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Background: Effective performance of clinical handovers should be one of the priorities of nursing education to promote efficient communication skills and ensure patient safety. However, to date, no studies have explored to what extent nursing students are involved in handovers., Objective: To explore nursing students' handover involvement during their clinical rotations and associated factors., Method: This was a secondary analysis of a large national cross-sectional study that involved 9607 undergraduate nursing students in 27 universities across 95 three-year Italian baccalaureate nursing programs. The involvement in the clinical handovers was the end point (from 0, never, to 3, always). A path analysis was performed to identify variables directly and indirectly affecting students' handover involvement., Results: Handover involvement was reported as 'only a little', 'to some extent', and 'always' by 1739 (18.1%), 2939 (30.6%), and 4180 (43.5%) students, respectively; only 749 (7.8%) of students reported never being involved. At the path analysis explaining the 19.1% of variance of nursing students' involvement, some variables emerged that directly increased the likelihood of being involved in handovers. These were being female (β = 0.115, p < 0.001); having children (β = 0.107, p = 0.011); being a 3rd-year student (β = 0.142, p < 0.001) and being a 2nd-year student as compared to a 1st-year student (β = 0.050, p = 0.036); and having a longer clinical rotation (β = 0.015, p < 0.001) in units with high 'quality of the learning environment' (β = 0.279, p < 0.001). Moreover, students who were supervised by the nurse teacher (β = -0.279, p < 0.001), or by a nurse on a daily basis (β = -0.253, p = 0.004), or by the staff (β = -0.190, p < 0.001) reported being less involved in handovers as compared to those students supervised by a clinical nurse. Variables with indirect effects also emerged (model of student's supervision adopted at the unit level, and number of previous clinical rotations attended by students). Moreover, handover involvement explained 11.5% of students self-reported degree of competences learned during the clinical experience., Conclusions: Limiting students' opportunity to be involved in handover can prevent the development of communication skills and the professional socialization processes. Strategies at different levels are needed to promote handover among undergraduate nursing students., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To explore nursing students' interprofessional educational (IPE) experiences during their most recent clinical rotation and to explore the factors supporting IPE experiences., Design: National cross-sectional study on data collected in 2016., Setting: 95 Bachelor of Nursing Sciences programmes; 27 Italian Universities., Participants: Students who (a) were attending or just completed their clinical rotations lasting at least 2 weeks in the same unit, and (b) willing to participate in the study., Primary and Secondary Outcomes: First to measure the occurrence of IPE experiences in the most recent clinical rotation; the secondary outcome was to discover factors associated with IPE occurrence., Measures: The primary outcome was measured using questions based on a 4-point Likert scale (from 0='never' to 3='always'). Explanatory variables were collected at both individual and regional levels with items included in the same questionnaire., Results: 9607 out of 10 480 students took part in the study. Overall, 666 (6.9%) perceived not having had any IPE experience, while 3248 (33.8%), 3653 (38%) and 2040 (21.3%) reported having experienced IPE opportunities 'only a little', to 'some extent' or 'always', respectively. From the multilevel analysis performed using the generalised linear mixed model, factors promoting the occurrence of IPE experiences were mainly set at (a) the clinical learning environment level (high: learning environment quality, self-directed learning encouragement, learning opportunities, quality of safety and nursing care and quality of tutorial strategies); and (b) the regional level, where significant differences emerged across regions. In contrast, male gender was negatively associated with the perception of having had IPE experiences., Conclusions: A large number of nursing students experienced either 'never' or 'only a little' IPE opportunities, thus suggesting that nursing education tends to remain within the nursing profession. Limiting students' interprofessional exposure during education can prevent future collaborative approaches that have been shown to be essential in providing best patient care. In order to increase IPE exposure, it is necessary to develop strategies designed both at the singular unit and regional levels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

. The nurses' tasks performed by aids in hospital settings: a mixed-methods study., Introduction: The role of Nurses' aides (NAs) in the clinical practice has been widely debated to date., Aims: To describe the activities/tasks performed by NAs and the dedicated time; to identify the activities/tasks shifted from nurses to NAs and to investigate the motivations., Methods: A multi-center mixed-methods study was conducted. Fifty-six NAs working in 17 hospitals in the North-Italy were observed during daily practice and then interviewed about the motivations associated with task shifting., Results: NAs mainly performed direct care tasks (67.7% of the observed time), such as helping with personal hygiene, feeding and mobilization. Larger hospitals (p = 0.034), surgical units (p = 0.001), a skill mix> 40% (p = 0.044) and a reduced nurse to patient ratio (p = 0.041), were significantly associated with a higher amount of indirect care activities/tasks performed by NAs. The tasks shifted most frequently from nurses to NAs were: mobilization (22; 39.3%) and personal hygiene (21; 37.5%) of unstable patients, feeding patients with dysphagia (19; 34%), intra-venous set replacement (16; 28.6%) and pressure ulcers' dressing (11; 19.6%). NAs reported that they chose to act autonomously because of their experience and the trust-based relationship with nurses, in order to promptly respond to patients needs and to reduce nurse workload., Conclusions: It is necessary to further assess the development of the NAs role in the hospital setting to understand their inclusion in the nursing care.

Background: Easy-to-access tools have been demonstrated to improve evidence-based practice (EBP) competences among nursing students. However, students' perception of access to EBP tools (e.g., clinical practice guidelines [CPGs], protocols) is unknown., Aims: To explore: (1) nursing students' opportunity to access EBP tools during their education, and (2) associated factors., Methods: A national cross-sectional study including all Italian nursing programs. Nursing students were deemed eligible according to the following inclusion criteria: Those who (1) were attending or just ended their practical rotation lasting at least 2 weeks at the time of the survey, and (2) expressed through written informed consent their willingness to take part in the study. Participants were asked about their perceived opportunity to access EBP tools during their most recent clinical learning experience (from 0 - not at all to 3 - always). A set of explanatory variables was collected at the individual, nursing program, and regional levels by using a questionnaire., Results: Nine thousand six hundred and seven (91.6%) out of 10,480 nursing students took part in the study. Overall, 4,376 (45.6%) students perceived not at all or only a small opportunity to access EBP tools during their most recent clinical rotation. In the multilevel analysis, factors promoting access were mainly set at the clinical learning environment level (high safety and nursing care quality, high self-directed learning opportunities, high quality of the learning environment, and being supervised by a clinical nurse). In contrast, male gender and lower academic class were associated with a lower perception of accessibility to EBP tools. A consistent variability in the perceived opportunity to access EBP tools emerged across regions., Linking Evidence to Action: Evidence-based decision-making is increasingly expected from nurses. Therefore, nursing faculties should safeguard and continuously improve students' competence regarding EBP, by implementing strategies mainly at the nursing program and regional levels., (© 2018 Sigma Theta Tau International.)

