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Aim To explore influences on nurses' missed care decision-making processes in acute hospital paediatric care. Background Many contemporary studies describe the phenomenon of missed care. It is clear that environment and organizational culture influence the nursing activities; however, what influences their decision-making processes has not been investigated. Method A descriptive qualitative inquiry was performed using semi-structured interviews with paediatric nurses (n = 20) from one Italian paediatric hospital. Findings Thematic analysis revealed four themes: nurses' value system; hospital logistics, structures and resources; prioritization processes; and the informal caregiver's role. Conclusion This paper offers insights into the various factors involved in nurses' decision-making process when contemplating missed care that will be of use to managers when planning care or addressing missed care in the paediatric clinical setting. Implications for nursing management Knowledge and awareness of missed care in children's nursing needs greater exploration, especially in relation to what influences nurses' decision-making choices around missed care. Overall, a greater understanding of this will help managers to manage situations effectively and ethically so that missed care does not impact on outcomes for children in health care.

Aim The aim of this study is to explore how a nutritional intervention that improves the biochemical and functional profile of dysphagic older people impacts on nursing workload and costs for nursing homes. Background Dysphagic institutionalized older people particularly at risk of malnutrition require more intensive support from nursing staff and higher costs for nursing homes. Method This is an open pre-post longitudinal multicentre quasi-experimental study without a control group. Results There is a significant reduction in the number of enemas (from 3.51 to 1.11 enemas), with an average nursing workload reduction from 52 to 16 min per patient every month. Each nurse also spent 20 h less per patient every month spoon-feeding. This resulted in nursing staff cost savings. Conclusions The nutritional intervention led to a significantly better quality of life for the patients manifested through increased independence and social engagement. This reduced workload for nursing staff and costs for nursing home administrators. Implications for nursing management Sensitive, targeted nutritional interventions have the potential to improve nursing home residents' quality of life and enable a more efficient use of resources. This study revealed reduced workload and cost savings due to less time spent administering enemas and spoon-feeding, in addition to reduced malnutritional consequences.

© 2019 John Wiley & Sons Ltd Aims and objectives: To review and synthesise research studies on surgical and medical inpatients’ perceptions on unmet nursing care needs. Background: Missed nursing care is a growing phenomenon that has been shown to adversely affect care outcomes—mainly in adult medical and surgical care settings. However, to date the aggregated and synthesised evidence of missed care comes from research that measures perceptions on missed care in surgical and medical settings from nurses, but not from the patients. Design: Scoping review. Methods: In September 2018, three databases were searched: MEDLINE/PubMed, CINAHL and SCOPUS and papers were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were as follows: primary studies; published in peer-reviewed journals; in English or Italian; and regarding routine care provided to adult inpatients. Quality appraisal and a thematic analysis were conducted. Results: Of the 1541 abstracts initially identified, 44 papers were included. Five themes emerged: “communication,” “self-management, autonomy and education,” “personal sphere,” “essential physical care” and “emotional and psychological care.” The majority of the unmet needs were related to the “personal sphere” and “emotional and psychological care.” These unmet needs were not identified in previous literature on nurses’ perspectives of missed care. Also, physical care deficits like oral hygiene were identified. Conclusion: It is important to take into account patients’ perspectives. The themes focusing on patients’ personal sphere, and emotional and psychological care, underline how patients need nurses to pay more attention to their cultural background, consider the person as a whole and for nursing care to be holistic and respectful of patients’ dignity. Relevance to Clinical Practice: This study intends to raise awareness amongst nurses and policymakers about the importance of addressing missed nursing care and unmet patients’ needs in adult medical or surgical inpatient settings to ensure high-quality care and patient satisfaction.

Aim To explore nursing management issues within COVID-19 narratives of Italian front-line nurses. Background The COVID-19 pandemic has dramatically affected health systems and professionals worldwide. Italian nurses have key messages for nursing leaders following their acute experiences in the pandemic. Method A descriptive qualitative study with thematic analysis. Results Twenty-three testimonies from clinical nurses were analysed. Six macrothemes were identified as follows: organisational and logistic change; leadership models adopted to manage the emergency; changes in nursing approaches; personal protective equipment issues; physical and psychological impact on nurses; and team value/spirit. Conclusions Our testimonies highlighted the huge impact of COVID-19 on the Italian nursing workforce, especially in terms of the high risks associated with caring for COVID-19 patients, exacerbated by the shortage of appropriate personal protective equipment. Nurses had to care for their colleagues and live separately from their families to avoid infecting them, revealing nurses' resilience and the important role of effective and sensitive management. Implications for nursing management Nurse managers must be prepared for the impact of pandemics on staff and need to ensure availability and replacement of quality personal protective equipment, rehearse strategies for communicating with patients while wearing personal protective equipment and establish protocols for communicating with relatives.

