June 20, 2017

Research explores relationship between SSIs and nurse education

By: James X Stobinski, PhD, RN, CSSM, CNOR

Are there nursing characteristics such as certification status or educational attainment that impact surgical site infection rates?

The answer to questions such as this may provide evidence of modifiable factors that could lessen surgical site infections (SSIs) and thus decrease the financial and emotional impact from these adverse events. The Competency and Credentialing Institute (CCI) in Denver has conducted research in this field, and I presented preliminary findings of the most recent study at the 2017 AORN Global Surgical Conference and Expo. The study is expected to provide some answers to this question and also furnish the methodology for future research of this kind.

SSIs remain a common healthcare-associated infection (HAI) that places a heavy burden on patients and families. The toll can be expressed in monetary terms, but there is also a significant impact on quality of life and emotional well-being for the individual contracting the infection.

An SSI following a total joint procedure, which is among the common surgical procedures performed in the US, can have life-altering implications. Other commonly performed surgeries include hysterectomies and colon cases, and complications such as SSIs can also consume a large amount of resources. Increasingly, there are also larger financial implications for healthcare facilities for these infections beyond the diversion of resources. The prevention of SSIs has drawn considerable attention from professional groups, accreditation organizations, healthcare insurers, and government agencies.

The study of HAIs in general and SSIs specifically has been extensive, with a wide variety of factors thought to contribute to SSIs having been studied. However, there is not yet extensive research evidence examining the relationship between adverse patient outcomes such as SSIs and the characteristics of the nursing workforce.


Nursing certification

There are a great number of variables regarding the perioperative nursing workforce. In addition, there is a diversity of pre-licensure education paths for RNs who work in the OR. There is also no standardized educational course for entry into the specialty of perioperative nursing. Although certification exists for perioperative nurses, the process is typically voluntary, and it is likely that the majority of nurses are not certified.

An underlying assumption for the certification process is that it contributes to better quality care and improves the performance of those holding the certification. The premise of a link between improved patient outcomes and certification has been in place for decades, but this correlation has not been extensively studied; most of the research has been done in the last 10 years. (An excellent summary of the existing nursing research regarding certification is available on the American Board of Nursing Specialties’ website at www.nursingcertification.org/.)

Although the facts outlined above are a bit daunting, these circumstances do present an opportunity for further research. CCI is the organization that administers the CNOR credential for perioperative nursing practice. As one of the largest nursing certification organizations, CCI has an interest in research that examines the relationship between nursing characteristics and patient outcomes.


Research methodology

Earlier results of CCI research were published in the AORN Journal. For the current study, CCI returned to a group of researchers who were familiar with the National Database of Nursing Quality Indicators (NDNQI), which was used for the 2014 study. As defined on the Press Ganey website, NDNQI is “…a national database and RN surveys for examining relationships between nursing and patient outcomes…” This database “…delivers evidence to support the importance of nurse-sensitive measures in overall patient experience strategy.”

In 2016, CCI contracted with researchers Diane Boyle, PhD, RN, FAAN, professor, University of Wyoming; Sandra Bergquist-Beringer, PhD, RN, CWCN, professor, University of Kansas School of Nursing; and Emily Cramer, PhD, research assistant professor, University of Kansas School of Nursing to further investigate the relationship between nursing characteristics and SSIs.

The research combined data from the NDNQI database and the SSI tracking system administered by the Centers for Disease Control and Prevention. That tracking system is the National Healthcare Safety Network (NHSN), the nation’s most widely used HAI tracking system. This research addresses the knowledge gap regarding nursing characteristics and SSIs with a multisite study combining data from the NHSN database with nursing-centric information gleaned from the NDNQI database.

This study—the first attempt to merge the NHSN and NDNQI databases—represents the leading edge of investigation of possible modifications to nursing characteristics in the quest to improve patient outcomes. The methodology was a retrospective, secondary analysis of merged data from the NDNQI and NHSN databases.

A total of 69 hospitals participated in the study, which merged data for the year 2014 from the NHSN database and information found on these hospitals in the NDNQI data bank. Variables in the study included certification status of the nursing staff and nurse education levels as well as patient ASA scores, wound classification, and procedure times. The types of surgeries studied were confined to colon procedures and abdominal hysterectomies.

In preliminary results, presented at the AORN conference, there were some encouraging but limited findings. A bivariate analysis revealed that nonteaching hospitals had significantly fewer SSIs than did teaching hospitals and academic medical centers. It also found that higher nursing certification rates were associated with fewer SSIs. This was true with the CNOR, CRNFA, and CAPA credentials as well as with other nursing certifications found in the units providing postsurgical care.

However, when a more complex multivariate analysis was performed, these certification rates and other nursing factors such as tenure on the unit were not found to be statistically significant. In this complex analysis, factors such as ASA status, wound classification, and the Magnet status of the facility were found to be statistically significant. The findings suggest that the effect of nursing certification is a relatively minor factor and that other variables have a much greater impact on whether a patient will develop an SSI.

The findings, including details of the results, methods, and statistical tests utilized, are currently being prepared for publication. That level of detail exceeds the scope of this article.

Previous attempts to study the relationship between nursing characteristics and patient outcomes were beset with limitations such as small sample size, lack of rigor, and the absence of a theoretical framework. Setting aside the limitations of these studies, there remains a paucity of research in this area. The value of this study is in establishing the methodology for future research.

This study attempted to address these issues, and there has been some success in that respect. It was guided by Donabedian’s Structure–Process–Outcomes theoretical framework and included thousands of surgical cases from the 69 participating hospitals.


Future research

The importance of this study is that it establishes the methodology for future work to include the merging of a government database (NHSN) and the privately held NDNQI database. The lessons learned in navigating technological and logistical hurdles will ultimately prove beneficial to future researchers. The use of large, diverse samples and national databases within an established theoretical framework lends credibility and increases both the power and the utility of these studies.

The OR is the financial engine of a hospital, and the financial health of that department can affect the larger facility. Under the value-based purchasing initiatives from the Centers for Medicare & Medicaid Services, the loss of revenue associated with SSIs and other adverse events will have a financial impact far outside the OR.

In a 2015 AORN Journal editorial, I wrote about the connection between certification and patient safety, stating: “The transition to new models of care will place an increasing emphasis on quality, and clear financial implications will exist for facilities that cannot meet such demands.”

SSIs have a far-reaching impact on the quality of life of patients and can be detrimental to the financial health of a facility. As a profession, perioperative nursing has an ethical obligation to investigate the causes of adverse outcomes such as SSIs and to put in place remedies where possible.

Research studies such as the recent work done by CCI on the relationship between nursing characteristics and SSIs is but one example of the work that can be done in this field. There are great opportunities for new knowledge as increasing amounts of data become available and research techniques are refined. There is not a long-established tradition of nursing research in perioperative nursing, but the area of SSI prevention presents a unique prospect for the profession. ✥




Boyle D K, Cramer E, Potter C, et al. The relationship between direct-care RN specialty certification and surgical patient outcomes. AORN J. 2014;100(5):511-528.

Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-1748.

Donabedian A. The role of outcomes in quality assessment and assurance. QRB Qual Rev Bull. 1992;18(11):356-360.

Stobinski, J X. Certification and patient safety. AORN J. 2015; 101(3):374–378.

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