Context: Error reporting is considered one of the most important mediating factors for patient safety (PS). However, reporting errors can be challenging for health care students., Objectives: The aims of the study were: (i) to describe nursing students' opportunity to report errors, near misses or PS issues that emerged during their clinical learning experience; and (ii) to explore associated factors of the process of reporting itself., Methods: A national survey was conducted on 9607 (91.7%) undergraduate nursing students. The endpoint was to have reported PS issues in the last clinical learning experience (from 0 'never' to 3 'always'). Explanatory variables were set individual, nursing programme and regional levels., Results: A total of 4004 (41.7%) nursing students reported PS issues from 'never/rarely' to 'sometimes'. In the multi-level analysis, factors increasing the likelihood of reporting events affecting PS have been mainly at the nursing programme level: specifically, higher learning opportunities (odds ratio [OR] = 3.040; 95% confidence interval [CI], 2.667-3.466), self-directed learning opportunities (OR = 1.491; 95% CI, 1.364-1.630), safety and nursing care quality (OR = 1.411; 95% CI, 1.250-1.594) and quality of tutorial strategies OR = 1.251; 95% CI, 1.113-1.406). By contrast, being supervised by a nurse teacher (OR = 0.523; 95% CI, 0.359-0.761) prevented the disclosure of PS issues compared with being supervised by a clinical nurse. Students attending their nursing programmes in some Italian regions showed a higher likelihood (OR from 1.346 to 2.938) of reporting PS issues compared with those undertaking their education in other regions., Conclusions: Nursing students continue to be reticent to report PS issues. Given that they represent the largest generation of future health care workers, their education regarding PS should be continuously monitored and improved; moreover, strategies aimed at developing a non-blaming culture should be designed and implemented both at the clinical learning setting and regional levels., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Introduction: The indicators used in the Italian National Outcome Strategy does not include measurement of nursing care outcomes so these have not yet been assessed systematically in our country but only in the context of specific research projects. Positive and negative outcomes of nursing care have been documented in the literature, the latter associated with missed nursing care, a phenomenon that occurs when conditions are such that nurses are unable to deliver planned care to patients., Objectives: To describe the rationale, methodology and main results achieved to date in the development of a regional policy aimed at establishing a panel of indicators for monitoring nursing care-sensitive outcomes hospitals in publicly funded hospitals in the Veneto Region (northern Italy)., Methods: A plurennial, multi-method project based on [1] identification of selection criteria for a Minimum Data Set of indicators; [2] a rapid review of the literature and of the policies established internationally to measure nursing care-sensitive outcomes; [3] the establishment of an initial panel of indicators and evaluation of any critical issues with the chosen indicators, and [4] identification of the most appropriate tool for measuring missed nursing care., Results: The medical and surgical units were considered to be the most suitable settings for the pilot study. Following the literature review, indicators that were already being monitored in the current regional information system were chosen, with the intent to prevent an additional administrative burden to nurses. By using a progressive consensus process, five outcome indicators (functional status, falls, pressure sores, urinary tract infections, aspiration pneumonia) and one process indicator (missed nursing care) were selected., and the tools for measuring the above-mentioned indicators and their related risks, were identified. A regional policy was then established to measure these indicators in a pilot phase, with the intent of implementing them as stable indicators to be measured in the new computerized hospital information system., Conclusions: An initial panel of nursing-sensitive outcome indicators has been defined to be used in Internal Medicine and General Surgery units of hospitals in Italy's Veneto Region. Despite its limitations, the project represents the first effort to create a regional policy to measure the contribution of nursing care to the health outcomes of patients and that will also the identification of potential relations with other variables such as personnel staffing and/or skill mix.

. Extent and type of implicit rationing of nursing care in seven South Tyrolean hospitals: a descriptive study., Introduction: Implicit rationing of nursing care is an international phenomenon, defined as withholding of or failure to carry out necessary nursing interventions due to a lack of nursing resources., Aims: To describe the extent and type of nursing care implicitly rationed in South Tyrolean hospitals, and to explore differences across clinical areas and between registered nurses (RNs) and support staff., Methods: The Basel Extent of Rationing of Nursing Care (BERNCA) questionnaire was completed between September and November 2015, by 934 RNs and support staff of the seven hospitals, involved in direct adult patient care (24 medical, 13 surgical, 5 rehabilitation, 4 intensive care units). Descriptive and explorative analyses were performed., Results: The most rationed activities concerned "nursing care planning" (37.3%), "surveillance of confused patient" (30.7%), "providing emotional support" (30.1%) and "talking with patients and family" (28.4%). Of the ten most rationed activities, seven were common to RN and support staff, and across clinical areas, although with different frequencies. Significant differences between clinical areas were observed for: "nursing care planning", "rehabilitation care", and "comfort/talking with patients and family"., Discussion: Implicit rationing of nursing care occurs in South Tyrolean hospitals, mainly related to care planning and documentation. Higher priority is given to activities related to direct patient care. Further investigations on priority setting to increase the awareness among frontline nurses of what is rationed, and to guarantee the safety and quality of care is warranted.

Presented here is the approach used by a multidisciplinary working group fo the drafting of the "core" competence profile of the healthcare professions manager in the Veneto Region. Defining a competence profile allows for specifying a standard for measuring the skills acquired by a professional and the gap level from what is expected by the organization, as well as orienting the preparatory education to carry out the related role.