Aim To describe nurses' reported missed nursing care activities among hospitalized adult patients medical and surgical wards and explore gaps in service provision. Background In 2015, Italy replicated the RN4CAST study, which heralded the exposition of missed care as an international phenomenon. In Italy, nurse-patient workload is high, with high levels of burnout and dissatisfaction reported, all factors associated with missed care. Methods A cross-sectional study (n = 3,590) was conducted using the 13-item online Task Left Undone Tool aimed at collecting data on missed nursing care. Results The frequency of omission of activities ranged between 7% and 50%. There were significant differences between morning, afternoon and night shifts and the various clinical settings. Oral care was the most frequently missed care activity. Conclusions This study takes step forward in identifying and reducing missed care on medical and surgical wards, both in Italy and also internationally, which needs to take into account the specific organisational characteristics of each setting. Implications for nursing management Although more essential activities are missed less frequently, much is known about the relational deficits such as information giving, education, communication and discharge advice, which managers ought to spearhead through local initiatives to improve these practices.

PURPOSE Unmet needs for advanced-disease cancer patients are fatigue, pain, and emotional support. Little information is available about the feasibility of interventions focused on patient-reported outcome measurement developed according to the Medical Research Council (MRC) Framework in advanced-disease cancer patients. We aimed to pilot a nurse-led complex intervention focused on QoL assessment in advanced-disease cancer patients. METHODS The INFO-QoL study was based on an exploratory, nonequivalent comparison group, pre-test-post-test design. Study sites received either the INFO-QoL intervention or usual care. Adult advanced-disease cancer patients admitted to hospice inpatient units that gave their informed consent were included in the study. Subjects were 187 patients and their families and 19 healthcare professionals. We evaluated feasibility, acceptability, and patients' outcomes using the Integrated Palliative Care Outcome Scale. RESULTS Nineteen healthcare professionals were included. The mean competence score increased significantly over time (p

BACKGROUND: The terms critical incident technique and reflection are widely used but often not fully explained, resulting in ambiguity. PURPOSE: The aims of this review were to map and describe existing approaches to recording or using critical incidents and reflection in nursing and health professions literature over the last decade; identify challenges, facilitating factors, strengths, and weaknesses; and discuss relevance for nursing education. METHODS: A systematic narrative review was undertaken. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature were searched using MeSH terms, returning 223 articles (2006-2017). After exclusions, 41 were reviewed. RESULTS: Articles were categorized into 3 areas: descriptions of the development of an original tool or model, critical incidents or reflection on events used as a learning tool, and personal reflections on critical incidents. CONCLUSIONS: Benefits have been identified in all areas. More attention is needed to the pedagogy of reflection and the role of educators in reflection.

AIMS AND OBJECTIVES To understand the experiences and support needs of informal caregivers of patients with chronic obstructive pulmonary diseases chronic obstructive pulmonary disease who return home following an acute exacerbation. BACKGROUND The presence of an informal caregiver is important to provide practical and emotional support after an episode of acute exacerbation of chronic obstructive pulmonary disease. However, caregiving in such circumstances can be challenging and stressful. DESIGN Phenomenology. METHODS This is a phenomenological study based on semi-structured interviews with sixteen primary caregivers of chronic obstructive pulmonary disease patients. Interview data were analysed using Colaizzi's descriptive analysis framework, to identify significant themes and sub-themes. Data were collected between April-December 2017 in a Teaching Hospital in Italy. The study was designed and reported following the COREQ guidelines and checklist. RESULTS Analysis elicited five themes embracing various aspects of the caregivers' lived experiences: (a) a home disrupted, (b) living with constant vigilance and anxiety, (c) feeling the need to escape (d) self-justifications for caregiving role/duty, and (e) feeling abandoned by professionals. CONCLUSIONS Our results show that carers experience a range of difficulties when caring for their relative at home with chronic obstructive pulmonary disease. Some of these are linked to the physical disruption of their home but many are linked to feelings of inability to cope and the psycho-social impact of the caring role. The study also shows how participants felt unsupported by professionals. Focused support for carers is required to enable them to meet these challenges. RELEVANCE TO CLINICAL PRACTICE Healthcare professionals should be trained to provide technical and psychological support to caregivers especially during the phases of disease that may involve episodes of exacerbation. Home care and continuity of care can work if there is excellent communication and collaboration between healthcare professionals and caregivers. Developing appropriate support for family caregivers is essential to address the problems they can face.

