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Missed nursing care threatens quality and safety, but patient counts may not capture shift-level demands. We examined associations of patient-count and perceived workload indicators with missed care, separating within- and between-nurse effects.
A multicenter observational study using repeated shift-level measurements.
The study included 502 shift records from 213 nurses in 16 medical–surgical units across six Italian hospitals; the primary analysis included 480 records from 196 nurses. Patient-count indicators were nurse-reported numbers of assigned, isolated, and specialist-care patients; perceived workload included work rhythm/quantity, mental workload, emotional workload, and work organization. Grouped-binomial generalized estimating equations modeled the proportion of applicable activities missed, with nurse clustering, robust standard errors, exchangeable correlation, and hospital fixed effects. Workloads were decomposed into within- and between-nurse components, and four missed-care domains were examined.
Nurses reported a mean of 6.5 missed activities per shift; 29.9% of shifts had no missed care. The seven workload indicators were jointly associated with missed care (robust Wald χ 2[7] = 22.95, p = 0.002). Work rhythm/quantity was the only individual indicator with a nominal p-value below 0.05 (OR 1.24 per SD, 95% CI 1.03–1.49; p = 0.023), but it did not remain significant after Benjamini–Hochberg correction (q = 0.159). Assigned patient count was not clearly associated (OR 1.14, 95% CI 0.94–1.40; p = 0.192). In exploratory within–between analyses, the between-nurse work rhythm/quantity component was associated with missed care (OR 1.42, 95% CI 1.11–1.82; p = 0.005), whereas the within-nurse component was not (OR 1.03, 95% CI 0.90–1.17; p = 0.649). Domain-specific associations did not remain significant after multiplicity adjustment.
The workload indicators were jointly associated with missed nursing care, with secondary analyses indicating that the global signal was evident in the perceived-workload block. However, no individual workload indicator remained statistically significant after multiplicity adjustment. Work rhythm/quantity and its between-nurse component should therefore be regarded as exploratory signals requiring confirmation in studies with denser repeated measurements.
Workload surveillance research should evaluate patient-count and multidimensional perceived-workload indicators together. The present coefficient-specific findings are insufficient to support the operational use of work rhythm/quantity as a stand-alone workload indicator.
Middle Nurse Managers (MNMs) play a pivotal role in translating organizational strategy into operational practice, ensuring care quality, and fostering team performance. Despite their importance, limited research has examined the factors influencing MNMs' competencies, particularly the interplay between individual and organizational determinants.
To examine the direct and moderating effects of self-efficacy and other organizational and individual factors on MNMs' competence knowledge and competence application across Italy.
A cross-sectional, multicenter study was conducted between September 2022 and December 2023 with the participation of 382 MNMs from public and private healthcare organizations. Data were collected using validated instruments, including the Chase Nurse Manager Competencies Scale, the Questionnaire on Experience and Work Evaluation (QEEW 2.0), and the Leadership Self-Efficacy Scale. Structural equation modeling (SEM) tested direct effects of educational appropriateness, leadership training intentions, autonomy, role clarity, and work complexity, and the moderating role of self-efficacy.
Educational appropriateness, autonomy, and role clarity were significantly associated with competence knowledge, while educational appropriateness and autonomy were associated with competence application. Self-efficacy was directly associated with both competence outcomes and significantly moderated the relationship between educational appropriateness and autonomy with each competence dimension, with positive associations observed among individuals with higher self-efficacy (β = −0.456 for knowledge; β = −0.459 for application, p < 0.001).
Self-efficacy was associated with competence outcomes and moderated the associations between organizational factors and competence. High self-efficacy may reduce reliance on perceived educational appropriateness, whereas lower self-efficacy increases its importance.
Nursing leadership was pivotal during the acute COVID-19 response, yet less is known about how crisis-era leadership practices persisted, changed, or were replaced by new responsibilities during recovery. This study explored nursing leadership trajectories in Italy from the first pandemic wave to 5 years later.
Two-wave qualitative study with a longitudinal follow-up subsample and a supplementary 2025 refreshment sample, conducted within a descriptive–interpretive orientation.
Semi-structured interviews were conducted with nurse managers and staff nurses in Italian public healthcare settings at two time points: Phase 1 (August–December 2020; n = 22) and Phase 2 (June–September 2025; n = 22). Nine participants were re-interviewed and 13 were newly recruited in 2025, yielding 44 interviews with 35 unique participants. Interviews were transcribed in Italian and analyzed using team-based thematic analysis with a hybrid deductive–inductive strategy. Deductive sensitizing domains were derived from the 2020 dataset and nursing leadership literature, while inductive analysis identified issues newly prominent in 2025. For returning participants, within-case summaries supported longitudinal comparison. Reporting followed COREQ and SRQR guidance.
Findings are reported as patterns of continuity, change, and newly prominent phenomena rather than as uniform within-person change across the full sample. Six themes described leadership trajectories: (1) sustaining emotional support and compassionate leadership; (2) adaptive leadership and system learning; (3) leading digital adoption and technology-enabled care; (4) ethical challenges and moral resilience; (5) coordinating post-COVID pathways across settings; and (6) workforce stewardship, shortages, and retention efforts. Across waves, participants described leadership as shifting from immediate crisis reassurance and improvisation toward institutionalized preparedness, digital change work, cross-sector coordination, and workforce advocacy.
Within this sample, nursing leadership was described as moving from acute crisis containment toward a broader portfolio of organizational, ethical, digital, and workforce-oriented responsibilities in the post-pandemic period.
Health organizations should proactively support nurse leaders' capacity for compassionate leadership and moral resilience, invest in digital competencies, and strengthen retention and preparedness strategies to sustain the nursing workforce beyond crisis periods.