Background: Patient satisfaction with nursing care (NC) is an important predictor of overall satisfaction with the hospital experience. However, the concept of patient satisfaction has been criticised both at the theoretical and at the methodological levels, and more attention on patient dissatisfaction has been called for with the aim of identifying strategies to improve the quality of care., Aims: To describe dissatisfaction with NC as perceived by acute medical patients and identify predictors., Design and Methods: A secondary analysis of longitudinal data involving 12 Italian medical units was performed. A consecutive sample of 1016 patients ≥65 years (2012-2013) was included, and their satisfaction with NC was assessed, administering the Italian version of the Patient Satisfaction Scale (PSS) at the day of discharge. The scale was based on 11 items evaluated on a four-point Likert scale (score ranging from 11 - very dissatisfied to 44 - very satisfied). Patients were defined as 'satisfied with NC' when the score was ≥33, whereas they were considered as 'dissatisfied with NC' when the score was <33. A logistic regression analysis was performed to identify the predictors of patient dissatisfaction with NC., Results: There were 788 (77.6%) patients satisfied (≥33 at the PSS) and 228 (22.4%) dissatisfied with NC (<33). The risk of dissatisfaction was likely to be higher in female patients (RR 1.883, 95% CI 1.359-2.609), in those who developed pressure sores during the in-hospital stay (RR 1.555, 95% CI 1.021-2.368), who received NC with high skill mix (RR 1.072, 95% CI 1.034-1.111) and those who were admitted to a large hospital (RR 1.001, 95% CI 1.001-1.002). In contrast, increased age (RR 0.987, 95% CI 0.975-0.998), increased amount of care offered by Registered Nurses (RR 0.984, 95% CI 0.974-0.994), a higher proportion of baccalaureate nurses on staff (RR 0.975, 95% CI 0.958-0.993) and being admitted to a teaching hospital (RR 0.497, 95% CI 0.130-0.910) all decreased the likelihood of being dissatisfied with NC., Conclusions: Dissatisfaction with NC was affected by individual, NC and hospital variables, such as the amount of staff resources, nurses education and skill mix. The findings emerged may inform clinicians, managers and policymakers regarding strategies that should be designed and implemented to prevent patient dissatisfaction., (© 2017 Nordic College of Caring Science.)

Background: Given the progressive demographic ageing of the population and the National Health System reforms affecting care at the bedside, a periodic re-evaluation of in-hospital mortality rates and associated factors is recommended., Aims: To describe the occurrence of in-hospital mortality among patients admitted to acute medical units and associated factors. Two hypotheses (H) were set as the basis of the study: patients have an increased likelihood to die H 1 : at the weekend when less nursing care is offered; H 2 : when they receive nursing care with a skill-mix in favour of Nursing Aides instead of Registered Nurses., Methods: Secondary analysis of a prospective study of patients >65 years consecutively admitted in 12 Italian medical units. Data on individual and nursing care variables were collected and its association with in-hospital mortality was analysed by stepwise logistic regression analysis., Results: In-hospital mortality occurrence was 6.8 %, and 37 % of the patients died during the weekend. The logistic regression model explained 34.3 % (R 2 ) of the variance of in-hospital mortality: patients were six times (95 % CI = 3.632-10.794) more likely at risk of dying at weekends; those with one or more AEDs admissions in the last 3 months were also at increased risk of dying (RR 1.360, 95 % CI = 1.024-1.806) as well as those receiving more care from family carers (RR = 1.017, 95 % CI = 1.009-1.025). At the nursing care level, those patient receiving less care by RNs at weekends were at increased risk of dying (RR = 2.236, 95 % CI = 1.270-3.937) while those receiving a higher skill-mix, thus indicating that more nursing care was offered by RNs instead of NAs were at less risk of dying (RR = 0.940, 95 % CI = 0.912-0.969)., Conclusions: Within the limitations of this secondary analysis, in addition to the role of some clinical factors, findings suggest redesigning acute care at weekends ensuring consistent care both at the hospital and at the nursing care levels.

To describe the prevalence and incidence density of hospital-acquired unavoidable pressure sores among patients aged ≥65 years admitted to acute medical units. A secondary analysis of longitudinal study data collected in 2012 and 2013 from 12 acute medical units located in 12 Italian hospitals was performed. Unavoidable pressure ulcers were defined as those that occurred in haemodynamically unstable patients, suffering from cachexia and/or terminally ill and were acquired after hospital admission. Data at patient and at pressure ulcer levels were collected on a daily basis at the bedside by trained researchers. A total of 1464 patients out of 2080 eligible (70.4%) were included. Among these, 96 patients (6.5%) hospital-acquired a pressure ulcer and, among 19 (19.7%) were judged as unavoidable. The incidence of unavoidable pressure ulcer was 8.5/ 100 in hospital-patient days. No statistically significant differences at patient and pressure ulcers levels have emerged between those patients that acquired unavoidable and avoidable pressure sores. Although limited, evidence on unavoidable pressure ulcer is increasing. More research in the field is recommended to support clinicians, managers and policymakers in the several implications of unavoidable pressure ulcers both at the patient and at the system levels., (Copyright © 2017 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Background: Normal saline is considered a safe alternative for heparin as a locking solution in totally implantable venous access devices. The incidence rate of partial occlusion with the use of normal saline (easy injection, impossible aspiration) is estimated at 4%., Objective: The aim of this study was to investigate determinants of partial occlusions with the use of normal saline solution and the maintenance of positive pressure in the catheter., Methods: We enrolled 218 patients with different solid tumors who underwent pharmacologic treatment through the port with different frequencies: from once every week to at least once every month. The port was flushed with normal saline solution keeping a positive pressure in the catheter., Results: We performed 4111 observations and documented normal port functioning in 99% of observations (n = 4057) and partial occlusions in 1% of observations (n = 54). Partial occlusions were significantly associated with frequency of port flushing (P < .05), chemotherapy (P < .001), and blood sample collection (P < .001)., Conclusions: The use of positive pressure in addition to normal saline reduces the incidence rate of partial occlusions. The type of treatment, blood sample collection, and treatment schedule are important determinants of partial occlusions., Implications for Practice: Nurses play a key role in maintaining a functioning port using positive pressure during the flushing techniques. Certain risk factors must be monitored to prevent partial occlusions, and certain patients are more likely to present with port-related problems.

Background: Informal caregiving offered by family members has been widely studied in the community setting, but little attention to date has been dedicated to that offered at the hospital level., Aims: To describe the proportion of patients admitted to acute medical units receiving care from informal caregivers as decided by the family and to identify the factors affecting the numbers of care shifts performed by informal caregivers., Design and Methods: A longitudinal study was performed involving 12 acute medical units located in 12 northern Italian hospitals., Results: All patients (N = 1464) admitted to medical units were included, and 77.1% of them received at least one shift of informal care during their in-hospital stay, especially during the mornings and afternoons. At the patient level, those at higher risk of prolonged hospitalisation and difficult discharge at admission, and those reporting higher occurrence of adverse events, such as pressure sores, confusion events and use of physical restraints during hospitalisation, were more likely receiving informal care. At the nursing care level, a higher amount of missed nursing care was associated with an increased number of care shifts offered by informal caregivers during patient hospitalisation, whereas the amount of care offered by staff was a protective factor., Conclusions: Families play a care role in the care of older patients admitted to acute medical units. They contribute substantially to the care of patients, especially during morning and afternoon shifts., (© 2016 Nordic College of Caring Science.)