Background: Developing nursing research skills, awareness and research utilisation are important for improving healthcare outcomes and are key to ensuring the full understanding and knowledge base necessary for optimal delivery of care. Nevertheless, little is known about research awareness in children's nurses. Aims and objectives: To address this issue, an integrative literature review was conducted for studies published between January 2007 and January 2017 to obtain up-to-date evidence about the extent of research awareness and utilisation among children's nurses. Methods: Using PubMed, Cochrane Library, ILISI and CINAHL databases, 21 studies related to children's nurses' research awareness were included in the final review, which was later developed and structured in keeping with PRISMA checklist and guidelines. Conclusions: The studies isolated show that nurses' knowledge about and utilisation of research vary and that there are many existent barriers to and facilitators of evidence-based practice in the paediatric setting. Some studies report that introducing a cultural and/or change in clinical practice change to improve research utilisation can have positive impacts on healthcare outcomes and the quality of nursing care of children. It is recommended that structured approaches to improving research utilisation be considered and additional research is needed to explore the benefits of these approaches. Relevance to clinical practice: Despite more than three decades of the evidence-based practice movement within nursing, barriers still exist among children's nurses in the use of research in practice. If the use of research to improve the delivery of children's nursing care is to become a reality, then nurses' research awareness needs to improve to underpin care delivery with optimal evidence in a cohesive informed manner. Keywords: awareness; evidence-based nursing; evidence-based practice; nurses; nursing research; paediatric.

International mobility for nursing students is still a relatively new phenomenon. While educators and students are both excited by the opportunity that mobility presents, there are often many challenges inherent within third level organisations and practice organisations. These obstacles not only serve to make international mobility arrangements complex to manage but also mean that these opportunities are only available to very small numbers of students. Furthermore the benefits of undergraduate international exchanges remain largely anecdotal and the elements that facilitate success are not entirely clear. To address these issues, a qualitative study was conducted to identify the elements that characterize a nursing student's successful learning during international clinical placement. Semi-structured interviews were carried out with six students who had completed their international clinical placements experiences in Portugal, Spain, and Italy. Three common themes emerged from the data analysis: relationship with institutions and countries, student's thoughts and feelings and learning outcomes and the role of the nursing student's clinical supervisor. These themes contain seven sub-categories, representing the characterizing elements of the student's experience of mobility in the foreign country. These results are useful to nurse educators internationally to inform clinical learning experiences within exchange programmes.

© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd. Aim: To develop an instrument to investigate knowledge and predictive factors of needlestick and sharps injuries (NSIs) in nursing students during clinical placements. Design: Instrument development and cross-sectional study for psychometric testing. Methods: A self-administered instrument including demographic data, injury epidemiology and predictive factors of NSIs was developed between October 2018–January 2019. Content validity was assessed by a panel of experts. The instrument's factor structure and discriminant validity were explored using principal components analysis. The STROBE guidelines were followed. Results: Evidence of content validity was found (S-CVI 0.75; I-CVI 0.50–1.00). A three-factor structure was shown by exploratory factor analysis. Of the 238 participants, 39% had been injured at least once, of which 67.3% in the second year. Higher perceptions of “personal exposure” (4.06, SD 3.78) were reported by third-year students. Higher scores for “perceived benefits” of preventive behaviours (13.6, SD 1.46) were reported by second-year students.

Introduction Nursing care in cardiology requires advanced skills, continuity of care and global care of the chronic patient. The relationship with the patient requires a psychological and moral commitment which, combined with time-pressure and high workloads, increases the risk of negatively impacting nurses' well-being. Emotional exhaustion in nurses has negative consequences on care, therefore nursing leaders should monitor this outcome and ensure that its incidence is limited. Purpose To test the relationship between the nursing working environment and emotional exhaustion among nurses in cardiology wards. Methods The data are drawn from the database of the larger study, RN4CAST@IT. This was a multi-center and multi-level study. A convenience sample of nurses providing bedside care was included. For the analyses presented here, the data relating to nurses working in Cardiology wards were extracted. The data were collected through a web survey between September and December 2015. The questionnaire investigated several topics about nursing staff including nurse-patient ratios, skill mix, working environment measured with PES-NWI, and emotional exhaustion with the Maslach Burnout Inventory. Descriptive statistical analyses were conducted to describe the sample and variables taken into consideration; a binomial logistic regression model was built to test the relationships between the dependent variable “high Emotional Exhaustion;' and the independent variables “PES-NWI composite score”, “workload” and “skill mix”. Results Responses by 291 cardiology nurses were analysed. Binary logistic regression, adjusted for skill mix and staffing, showed that, better working environment conditions reduced the risk that nurses working in the cardiology develop high Emotional Exhaustion by 96% (OR 0.038; 95% CI 0.011–0.136). Conclusions Considering the relationship that these analyses have shown between a favourable working environment, capable of involving professionals, of providing adequate resources and leadership, and the risk that professionals may develop a high level of emotional exhaustion, we need to reflect how it impacts on patients. These results are the starting point for analysing the organization of clinical contexts, with their peculiarities, to make them more and more suitable for people, both patients and professionals. Funding Acknowledgement Type of funding source: None

