The organization of nursing work in Italian hospitals-implications for job satisfaction, nurse well-being and patient safety

Enhancing the well-being of nurses and their job satisfaction are two of the most discussed topics in the international literature in the last years. The COVID-19 pandemic has increased the interest in these two topics, and several studies have explored moral distress and burnout experienced by healthcare professionals (Galanis et al., 2021). The incidence of the phenomenon has grown so much recently that the topic has attracted the attention not only of scientific journals but also of daily press, which focuses on the emotional distress of nurses and their frequent intention to leave the profession. Nurses' distress has been shown to be related to excessive workload, poor organization and difficulty delivering safe care in contexts (Sasso et al., 2019). Currently, in Italy, national and regional laws regulate the nurse–patient ratios, which established how many professionals should be present at each shift. The number of nurses is calculated according to the minutes of care one patient needs daily, and it varies according to the type of ward and to the bed occupation rate. According to the law and to the number of nurses currently working in Italy (6.6 per 1000 habitants) (OECD, 2023), the average nurse-to-patient ratio is 9.5 patients for each nurse (9.5:1) (Sasso, Bagnasco, Aleo, et al., 2017), far from the safe nurse-to-patient ratio of 6:1 (Aiken et al., 2014). In this context, functional nursing is the most used care delivery model. It seems to be more efficient and more productive because it allows to complete more tasks with fewer nurses, but in reality, it could have a worse impact on patients (Parreira et al., 2021). Moreover, if we look at functional nursing through the lenses of missed care, we can find several omissions in the daily nursing care because lower nurse staffing levels have been associated with higher levels of missed nursing care (Griffiths et al., 2018). This is a critical issue for our healthcare organizations because this model is task-focused with a direct negative influence on nurses' satisfaction with their role. Due to the widespread nature of these phenomena, several Italian researchers are exploring ways to manage these issues and improve nurses' working conditions and, consequently, also patients' outcomes. On the one hand, efforts are being made to describe the conditions in which Italian nurses work, with results highlighting occurrences like missed nursing care and violence against healthcare professionals (Bagnasco et al., 2020, 2022). On the other hand, research projects have been developed to measure the effects of person-centred care delivery models on nursing and patients' outcomes (Cocchieri et al., 2022; Dal Molin et al., 2018). Additionally, it is important to consider the influence of patients' associations, which claim for safe healthcare environments and safe care for patients. Moreover, together with the international society for quality accreditation, they request public reports about patients' outcomes. In this scenario, nursing-sensitive outcomes may play a fundamental role, and they could be used as a tool to compare the results of different nursing interventions on patient outcomes and highlight the ‘intensity’ of nursing care. Nursing intensity weights (NIWs) could be incorporated into the diagnosis-related groups (DRG) systems, which would enable hospital to have more resources to address the factors that lead to missed care, such as improved staffing levels, and consequently improve healthcare outcomes (Sasso, Bagnasco, Zanini, et al., 2017). The drive to improve better working conditions and safer settings for patients and nurses should be also fuelled by recent data about the reduced enrolment of nursing students. All the above-mentioned reflections lead us to some considerations about the way nurses work and how its management needs to be improved. One strategic solution could be the provision of higher-level clinical and managerial education for nurses. The opportunity for nurses to become advanced practice nurses, through clinical master's degrees, and doctoral courses to develop managerial and research competencies are key to the development of the profession. Moreover, nursing managers and nursing researchers should keep on working together and build a culture of evidence-based management (Sasso, Bagnasco, Zanini, et al., 2017). This would enable to effectively measure the intensity of nursing care, implement updated evidence-based organizational interventions and monitor nursing-sensitive processes, through data collection and indicators. This in turn would also enable to provide evidence and inform executive managers and policymakers on how nursing impacts on the quality of care. To conclude, the current Italian healthcare sector is going through a complex historical phase similar to other European countries, which prompts nursing stakeholders to cooperate in order to achieve gold standards in nursing management, keeping in mind that nurse well-being and patient safety are two sides of the same coin.