The national expenditure limits set by the spending review has required reorganization and streamlining measures. The present study was conducted in 2015, among 2,020 nurses and 861 doctors in the autonomous province of Trento (Italy), to describe their perceptions of the containment measures introduced in healthcare spending, following the spending review. Results show that nurses and doctors were most affected by the measures regarding staff management (staff turnover rate, reducing overtime and changes in training). These measures, however, cannot be adopted for a long period of time without leading to negative effects on organization and quality of care.

Background: The clinical learning environment is fundamental to nursing education paths, capable of affecting learning processes and outcomes. Several instruments have been developed in nursing education, aimed at evaluating the quality of the clinical learning environments; however, no systematic review of the psychometric properties and methodological quality of these studies has been performed to date., Objectives: The aims of the study were: 1) to identify validated instruments evaluating the clinical learning environments in nursing education; 2) to evaluate critically the methodological quality of the psychometric property estimation used; and 3) to compare psychometric properties across the instruments available., Design: A systematic review of the literature (using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) and an evaluation of the methodological quality of psychometric properties (using the COnsensus-based Standards for the selection of health Measurement INstruments guidelines)., Data Sources: The Medline and CINAHL databases were searched. Eligible studies were those that satisfied the following criteria: a) validation studies of instruments evaluating the quality of clinical learning environments; b) in nursing education; c) published in English or Italian; d) before April 2016., Review Methods: The included studies were evaluated for the methodological quality of the psychometric properties measured and then compared in terms of both the psychometric properties and the methodological quality of the processes used., Results: The search strategy yielded a total of 26 studies and eight clinical learning environment evaluation instruments. A variety of psychometric properties have been estimated for each instrument, with differing qualities in the methodology used. Concept and construct validity were poorly assessed in terms of their significance and rarely judged by the target population (nursing students). Some properties were rarely considered (e.g., reliability, measurement error, criterion validity), whereas others were frequently estimated, but using different coefficients and statistical analyses (e.g., internal consistency, structural validity), thus rendering comparison across instruments difficult. Moreover, the methodological quality adopted in the property assessments was poor or fair in most studies, compromising the goodness of the psychometric values estimated., Conclusions: Clinical learning placements represent the key strategies in educating the future nursing workforce: instruments evaluating the quality of the settings, as well as their capacity to promote significant learning, are strongly recommended. Studies estimating psychometric properties, using an increased quality of research methodologies are needed in order to support nursing educators in the process of clinical placements accreditation and quality improvement., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Few resources are available to quantify clinical trial-associated workload, needed to guide staffing and budgetary planning. The aim of the study is to describe a tool to measure clinical trials nurses' workload expressed in time spent to complete core activities. Clinical trials nurses drew up a list of nursing core activities, integrating results from literature searches with personal experience. The final 30 core activities were timed for each research nurse by an outside observer during daily practice in May and June 2014. Average times spent by nurses for each activity were calculated. The "Nursing Time Required by Clinical Trial-Assessment Tool" was created as an electronic sheet that combines the average times per specified activities and mathematic functions to return the total estimated time required by a research nurse for each specific trial. The tool was tested retrospectively on 141 clinical trials. The increasing complexity of clinical research requires structured approaches to determine workforce requirements. This study provides a tool to describe the activities of a clinical trials nurse and to estimate the associated time required to deliver individual trials. The application of the proposed tool in clinical research practice could provide a consistent structure for clinical trials nursing workload estimation internationally., (© 2016 John Wiley & Sons Australia, Ltd.)

. The Clinical Learning Quality Evaluation Index for nursing students., Introduction: The Italian nursing programs, the need to introduce tools evaluating the quality of the clinical learning as perceived by nursing students. Several tools already exist, however, several limitations suggesting the need to develop a new tool., Aim: A national project aimed at developing and validating a new instrument capable of measuring the clinical learning quality as experience by nursing students., Methods: A validation study design was undertaken from 2015 to 2016. All nursing national programs (n=43) were invited to participate by including all nursing students attending regularly their clinical learning. The tool developed based upon a) literature, b) validated tools already established among other healthcare professionals, and c) consensus expressed by experts and nursing students, was administered to the eligible students., Results: 9606 nursing in 27 universities (62.8%) participated. The psychometric properties of the new instrument ranged from good to excellent. According to the findings, the tool consists in 22 items and five factors: a) quality of the tutorial strategies, b) learning opportunities; c) safety and nursing care quality; d) self-direct learning; e) quality of the learning environment., Conclusions: The tool is already used. Its systematic adoption may support comparison among settings and across different programs; moreover, the tool may also support in accrediting new settings as well as in measuring the effects of strategies aimed at improving the quality of the clinical learning.

. An overview of education models for nursing students clinical practice: a literature review., Introduction: In the past decade the nursing education research developed and tested a number of clinical educational models., Aim: To describe the most used clinical educational models and to analyze their strengths and weaknesses in fostering the learning processes of nursing students., Methods: A literature review of studies on clinical education models for undergraduate nursing student, published in English, was performed. Electronic database Pubmed and Cinhal were searched until November 2016., Results: Nineteen studies were included in the review and five clinical education model identified: 1) the university tutor supervises a group of students and selects learning opportunities; 2) a clinical expert/tutor nurse works side by side with one student; 3) the student is responsible of his/her learning process with the supervision of the ward staff; 4) a clinical tutor of the ward is dedicated to the students' supervision; 5) the student is not assigned to a ward but clinical learning opportunities matched with his/her needs are selected by the university., Conclusions: All the clinical education models shared the focus on students' learning needs. Their specific characteristics better suit them for different stages of students' education and to different clinical settings.