Background In some clinical settings, nurses have difficulty describing the outcomes of their caring activities. Understanding the reasons for this could help nurse leaders to improve the effectiveness and visibility of nursing practice and safeguard nurses' working conditions. Objective The aims of this study were to understand how nurses working in 2 different adult cancer centers make healthcare decisions and assess the respective outcomes on their patients. Methods Through a constructivist grounded theory approach, we involved 15 clinical cancer nurses with different experiences and educational backgrounds and 6 nurse managers, working in 2 comprehensive cancer centers, 1 in Italy and 1 in Switzerland. Data were collected in 2 phases using 20 semistructured interviews and 9 field observations. Results Six macrocategories emerged: interacting with situational factors, deciding relevant interventions, using multiple decision-making approaches, evaluating interventions and reporting them, pursuing healthcare outcomes, and clarifying professional identity and roles. Nurses' decision-making processes varied and were influenced by various factors, which mutually influenced one another. This process was interpreted using an explicative theory called "dynamic decision-making adaptation." Conclusions The present study showed how the aims, contents, and degree of autonomy in the nurses' decision-making process are strongly influenced by the dialectic interaction between professional and contextual factors, such as competency and professional identity. Implications for practice Cancer nurses could influence their clinical practice by developing nursing competencies that effectively resolve patients' problems. This is a key factor that nurses govern autonomously and therefore a responsibility that involves the entire nursing educational, organizational, and scientific leadership.

AIMS: This paper critically reviews the use of mixed method research in nursing with a particular focus on the extent to which current practice informs nurse researchers. It also aims to highlight gaps in current knowledge, understanding and reporting of this type of research. BACKGROUND: Mixed method research is becoming increasingly popular among nurses and healthcare professionals. Emergent findings from this type of research are very useful for nurses in practice. The combination of both quantitative and qualitative methods provides a scientific base for practice but also richness from the qualitative enquiry. However at the same time mixed method research is underdeveloped. METHODS: This study identified mixed methods research papers and critically evaluated their usefulness for research practice. To support the analysis we performed a two-stage search using CINAHL to find papers with titles that included the key term 'mixed method'. RELEVANCE TO CLINICAL PRACTICE: This paper highlights current gaps in knowledge, understanding and reporting of mixed method research. While these methods are useful to gain insight into clinical problems nurses lack guidance with this type of research. This study revealed that the guidance provided by current mixed method research is inconsistent and incomplete and this compounds the lack of available direction. There is an urgent need to develop robust guidelines for using mixed method research so that findings may be critically implemented in practice. CONCLUSION: An analysis of studies that used mixed method research revealed some inconsistencies in application and reporting. Attempts to use two distinct research methods in these studies often meant that one or both aspects had limitations. Overall methods were applied in a less rigorous way. This has implications for providing somewhat limited direction for novice researchers. There is also potential for application of evidence in healthcare practice that limited validity. This article is protected by copyright. All rights reserved.

AIM To identify items for a new instrument that measures emotional behaviour abilities of meaningful learning, according to Fink's Taxonomy. BACKGROUND Meaningful learning is an active process that promotes a wider and deeper understanding of concepts. It is the result of an interaction between new and previous knowledge and produces a long-term change of knowledge and skills. To measure meaningful learning capability, it is very important in the education of health professionals to identify problems or special learning needs. For this reason, it is necessary to create valid instruments. DESIGN A Delphi Study technique was implemented in four phases by means of e-mail. METHODS The study was conducted from April-September 2015. An expert panel consisting of ten researchers with experience in Fink's Taxonomy was established to identify the items of the instrument. Data were analysed for conceptual description and item characteristics and attributes were rated. Expert consensus was sought in each of these phases. An 87·5% consensus cut-off was established. RESULTS After four rounds, consensus was obtained for validation of the content of the instrument 'Assessment of Meaningful learning Behavioural and Emotional Abilities'. This instrument consists of 56 items evaluated on a 6-point Likert-type scale. Foundational Knowledge, Application, Integration, Human Dimension, Caring and Learning How to Learn were the six major categories explored. CONCLUSIONS This content validated tool can help educators (teachers, trainers and tutors) to identify and improve the strategies to support students' learning capability, which could increase their awareness of and/or responsibility in the learning process.