Evidence-based practice (EBP) competence is essential to high-quality and safe nursing care, yet rigorously validated instruments to assess EBP competencies are lacking in the Italian context.
To translate, culturally adapt, and psychometrically validate the Italian version of the Evidence-Based Practice Competency Scale for registered nurses and advanced practice nurses.
In 2024, a cross-sectional online survey of Italian nurses was conducted. The 24-item EBP Competency Scale was translated and culturally adapted following international guidelines. Content validity was assessed by a 16-member expert panel, and 405 nurses completed the scale and a sociodemographic questionnaire. The sample was randomly split for exploratory and confirmatory factor analyses, and internal consistency, test–retest reliability, and measurement invariance by prior EBP training were examined.
Content validity indices were high (I-CVI = 0.75–1.00; S-CVI = 0.92). A one-factor model explained 72.1% of variance and showed excellent fit. Reliability was very high (α = 0.974; ICC = 0.83). Multigroup CFA supported configural and metric invariance and partial scalar invariance, with lower latent EBP competence in nurses without prior training.
The Italian EBP Competency Scale is a valid and reliable instrument for assessing EBP competence among Italian nurses. Its use can support benchmarking, guide EBP-focused education and implementation strategies, and provide a foundation for future advanced psychometric applications.
Organizational culture and readiness are critical determinants of evidence-based practice (EBP) implementation. The Organizational Culture and Readiness Scale for System-Wide Integration of EBP (OCRSIEP), developed within the ARCC framework, is a validated tool to assess these dimensions, but no Italian version currently exists.
To translate, culturally adapt, and psychometrically validate the OCRSIEP and its short form in Italian.
A validation study was conducted, using exploratory and confirmatory factor analyses to derive and test the underlying model, followed by reliability testing with multiple indices and measurement invariance analyses.
Data were collected from 405 Italian nurses. Factor analyses supported a 19-item, six-factor structure explaining 59.5% of the variance, with a second-order factor indicating an overarching construct. The three-item short form showed strong model fit and explained 67% of the variance. Subscales demonstrated acceptable-to-excellent reliability, and partial scalar invariance was established across public and private facilities.
The Italian OCRSIEP scales are valid and reliable tools to assess organizational readiness for EBP implementation. They can guide leaders, educators, and researchers in monitoring, benchmarking, and advancing EBP–oriented system transformation within the Italian healthcare context.
Doctoral research in nursing is central to advancing scientific knowledge, strengthening professional identity, and informing evidence-based practice, education, and health policy. Analyzing the thematic content of doctoral theses offers insight into research priorities and national variations in nursing scholarship. Yet, no systematic cross-country analysis has examined the thematic focus of such work.
To explore and describe the diversity and scope of doctoral nursing research themes across eight countries in the Sigma Europe Region, identifying key areas of scholarly focus and shared priorities.
A document-based qualitative study using reflexive thematic analysis, as outlined by Braun and Clarke, to examine patterns of meaning within thesis summaries.
The study included doctoral nursing thesis summaries defended between January 2020 and December 2023, sourced from national and institutional repositories in eight countries of the Sigma Europe Region. A total of 15 repositories (4 national, 11 institutional) were systematically searched, and additional summaries were obtained via direct contact with universities offering doctoral nursing programmes.
Data were collected between September 2024 and February 2025 using predefined inclusion and exclusion criteria. In total, 431 eligible thesis summaries were analyzed following Braun and Clarke's six-phase framework, supported by MAXQDA software for data management and coding.
Thematic analysis identified three overarching domains: (1) foundations of nursing practice and care philosophy, (2) systemic and organizational dimensions of nursing, and (3) clinical innovation and public health impact. Ten interrelated themes emerged, including holistic and patient-centred care; emotional, psychological, and quality-of-life dimensions; communication in healthcare; workforce challenges; transforming nursing practice; maternal, neonatal and pediatric health; digital and virtual health innovations; public health and chronic disease management; and disease management, caregiving, and outcomes. Cross-cutting elements such as cultural sensitivity and resilience spanned multiple themes.
This cross-national synthesis demonstrates the breadth and depth of doctoral nursing research in the Sigma Europe Region. Findings highlight nursing's pivotal role in addressing healthcare needs through innovative, person-centred, and evidence-informed solutions, and underscore the value of international collaboration in shaping resilient, equitable, and future-ready healthcare systems.
To explore and map the landscape of doctoral nursing research across eight countries.
A scoping review.
This review followed the Joanna Briggs Institute methodology for scoping reviews and included doctoral theses in nursing defended between 2020 and 2023 in Austria, Italy, Israel, the Netherlands, Poland, Portugal, Slovakia and the United Kingdom.
Searches were conducted across 15 national and university repositories (4 national, 11 university) in the eight participating countries.
This review included 431 doctoral nursing theses, the majority of which employed quantitative methodologies and focused on patient populations and healthcare professionals. Key topics included clinical nursing care, quality of care, quality of life, home care, perinatal care and the work environments.
Nursing doctoral research shows progress in healthcare delivery, patient care and education via digital tools, holistic approaches and professional development. Yet gaps persist in mental health, paediatrics and marginalised groups. Limited qualitative/mixed-methods research and weak interdisciplinary collaboration reveal further opportunities.
This review underscores that nursing doctoral research is addressing major healthcare and professional challenges. Nonetheless, the identified gaps emphasise the need for more comprehensive and inclusive research to enhance equity and guide future nursing practices and policies.
This review provides an overview of the scope of doctoral nursing research across eight countries, identifying key trends and research gaps. The findings are expected to inform nursing academia, policymakers, and healthcare professionals by guiding future research priorities, fostering interdisciplinary collaboration, and promoting equitable, patient-centred care practices.
No direct involvement in data collection; one lay reviewer gave feedback on readability and practice implications, informing minor refinements.
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