Rationale: There is growing interest in validating tools aimed at supporting the clinical decision-making process and research. However, an increased bureaucratization of clinical practice and redundancies in the measures collected have been reported by clinicians. Redundancies in clinical assessments affect negatively both patients and nurses., Methods: To validate a meta-tool measuring the risks/problems currently estimated by multiple tools used in daily practice. A secondary analysis of a database was performed, using a cross-validation and a longitudinal study designs. In total, 1464 patients admitted to 12 medical units in 2012 were assessed at admission with the Brass, Barthel, Conley and Braden tools. Pertinent outcomes such as the occurrence of post-discharge need for resources and functional decline at discharge, as well as falls and pressure sores, were measured. Explorative factor analysis of each tool, inter-tool correlations and a conceptual evaluation of the redundant/similar items across tools were performed. Therefore, the validation of the meta-tool was performed through explorative factor analysis, confirmatory factor analysis and the structural equation model to establish the ability of the meta-tool to predict the outcomes estimated by the original tools., Results: High correlations between the tools have emerged (from r 0.428 to 0.867) with a common variance from 18.3% to 75.1%. Through a conceptual evaluation and explorative factor analysis, the items were reduced from 42 to 20, and the three factors that emerged were confirmed by confirmatory factor analysis. According to the structural equation model results, two out of three emerged factors predicted the outcomes., Conclusions: From the initial 42 items, the meta-tool is composed of 20 items capable of predicting the outcomes as with the original tools., (© 2016 John Wiley & Sons, Ltd.)

Describing the trajectories of hospital-associated functional decline in older patients admitted to acute medical units and identifying predictors at the individual, nursing, and hospital levels, were the aims of the study. A longitudinal survey among 12 acute medical units in which 1464 patients were consecutively enrolled and evaluated using the Barthel Index (BI), was performed. Functional decline was defined as a decrease in the BI of at least 5 points from admission to discharge. In all, 17.1% participants (n = 251) demonstrated functional decline. In accordance with multiple logistic regression analysis, 28.8% (R(2)) of the variance in the functional decline was explained by: confusion/disorientation (RR = 4.684; 95% CI = 3.144-6.978), admission from nursing homes (RR = 2.464; 95% CI = 1.642-3.697), daily care expressed in minutes offered by nursing aides (RR = 1.535; 95% CI = 1.275-1.849), higher workforce skill-mix (RR = 2.221; 95% CI = 1.763-2.797), bladder catheter insertion (RR = 1.599; 95% CI = 1.128-2.268), and higher BI score at admission (RR = 1.019; 95% CI = 1.014-1.024). Increasing the amount of care delivered by competent nurses-having a bachelors degree-providing and supervising direct-care activities, may reduce the occurrence of functional decline in older patients admitted to medical units., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The Conley Scale is one of the most widespread fall-risk screening tools in medical unit settings, despite the lack of data regarding its validity in patients currently admitted to these units., Aims: Establishing the validity of the Conley Scale in identifying patients at risk of falling in an acute medical setting., Methods: A 6-months longitudinal study in 12 acute medical units from September 2012 to March 2013, a total of 1464 patients with ≥65 years of age were consecutively enrolled and evaluated with the Conley Scale within 24 h of admission. A construct validity, internal consistency, and a priori and a posteriori predictive validity study was performed., Results: The explorative factor analysis showed a two-factor structure explaining a total variance of 48.3 %: previous history (30.41 %), and physical and cognitive impairment (17.9 %). The scale reported a poor internal consistency (Cronbach's α = 0.465) and the capability to correctly identify 18/649 patients as being at risk of falling, whereas the negative predictive value was 98.5 %. The sensitivity and specificity values were 60.0 and 55.9 %, respectively. No difference emerged between patients scored as at risk and those scored as not at risk in the time elapsed from admission to the first fall (HR = 0.600, 95 % CI 0.289-2.247 p = .166)., Discussion: The Conley Scale is not able to predict falls in elderly acute medical patients, and has reported poor internal consistency and accuracy., Conclusions: More studies are needed to develop appropriate tools to predict the risk of falling in elderly individuals admitted to an acute medical setting.

Unlabelled: . Validation of the Italian Clinical Learning Environment Instrument (SVIAT): study protocol., Introduction: Nursing students obtain most of their university credits in internship environments whose quality can affect their clinical learning. Several tools are available to measure the quality of the clinical learning environment (CLE) as perceived by students: these instruments developed in other countries, were validated in Italian but do not discriminate those CLEs capable (or not) to promote significant clinical learning., Aim: To validate an instrument to measure the capability of the CLE to generate clinical learning; the secondary aim is to describe the learning environments as perceived by nursing students according to individual course site and tutorial models adopted., Methods: The study will be developed in three phases: a) instrument development and pilot phase, b) validation of the psychometric properties of the instrument and c) description of the CLEs as perceived by the students including factors/item confirmed in the validation process. Expected outcomes. A large validation, with more than 8,000 participating students is expected; the construct under lying will be confirmed through exploratory and confirmatory factor analysis and will report high internal consistency; the instrument will report also a high test-retest and inter-rater reliability; in addition, the instrument will demonstrate predictive ability by discriminating those units able (or not) to activate effective learning processes.

Missed nursing care (MNC), such as nursing care omitted or delayed, has not been measured in the Italian context where several cost containment interventions affect the care offered in medical units. The aim of the study is to identify the amount, type, and reasons for MNC in the Italian medical care setting and to explore the factors that affect the occurrence of MNC. A 3-month longitudinal survey was carried out followed by a cross-sectional study design in 12 north eastern acute medical units. A total of 314 nursing staff members were involved. Multivariate logistic regression was performed to identify the predictors of MNC. Patient ambulation (91.4 %), turning the patient every 2 h (74.2 %), and right timing in administering medications (64.6 %) were the most perceived MNC. Among the most frequent reasons were the unexpected rise in patient volume or critical conditions (95.2 %), inadequate numbers of staff (94.9 %), and large numbers of admissions/discharges (93.3 %). The R (2) 33.2 % of the variance in MNC were explained by a full-time position (OR 4.743, 95 % CI 1.146-19.629), communication tensions between Registered Nurses and Nurses' Aides (OR 1.601, 95 % CI 1.020-2.515), the amount of experience in medical unit (OR 1.564, 95 % CI 1.021-2.397), and the amount of daily care offered by Nurses' Aides (1.039, 95 % CI 1.011-1.067). A substantial amount of basic and clinically relevant nursing interventions was perceived to be missed, and this may lead to an increase in negative outcomes for patients admitted to a medical unit. Appropriate standards of nursing care should be adopted urgently in medical units aiming to protect frail patients.