Aims and objectives To conduct a systematic review and meta-synthesis of findings from qualitative research about sexuality and intimate relationship among patients with dermatological diseases. Background Over the last few decades, there has been an increase in clinical research investigating aspects related to sex and sexuality in patients living with dermatological diseases. In fact, studies recognise a negative impact on various aspects of intimacy, such as sexual function, self-esteem and romantic relationships. The body of qualitative literature about sexuality in the context of dermatological diseases is emerging but consists mainly of small studies that would benefit from aggregation, synthesis and interpretation to highlight and summarise the overarching dimensions to this clinical issue. Design A systematic review and meta-synthesis of qualitative studies. Methods BioMed Central, Cochrane Library, MEDLINE, CINAHL, PsycINFO, PsycARTICLES, ERIC, Scopus, and Web of Science were searched between June-November 2017 with no publication date limits. Screening and selection of studies was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). After retrieval, the qualitative data were subject to meta-synthesis to identify overarching themes. Results Ten qualitative studies were found. We identified four themes: (a) Embarrassment and shame; (b) Impaired sense of attractiveness and sexual avoidance; (c) Relationship issues; and (d) Lack of professional support. The patients in these studies adopted negative coping styles, such as avoidance and hiding their bodies. Conclusion When assessing and evaluating patient care in dermatology, it is important that sexuality and the impact the disease could have on relationships is included. Relevance to clinical practice An important part of nursing care is ensuring that patients are helped to develop positive coping strategies rather than negative ones. Patients with dermatological conditions also need advice and treatment to address any physically related sexual problems. Nurses need to be the initiators of these sensitive conversations to put patients at ease and work together to implement positive measures to reduce the sexuality-related issues patients face.

Web-based learning, on its own or in combination with traditional teaching methods, has become a consolidated practice in many countries, and has been described as a valid and effective method that supports practical learning in undergraduate nursing students. The aim of this study was to explore the perception and effectiveness of web-based learning in facilitating the development of clinical skills in undergraduate nursing students. A qualitative descriptive study was conducted including online videos in three nursing schools of a university in Northern Italy. The participants were 26 undergraduate nursing students. A dedicated website was built including four videos and the respective checklists of four nursing techniques: insertion of a urinary catheter; insertion of a nasogastric tube; taking a blood sample; and the insertion of a peripheral intravenous line. Three Focus Groups were conducted, one for each nursing school. Thanks to its ease of use and unlimited access, web-based learning effectively supported students’ clinical learning process by offering additional virtual visual support. Web-based learning could be effectively used to reduce the gap between theory and practice, and even as an upgrade for already qualified nurses.

Aim Expand knowledge about the predictive factors of nurses’ intention to leave their job, and consequently to turnover. Background Nurse turnover is costly and negatively influences quality of care. Understanding the association between intention to leave and modifiable features of hospital organization may inform strategies to reduce turnover. Methods A cross-sectional survey of 3667 medical and surgical nurses was conducted in Italy. Measures included intention to leave; work environment; burnout; job satisfaction and missed care using the RN4CAST instruments. Descriptive, logistic regression analysis was used. Results Due to job dissatisfaction, 35.5% of the nurses intended to leave their current job, and of these, 33.1% the nursing profession. Push factors included: understaffing, emotional exhaustion, poor patient safety, performing non-nursing care, being male. Pull factors included: positive perception of quality and safety of care, performing core nursing activities. Conclusion The present study expands knowledge about the predictive factors of nurses’ intention to leave their job, and consequently to turnover, which is one of today’s major issues contributing to the shortage of nurses. Implications for Nursing Management Nurses’ intention to leave their job is the consequence of a poor work environment, characterized by factors such as understaffing and performance of non-nursing activities.

Aim To describe staff nurses’ perceptions related to the leadership styles adopted by their nurse managers, identify which leadership style ensured job satisfaction in staff nurses and describe which behaviours nurse managers should change. Background Empirical literature suggests that leadership styles of nurse managers significantly influence staff satisfaction. However, few studies investigate how staff nurses perceive the leadership styles of their nurse managers, and how these impact upon the staff nurses’ job satisfaction. Methods This was a mixed method study, which included the administration of the Multi-factor Leadership Questionnaire and three focus groups. Results Ward nurse managers mostly adopted a transactional leadership style (‘Management by exception active’) aimed at monitoring errors and intervening to correct errors and punish, which had a negative impact on staff nurses’ levels of job satisfaction. In contrast, the transformational leadership style, which is mostly correlated with satisfaction (‘Idealized Influence Attributed’, which staff nurses perceived as ‘respect’, ‘caring for others’, ‘professional development’ and ‘appreciation’), was rarely practiced by nurse managers. Conclusions The transformational leadership skills of Italian nurse managers need to be improved through behaviours based on greater respect, caring for others, professional development and appreciation. The present study could also serve as model to improve the leadership style of nurse managers in other countries. Implications for nursing management The themes of transformational leadership could serve as a guide for nurse managers to help them improve their leadership style, and improve the levels of job satisfaction in staff nurses. Owing to the complexity and the importance of this issue, classroom educational interventions would not be sufficient: it should be dealt as a strategic priority by nursing directors.

