followed the rules; instead, they listened to how different hospital staff described their daily work and watched how they actually behaved in the operating room. The team conducted ten interviews with eleven healthcare professionals across five different hospitals in the German-speaking part of Switzerland. These participants included surgeons, anesthesiologists, nurses, and infection prevention experts. To get a fuller picture, the researchers also spent about twelve hours observing eight different surgeries, watching how the team interacted without interfering. Their goal was to map the invisible relationships that determine whether a patient leaves the hospital healthy or returns with an infection.

The study revealed that preventing infection is a long chain of responsibility that stretches from the moment a patient is planned for surgery to the day they are discharged. No single person or team holds the entire burden. One surgeon described it as a chain involving at least ten to twelve people for a single operation. The anesthesiologist must time the antibiotics perfectly; the scrub nurse must maintain a sterile field; the surgeon must work efficiently; and the ward nurses must manage the wound dressing afterward. If any link in this chain breaks, the risk of infection rises. The researchers found that while formal protocols exist, the real work of prevention often happens through informal vigilance. Experienced nurses, for instance, often act as sensors, noticing small problems or tracking patients who return for repeat surgeries, even when no official rule requires them to do so.

However, a significant gap often exists between the people who make the rules and the people who follow them. The researchers found that the relationship between the surgical teams and the infection prevention and control (IPC) staff varied wildly from hospital to hospital. In some places, the two groups worked as close partners. In others, the surgical staff felt alienated, describing the IPC team as being "from another planet." This feeling arose when IPC staff were seen as outsiders who did not understand the chaotic, time-pressured reality of the operating room. When an infection prevention specialist had a background in clinical work, they were seen as credible and their advice was followed. When they lacked that clinical experience, their guidelines were often viewed as impractical or impossible to implement. One anesthesiologist noted that while IPC staff had good concepts, they often failed to consider how much time or effort a new rule would actually require.

Information flow within these hospitals was another major hurdle. The study identified four types of information: official policies, patient-specific details, feedback on infection rates, and the act of speaking up about safety concerns. Each traveled differently. Written guidelines were often ignored because they were buried in email inboxes or stored on intranet pages that no one checked. Instead, most critical information traveled through conversation. A change in practice often spread not through a memo, but because a specific group of staff, like anesthesiologists who rotated through different operating rooms, carried the new habit with them. Feedback on how well teams were doing was also uneven. While surgeons often received data on their own infection rates, nurses and anesthesiologists frequently received nothing. One nurse noted that without this feedback, they assumed there were no problems, even when infections were occurring.

Trust and hierarchy played a decisive role in whether safety measures were actually followed. The operating room is a place where rank matters. Junior staff were often too afraid to correct senior surgeons, even if they saw a mistake like a hand wash that was too short. One surgeon admitted that a resident would never tell an experienced attending physician to wash their hands again. Yet, in some teams, a culture of trust allowed anyone to speak up. When a surgeon questioned an antibiotic dose for an overweight patient, the anesthesiologist felt safe enough to verify it immediately. The researchers found that stable teams, where members worked together over time, fostered this kind of trust. In contrast, teams with frequent leadership changes or high turnover often resisted new safety measures, creating a defensive circle where old habits were hard to break.

Perhaps the most surprising finding was that different groups did not agree on what the biggest risks were. When asked what mattered most, surgeons focused on their own technique and the ventilation of the room. Nurses focused on hand hygiene and keeping the sterile field clean. Anesthesiologists prioritized the timing of antibiotics. Infection prevention staff saw the whole system as a team effort where every part had to mesh together. These differences were not just about knowledge; they were about perspective. A surgeon might believe that a patient's underlying health conditions made an infection inevitable, regardless of what the team did. A nurse might see a peripheral IV line as a major risk because it was handled casually, while the team treated it as unimportant. The researchers suggested that what looks like non-compliance is often just a difference in judgment about what is feasible and what is risky in the moment.

The study concluded that preventing surgical infections depends less on the existence of perfect guidelines and more on the quality of the relationships between the people involved. Formal rules become real practice only when they are backed by credibility, conversation, and trust. The connections between people are structural, meaning they are built into the hospital's organization, but they are also fragile. If the few individuals who bridge the gap between surgical teams and infection control leave or are replaced, the connection can break. The researchers emphasized that making these invisible relationships visible is the first step toward improvement. By understanding that prevention is a social accomplishment, not just a medical one, hospitals can begin to build the networks necessary to keep patients safe.