The aim of the study was to explore the experiences of night nurses. An interpretative phenomenological study was undertaken, and 35 nurses working in Italian medical, surgical and intensive care units were purposely recruited. Data were gathered in 2010 by semi-structured interviews, collecting nurses' narratives, memorable cases and metaphors, aimed at summarising the essence of work as a nurse during the night. The experience of night nursing is based on four interconnected themes: (i) working in a state of alert, (ii) growing by expanding autonomy and responsibility, (iii) assuring sensitive surveillance and (iv) experiencing deep intimacy. Memorable episodes were polarised along (i) expected/unexpected events; (ii) positive/negative epilogues; and (iii) life/death issues. Many of the emergent metaphors described working during the night as being in the middle of a space where an apparent calm scene takes place, but unpredictable factors may suddenly change the order of events and the outcomes, creating chaos. Working during the night alerts nurses, who increase autonomy, expanding their role and assuming more responsibility with respect to that assumed during daily shifts. The nurses' clinical reasoning is based on data they carefully listen to, and on the meaning that nurses give time by time to different noises and silence. While in the past a sense of companionships was reported, a loneliness or a 'neutral' experience concerning the relationships with colleagues seems to prevail during night nursing. Working night shifts is a complex task, and specific training must be assured to students/novices., (© 2015 John Wiley & Sons Ltd.)

Aim: Just as in many countries all over the world, the number of older people in Italy has increased rapidly. Consequently, an increasing number of nurses are engaged in the care of older patients. However, due to a lack of understanding of how nurses and patients perceive caring, nursing care may be compromised. The aim of this study is to explore, describe and compare the perceptions of gerontological nurses and patients related to the dimensions of caring in nursing in an Italian hospital setting., Methods: In this qualitative descriptive study, a variety of analytic techniques were used to analyse semi-structured interview data from a purposeful sample of 20 nurses and 20 patients from geriatric units in two different Italian hospitals., Findings: Although both nurses and patients gave rich descriptions of caring experiences, patients described features of caring in nursing that were visible (including nurses' caring gestures, giving attention and being competent) while nurses predominantly emphasised aspects of caring that were relatively invisible (such as reflecting on the patient's past needs, evaluating the nursing care rendered, planning for more appropriate future nursing care, taking multiple complex contextual factors into account to protect the patient and being competent)., Conclusion: Our data revealed more nuanced insight into the meaning of invisible and visible caring in nursing within the gerontological context than has been previously reported in the literature. This has implications for nursing education and practice because it may help nurses meet the actual needs of older patients in hospital settings., (© 2013 Nordic College of Caring Science.)

Unlabelled: Roles and competences of nurses with postgraduate master degree in nursing science in everyday practice. Multicentre descriptive survey., Introduction: Few information are available on the role and activities of Italian nurses with Laurea Magistrale (postgraduate master degree in nursing science)., Aim: To describe the implementation of the advanced competences acquired after Laurea Magistrale by nurses, as well as changes in their professional career., Methods: A multicenter descriptive study on 7 consecutive cohorts (from 2004/2005 to 2011/2012) of nurses of 3 universities of northern Italy was conducted. Data on managerial, teaching, research and clinical competences and changes in the professional role were collected with semi-structured questionnaires., Results: 232/285 graduates completed the questionnaire; 216 (88.8%) used their managerial competences, 178 (76.7%) educational competences, 122 (52.6%) clinical competences and 115 (49.5%) research competences. Eigthy graduates (34.4%) changed their professional roles, occupying managerial positions (from 89 to 212, +123, 14.5%) and in the education field (from 33 to 44 +11, 4.8%) while the number of nurses with a clinical role decreased (from 110 to 65, -45, -19.4%). The role changes occured mainly after three years from graduation (p = 0.006) with significant differences across areas (p = 0.018)., Discussion: Until recently the main field of occupation of Laureati magistrali was in management but the changing needs of the organizations require a major focus on the clinical competences. The characteristics of contexts that favour or prevent the implementation of the new compentences and the upgrade of the roles should be studied.

Aims: With the aim to identify the instruments validated for Italian nursing practice, a systematic review of the literature was undertaken., Results: A total of 101 instruments emerged. The majority (89; 88.1%) were developed in other countries; the remaining (14; 13.9%) were developed and validated in the Italian context. The instruments were developed to measure patient's problems (63/101; 62.4%), outcomes (27/101; 26.7%), risks (4/101; 4%) and others issues (7/101; 6.9%). The majority of participants involved in the validation processes were younger adults (49; 48.5%), older adults (40; 39.5%), children (4; 4%), adolescents (3; 3%), and children/adolescents (1; 1%). The instruments were structured primarily in the form of questionnaires (61; 60.4%), as a grid for direct observation (27; 26.7%) or in other forms (12; 11.9%). Among the 101 instruments emerged, there were 1 to 7 validation measures documented with on average 3.2 (95% CI 2.86-3.54) for each instrument., Conclusions: Developing validation studies giving priority to those instruments widely adopted in the clinical nursing practice is recommended.

Background: According to available evidence, when the nurse-to-patient ratio is insufficient the occurrence of accidental falls, pressure sores, malnutrition, hospital-acquired dependency in activities of daily living, infections associated with nursing practice and errors in administration of medication as well as mortality all increase. However, while several countries have established a body of evidence and policies concerning the minimum nurse-to-patient ratio, the amount of nursing care offered in Italian medical units remains under-studied., Methods: Evaluating variability in the nurse-to-patient ratio and in the skill-mix offered, 12 medical units willing to participate were evaluated with a face-to-face interview performed by a researcher to the nurse manager of the unit. The role of the unit at the hospital level, the nurse-to-patient ratio available on a daily basis, the skill-mix and the strategies enacted in the case of patient overcrowding or understaffing were collected., Results: The mission of the medical units is devoted mainly towards elderly people. The bed occupancy is high and the strategies adopted in case of patient overcrowding determine unstable environments both for medical units (extra beds) and other units (patients temporarily hosted). In the medical units, nurses attend to 5-13 patients in the morning, 7.6-14.6 in the afternoon, and 12.3-30.5 during the night. The skill-mix ranges from 43.5 % (more nursing aides than nurses are available on the ward) to 81.2 % (more nurses than nursing aides are available)., Conclusions: This assessment exercise indicates that nursing care in medical units faces high workloads. Establishing national minimum standards of nursing care to be delivered towards older people admitted in Italian medical units is recommended.