Quality-of-life assessment is a central concept in palliative care. Clinical interventions focused on assessing quality of life are complex interventions. Current research is insufficient to determine how to implement interventions focused on quality-of-life assessment in palliative care. To explore

Aims To identify patient safety competencies, and determine the clinical learning environments that facilitate the development of patient safety competencies in nursing students. Background Patient safety in nursing education is of key importance for health professional environments, settings and care systems. To be effective, safe nursing practice requires a good integration between increasing knowledge and the different clinical practice settings. Nurse educators have the responsibility to develop effective learning processes and ensure patient safety. Design Rapid Evidence Assessment. Data Sources MEDLINE, CINAHL, SCOPUS and ERIC were searched, yielding 500 citations published between 1 January 2004–30 September 2014. Review methods Following the Rapid Evidence Assessment process, 17 studies were included in this review. Hawker's (2002) quality assessment tool was used to assess the quality of the selected studies. Results Undergraduate nursing students need to develop competencies to ensure patient safety. The quality of the pedagogical atmosphere in the clinical setting has an important impact on the students' overall level of competence. Active student engagement in clinical processes stimulates their critical reasoning, improves interpersonal communication and facilitates adequate supervision and feedback. Conclusion Few studies describe the nursing students' patient safety competencies and exactly what they need to learn. In addition, studies describe only briefly which clinical learning environments facilitate the development of patient safety competencies in nursing students. Further research is needed to identify additional pedagogical strategies and the specific characteristics of the clinical learning environments that encourage the development of nursing students' patient safety competencies.

Aim To identify, evaluate and describe the psychometric properties of instruments that measure learning outcomes in healthcare students. Background Meaningful learning is an active process that enables a wider and deeper understanding of concepts. It is the result of an interaction between new and prior knowledge and produces a long-standing change in knowledge and skills. In the field of education, validated and reliable instruments for assessing meaningful learning are needed. Design A psychometric systematic review. Data sources MEDLINE CINAHL, SCOPUS, ERIC, Cochrane Library, Psychology & Behavioural Sciences Collection Database from 1990–December 2013. Review method Using pre-determined inclusion criteria, three reviewers independently identified studies for full-text review. Then they extracted data for quality appraisal and graded instrument validity using the Consensus-based Standards for the selection of the health status Measurement INstruments checklist and the Psychometric Grading Framework. Results Of the 57 studies identified for full-text review, 16 met the inclusion criteria and 13 different instruments were assessed. Following quality assessment, only one instrument was considered of good quality but it measured meaningful learning only in part; the others were either fair or poor. The Psychometric Grading Framework indicated that one instrument was weak, while the others were very weak. No instrument displayed adequate validity. Conclusions The systematic review produced a synthesis of the psychometric properties of tools that measure learning outcomes in students of healthcare disciplines. Measuring learning outcomes is very important when educating health professionals. The identified tools may constitute a starting point for the development of other assessment tools.

In the literature we found many studies that confirmed our concerns about nursing students' poor maths skills that directly impact on their ability to correctly calculate drug dosages with very serious consequences for patient safety. The aim of our study was to explore where students had most difficulty and identify appropriate educational interventions to bridge their mathematical knowledge gaps. This was a quali-quantitative descriptive study that included a sample of 726 undergraduate nursing students. We identified exactly where students had most difficulty and identified appropriate educational interventions to bridge their mathematical knowledge gaps. We found that the undergraduate nursing students mainly had difficulty with basic maths principles. Specific learning interventions are needed to improve their basic maths skills and their dosage calculation skills. For this purpose, we identified safeMedicate and eDose (Authentic World Ltd.), only that they are only available in English. In the near future we hope to set up a partnership to work together on the Italian version of these tools.

Aim This integrative review aims to explore how nursing leadership influences evidence-based practice in contemporary health care settings. Background Although managers and environmental ward culture have long been identified as being among the main barriers to evidence-based practice, there is little overall conceptualization and understanding of the specific role of nurse leaders in directly influencing and supporting this. Evaluation The team carried out an integrative literature review (n = 28) utilizing PubMed, CINAHL and the Cochrane Library (2006-2016). Key issues The key role of leadership, the methodology used, and understanding and addressing barriers to or facilitators of the implementation of evidence-based practice emerged as key issues. Conclusion Nurse managers have a particular influential role on the implementation of evidence-based practice in terms of providing a supportive culture and environment. For this they need to have an underlying knowledge but also to be aware of and address barriers to implementation, and understand the key role of nurse managers in creating and supporting the optimum environment. Implications for nursing management Nurse managers need to facilitate and enhance nurses' use of evidence-based practice. Both managers and nurses need to have the necessary academic preparation, support and resources required for practising using an evidence base.