Reflections on qualitative research. Interview of Luisa Saiani to Luigina Mortari. Luigina Mortari, an internationally known expert of epistemology and qualitative research, was interviewed to explore her thoughts on issues relevant for qualitative research: when a research question can be considered relevant; key methodological elements; ethical issues.

When patients talk about care: a qualitative phenomenological study. Introduction. Caring has been studied so far mainly from the nurses'point of view, but is equally important to elicit the patients' perspective to improve the understanding of actions and behaviors nurses can implement to respond to patients' expectations and idea of caring. Patients and nurses' perspectives may, in fact, be different. Aims. To describe and understand the caring experience of patients admitted to hospital, focusing on behaviors associated to a good caring. Methods. A qualitative, phenomenological hermeneutical research was conducted. Patients were interviewed with semi structured interviews and asked to tell when they had received a good care from nurses. Results. Ninety-three patients from different wards were interviewed. The caring dimensions described refer to the opportunity to experience a relationship of closeness with nurses, of being perceived as unique persons, understood, to relieve the sense of loneliness, sometimes experienced. Patients perceive that they are cared when receiving information consistent with their needs, that they are able to understand, when nurses are attentive and make them feel safe through constant monitoring and surveillance. Conclusions. The organizations should promote caring models oriented to the personalization of care, perceived as an essential element of care.

Turnover represents a problematic phenomenon due to both staff management and costs related to the quality of care. Turnover is quite studied in other Countries, but it is still little studied in Italy. The aim of this study was to analyzing psychosocial factors related to intention to leave the hospital, by using theoretical models from literature and applying them in the health context. The study involved 1295 nurses from North-Italy. The results showed that intention to leave may be considered the most direct predictor of turnover behavior. In fact, the demand for mobility to another hospital was requested by nurses with high level of intention to leave. Among examined individual and organizational characteristics, we found that young nurses with high education had higher turnover intention than old nurses. Moreover, nurses with high level of intention to leave not only perceived a low affective commitment to the unit, but also a low quality of relationship with both supersiors and physicians. The findings have important implications for both nurses and hospitals by helping to promote effective work environments, thus reducing turnover intention.

Aim: To provide an overview of the debate in the literature on the aging of the nursing profession., Method: Review of the main articles published since year 2000., Results: The rapid aging of the nursing workforce is a new phenomenon that Italian organizations have to face. Many nurses ready for retirement would be willing to remain in a more adequate work environment and salary. The story of a nurse retained at work is presented., Conclusions: A leadership careful of this phenomenon and able to re-plan work environments and supportive mechanisms need to be developed to take on this new challenge.

Background: In the public sector the selection of the health personnel is based on qualifications and exams with a written, an oral and practical test, on contents selected by the committee. The level of complexity and contents of the tests is very variable across committees., Aim: To analyze the tests for the selection of nurses, the level of complexity and contents assessed., Methods: A sample of tests was analysed and for each item, the cognitive level tested, according to Bloom's taxonomy, areas and health problems investigated., Results: One-hundred-twenty-eight selection tests of 14 hospitals and districts were analysed. Open questions are used in the majority of tests to assess mainly knowledge and not complex cognitive functions or problem solving skills. The contents vary widely and are not focused on priority health problems. Questions on prevention, health education and symptoms monitoring are missing., Conclusions: Written, oral and practical tests focus on the same contents and test mainly knowledge.

Introduction: The change process generally elicits reactions not always positive, although expected., Aim: To describe the reactions to change before and after one year from implementation., Methods: A questionnaire was administered to a group of nurses before and after their wards was moved to a new surgical department with a totally different organization., Results: The nurses remained moderately worried before and after the change. Worries for the impact of the change on the patients and themselves significantly increased. Nurses with 4-14 years of experience expressed higher levels of concern., Conclusions: The worries are a normal reaction but their better understanding may give indications on support strategies.

Introduction: The firing of a nursing manager was first documented in the 80' in US., Aim: To describe the involuntary turnover according to the literature and a case-story., Methods: Literature review and interview to a key informant., Results: The involuntary turnover is preceded by a hard time with indicators of a difficult relationships with the management; it initiates a profound crisis comparable to the loss of a significant person and feelings of failure prevail, self esteem and self confidence decrease. If the manager is fired, external help may be necessary - included psychological counseling - to overcome the traumatic experience. Before effectively facing the future, some time may be needed to deal with the loss effectively., Conclusions: The firing of a nursing manager is not an exception in Italy but the literature and discussion on the problem is lacking.

Aim: To describe the evolution and results of health projects run in hospitals and managed by Nursing Coordinators., Methods: A convenience sample of 13 north Italian hospital, and a sample of 56 Nursing Coordinators with a permanent position from at least 1 year, was contacted. The following information was collected with a structured interview: projects run in 2009, topic, if bottom up or top down, number of staff involved and state (ended, still running, stopped)., Results: In 2009 Nursing Coordinators started 114 projects (mean 1.8±1.2 each): 94 (82.5%) were improvement projects, 17 (14.9%) accreditation, and 3 (2.6%) research. The projects involved 2.732 staff members (73.7%; average commitment 84 hours); 55 (48.2%) projects were still running, 52 (45.6%) completed, for 5 (4.4%) there was no assessment and 2 (1.8%) had been stopped., Conclusions: Nurses are regularly involved in several projects. A systematic monitoring of the results obtained and stabilization strategies are scarce. Due to the large number of resources invested, a correct management and the choice of areas relevant for patients' problems and needs are pivotal.

Aim: The purpose of this study was to test a theoretical model linking the impact of expectations on commitment to change and to explore whether change-related communication is a mediating variable between leader-member exchange and expectations., Background: Expectations for change outcomes are an important condition to increase nurses' commitment to change. To understand the role of leadership and communication in expectations development is crucial to promote commitment to change., Method: A predictive, non-experimental design was used in a random sample of 395 nurses. Structural equation modelling was used to analyse the hypothesized model., Results: Positive expectations had a direct effect on affective commitment to change, whereas negative expectation had a direct effect on continuance commitment to change. Leader-member exchange and communication influenced nurse's expectations about change. Communication partially mediated the relationship between Leader-member exchange and expectations., Conclusion: These findings suggested that nurses' expectation about change were strongly linked to commitment to change. Furthermore, the enhancement of communication and relationship with leader contributed to the development of positive and negative expectations., Implications for Nursing Management: Strategies to promote commitment to change include developing positive expectations about change outcomes and building high-quality leadership style oriented to the communication., (© 2011 Blackwell Publishing Ltd.)

A thirty years long story of Assistenza Infermieristica e Ricerca, of the research projects launched and of the research networks implemented, is the occasion for an assessment of results achieved and of the future strategies. The journal achieved in getting started several successful projects (a rather unique achievement for a research journal, not only at national level). Most projects were companion studies of clinical trials but also independent epidemiological studies and a clinical trial were organized and published. The most challenging aspect is the ability to keep networks "alive" and able to continue to make and propose research.

Objective: The research studies published on Assistenza Infermieristica e Ricerca along the last 21 years were analysed to identify main trends., Method: Research articles were extracted and each was classified according to the main area, authors, place of origin, design., Results: The number of research papers is progressively increasing and represents 50% of the papers published in 2006-2001. Most papers are focused on clinical practice and deal with issues relevant for the practice such as symptom control, organization or problems of elderly and frail populations. The number of experimental-quasi-experimental studies is limited (12%) but the variety of research designs increased in the last 5 years, with qualitative and validation studies., Conclusions: Although the number good quality research papers is increasing, most studies are monocentric and research needs to be incremented and promoted.

Nurse staffing levels have always been an issue and the optimal level and mix of nurses required to deliver quality care as cost-effectively as possible continues to be discussed at both national and international levels. In Italy, a network of experts rom ten local health and hospital authorities was set up in June 2010. The, main objectives of the network were to define, validate and approve a panel of relevant indicators, identify minimum standards of safety and develop recommendations to guide decision-making regarding hospital nurse staffing levels. The indicators and recommendations developed by the network are presented in this paper.

Aims: This article is a report of a study of participants' responses to a reflective practice exercise about a mentoring programme., Background: Participants' opinions on mentoring programmes are considered a fundamental component of their evaluation. These opinions are commonly gathered through questionnaires, interviews and focus groups., Method: An 18-month, multi-professional, mentoring programme was started in 2000. About thirty participants (60% nurses) were involved each time in three consecutive classes. Participants' learning achievements were assessed by short essays. Participants' perception of themselves was evaluated during the last course (ended in 2008) by a reflective writing exercise: 'write a letter to yourself'. A phenomenological-hermeneutic analysis was conducted on the 27 returned letters. The letters were inductively analysed, the resulting core concepts were labelled and then grouped into categories to identify the main themes., Findings: Six themes were identified: (1) the mentoring programme can be a strategy for career advancement and professional development, but (2) it was also a challenging experience that put participants to the test; (3) the mentoring programme taught not only how to mentor students, but also how to be a mentor; (4) mentoring is an 'in progress' experience; (5) the mentoring programme was very positive for group processes and it created a web of professionals and (6) after the mentoring programme, many participants felt profoundly changed both professionally and personally., Conclusions: Mentoring is a profound relationship that can deeply change the mentee, and training to mentorship can affect the identity of the future mentor, as well., (© 2011 Blackwell Publishing Ltd.)

Introduction: The retention of nursing workforce is one of the challenges of nursing managers. Since the turnover intention is associated to the real turnover, a deeper understanding of reasons why young nurses would leave the hospital could give some hints to help to retain them., Aim: To explore the factors that affect the turnover intention in nurses with a work experience <3 years., Methods: Nurses with <3 years of experience, working in 3 large Italian hospitals completed a questionnaire aimed at exploring the turnover intention, job satisfaction, perception of self-competence, organizational commitment, perception of organizational support and of the quality of delivered care, asking to express their agreement on a likert scale from 1 to 5., Results: The results showed that 34.4% of the nurses intended to leave the hospital within 1 year, 43.8% of them had already asked to be transferred a to another hospital. The majority of nurses who intended to leave were male, with a full time employment and living farther than 30 kilometers from the hospital. Moreover they were less satisfied with their current job, for the relationship with the colleagues, the Nurse Manager and the physicians, perceived themselves less competent, less committed to their unit and less supported by the organization compared with than nurses who intended to stay., Conclusions: This study supports the importance of increasing job satisfaction and organizational commitment for nurses'retention.

The purpose of this study was to examine the variables that are related to person-environment fit in Italian nurses, highlighting the role of supervisor support and organizational support in the relationship between nurses' perceptions of care adequacy, job satisfaction, and turnover intention. Therefore, 1240 nurses from three hospitals completed a self-administered questionnaire. The results showed that supervisor support and organizational support act differently as moderators of the care adequacy-job satisfaction-turnover intention relationship. Finally, job satisfaction was a mediating variable between care adequacy and turnover intention. These findings have important implications for hospitals because they help to promote effective work environments and to reduce turnover intention., (© 2011 Blackwell Publishing Asia Pty Ltd.)

Context: Teaching strategies and methodology used in clinical training are varied and have different levels of outcome., Methods: A descriptive study was carried out in Italy on a convenience sample of third year students at four campuses of the Verona University, using a questionnaire divided into four sections: trainees' perception of the levels of usefulness of various teaching strategies, the levels of effectiveness, the level of supervision and the perceived complexity., Results: 308 students compiled the questionnaire. All the tutorial strategies included were perceived as having medium to high levels of usefulness, ten out of the eleven learning strategies were found to be very useful. A medium-high level of usefulness was perceived for supervision (M 2.9±1). The two skills recorded as needing the most supervision were the management of therapy (M 3.8±1.03; Me 4) and performing nursing techniques (M 3.7±0.95; Me 4). The most complex activities were considered to be confronting an emergency situation (M 3.8±1.03) and the planning of care for a group of patients (M 3.3±0.941), and these two activities had had the least amount of supervision., Conclusions: A tutoring model emerged that was centred on learning by experience and with guidance., (Copyright © 2010. Published by Elsevier Ltd.)

Introduction: Although the concept of complexity of care is widely used and discussed, its meaning is blurred and its characteristics are not well defined., Aims: To identify the words used to define the concept of complexity in the literature and its meaning., Method: A literature search was performed on the following databases: Pubmed, Medline, Ebsco, Cinahl and Cochrane. No temporal limits were set; publications written in English and Italian were included., Results: Several terms are used to define the concept of complexity, often interchangeably notwithstanding their different meaning. Three main concepts were identified: nursing intensity that includes the concepts of dependency, severity and complexity of patients care; nursing workload that comprises the concept of nursing intensity and all the activities not patient-related; and the patient acuity that includes the severity of illness and the caring intensity., Conclusions: A common definition is needed to be able to use the concept of complexity of care to allocate nursing resources.