Background: Paediatric nurses often face complex situations requiring decisions that sometimes clash with their own values and beliefs, or with the needs of the children they care for and their families. Paediatric nurses often use new technology that changes the way they provide care, but also reduces their direct interaction with the child. This may generate ethical issues, which nurses should be able to address in the full respect of the child. Research question and objectives: The purpose of this review is to describe the main ethical dimensions of paediatric nursing. Our research question was, ‘What are the most common ethical dimensions and competences related to paediatric nursing?’ Research design: A rapid evidence assessment. Method: According to the principles of the rapid evidence assessment, we searched the PubMed, SCOPUS and CINAHL databases for papers published between January 2001 and March 2015. These papers were then independently read by two researchers and analysed according to the inclusion criteria. Ethical considerations: Since this was a rapid evidence assessment, no approval from the ethics committee was required. Findings: Ten papers met our inclusion criteria. Ethical issues in paediatric nursing were grouped into three areas: (a) ethical issues in paediatric care, (b) social responsibility and (c) decision-making process. Conclusion: Few studies investigate the ethical dimensions and aspects of paediatric nursing, and they are mainly qualitative studies conducted in critical care settings based on nurses’ perceptions and experiences. Paediatric nurses require specific educational interventions to help them resolve ethical issues, contribute to the decision-making process and fulfil their role as advocates of a vulnerable population (i.e. sick children and their families). Further research is needed to investigate how paediatric nurses can improve the involvement of children and their families in decision-making processes related to their care plan.

Objectives To describe the experience and sources of comfort and discomfort in tracheostomy patients, when they communicate with nurses in the Intensive Care Unit. Research methodology/design Benner’s interpretive phenomenology. Data were collected through: a) semi-structured interviews conducted with the patients after leaving the intensive care unit; b) participant observation; c) situated interviews with intensive care nurses. Setting The intensive care unit of a hospital in Northern Italy. Findings Eight patients and seven nurses were included in this study. Two main themes were identified 1) feeling powerless and frustrated due to the impossibility to use voice to communicate; 2) facing continual misunderstanding, resignation, and anger during moments of difficulty and/or communication misunderstandings. The main communication discomfort factors were: struggling with not knowing what was happening, feeling like others had given up on me, living in isolation and feeling invisible. The main comfort factors were: being with family members, feeling reassured by having a call bell nearby and nurses' presence. Conclusions This study highlights the important role of communication in tracheostomy patients in intensive care and how closely it is linked to all the aspects of a person’s life, which cannot be underestimated as just not being able to use one’s voice.

Background:Prisons are contexts where nurses are required to have specific skills to ensure that, in a setting designed for the expiation of crime, prisoners receive the same type of care as anyone else. But this is not always the case, giving rise to ethical issues.Research questions:‘How do correctional nurses describe their working experience in prisons? What issues emerged?’Methodology:This is a qualitative descriptive study. Following purposive sampling, we conducted five focus groups. Thematic analysis was used to analyse the data.Participants and research context:Our sample included 31 correctional nurses in seven prisons in Northern Italy.Ethical considerations:The scientific merit of this study was recognized by the Academic Board of the University of Genoa. Approval to conduct the study was obtained from the Liguria Regional Government that funded this study and from the Local Health Authority that was the prison nurses’ employer. Formal consent was obtained from all the nurses who volunteered to participate in this study.Findings:Five themes emerged from the focus groups: (1) prisoners’ healthcare needs, (2) negotiation between custody and care, (3) satisfaction of working in prisons, (4) obstacles to quality care and (5) safety. ‘Manipulation’ was a transversal theme that emerged from all the focus groups.Discussion:The problems generated by the clash between prison security and nursing care priorities did not enable nurses to practice autonomously and provide the best possible to care prisoners, giving rise to ethical issues and moral distress. This in turn causes high nursing turnover rates that negatively impact continuum of care.Conclusion:In Italy, correctional nurses urgently require specific education interventions with the participation of all those who work in prisons. Interventions based on the post-modern concept of restorative nursing could offer prison nurses the opportunity to both resolve ethical issues and reduce moral distress.

Key wordsNursing scholarship, nursing research, nursing center infrastructure, conceptual designAbstractPurpose: This article profiles the establishment and initial phase (2010-2014) of a Center of Excellence (CoE) as an instrument to strengthen nursing scholarship and improve health care in Italy.Approach: This CoE is unique as a non-university-based center. The National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses (IPASVI) designated substantial administrative and funding support to the CoE for advancing nursing education, clinical practice, research development, and research training. Boyer's Model of Scholarship underpinned the CoE's conceptual framework, and its operational infrastructure was adapted from the U.S. National Institutes of Health P20 program award mechanism. Diverse methods included sponsoring research studies by nurse-led teams, research training courses, nursing education longitudinal studies, evidence-based practice training, and related pilot studies.Findings: Multiple collaborative projects were conducted via the CoE in conjunction with the successful launch of an expansive digital library and communication system accessible to nurses. The introduction of English proficiency courses was also a unique contribution.Conclusions: The CoE concept is a potential instrument to strengthen nursing scholarship in Italy with potential scalability considerations to other global settings.Clinical Relevance: An overlapping focus on research, education, and practice under the umbrella of nursing scholarship within a CoE while engaging all levels of nursing is important to impact healthcare changes.The professionalization of nursing has been depicted in terms of a global picture of the needs, issues, and recommendations for strategic planning and actions to advance nursing at the country or national level by the World Health Organization (WHO, 2010), with the call for action amplified by the U.S. Institute of Medicine (IOM, 2011). Common strands of recent reports stated that healthcare and health professional education are based on evidence and competency (WHO, 2009); the context of health issues in patient safety and quality of care are part of health professional training and care services (WHO, 2009); the continuum of practice is matched to the changing needs of the population (WHO, 2014); and ethics and value underpin practice, education, and research (IOM, 2011; WHO, 2009). A salient premise underscored the "need for a fundamental transformation of the nursing profession" (IOM, 2011), particularly expanding nursing's role beyond the traditional scope of practice (IOM, 2010). The "call for action" relative to the global state of professionalization informed changes in Italian nursing throughout the past decade.The purpose of this article is to describe a new approach in "scaling-up" Italian nursing to the global nursing standards (IOM, 2011; WHO, 2009). This approach was the institution of the first nursing Center of Excellence (CoE) infrastructure in Italy as a vehicle for change in the professional role of nursing through advances in nursing scholarship aimed at improving the health care of the populace. Background on the Italian context of professional nursing is presented, followed by highlights of the CoE organizational framework, outcomes, and lessons learned for nurses to assess its potential scalability in other global settings.Professional Transformation of Nursing in ItalyUnderstanding the healthcare system context within a country or nation is essential to forging change in the professional status of nursing. A priority is efforts to leverage assets and resources that will increase the chances for success in developing new nursing roles and expanding the scope of practice. For example, U.K. midwives worked diligently within the established British National Health Service to expand the scope of midwifery services to better meet the needs of women, children, and families across the past two decades (Kirkham, 1999). …

Aim To analyse through an exploratory descriptive survey how former and current doctoral students’ publications have contributed to the development of evidence between the establishment of the doctoral schools of nursing in 2006–2015. Design An exploratory descriptive survey. Methods We analysed the papers published in peer‐reviewed journals by the four Italian PhD Schools of Nursing between 2006–2015. Additional missing information was retrieved from Web of Science. Results We identified 478 scientific papers. The papers increased from 12 in 2006–110 in 2015. Most are published in 29 journals, of which 15 had an impact factor ranging between 0.236–3.755. These results show the increasingly significant contribution of nursing doctoral programmes to the production of evidence, which can be used to improve the quality of nursing and inform health policies. Nursing doctoral schools deserve a greater recognition, especially by Italian funding agencies and political institutions.

Palliative care (PC) is an approach that improves the quality of life (QoL) of patients and their families facing the problem associated with incurable terminal disease. A number of QoL assessment tools have been validated in PC and their use described for research purposes, to support clinical practice, and as part of the quality improvement programs. There is a paucity of evidence on the implementation of a nursing intervention focused on QoL assessment in PC practice. The aim of this study is to model and determine the feasibility of a nursing complex intervention focused on QoL assessment in PC practice. The intervention will be evaluated through a quasi-experimental non-equivalent comparison group before-after study design. This project can be classified as phases 1–2, according to the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. The study setting will take place in two inpatient hospice units in Italy. The study sample will be constituted of 39 multidisciplinary healthcare professionals and a sample of 46 advanced cancer patients admitted to hospices during the implementation of the intervention. This study will generate information to address the implementation of QoL measurement in palliative care practice. Findings of this study will be used to inform a phase 3 trial according to the MRC framework. ISRCTN41201864 retrospectively registered.

Some authors argue that it is not longer ethically correct to expose hospitalized patients to death risks associated with understaffing (Nickitas, 2014). Also the Care Quality Commission (CQC, an independent regulator of all health and social care services in England) has included staffing levels as one of the auditing quality standards when inspecting hospitals and health centres. The Royal College of Nursing, in its document Mandatory Nurse Staffing Levels (RCN, 2012), clearly defined which nurse staffing levels should be adopted by policy makers to ensure the provision of safe care. However, even in the UK where such pressure exists there are no legally defined nurse staffing levels.

Globally, nurses constitute the largest segment of healthcare professionals; therefore, they are also the most expensive, and in a hospital these costs can reach 25% of the total expenditure.1 When costs are calculated, usually the monthly sum of nursing working hours and nursing labour costs is divided by the total number of patient days to produce mean general measures such as ‘nursing hours per patient’ or ‘nursing costs per patient day.’ This is only a general average cost calculation that takes into account large groups of nurses caring for large groups of patients, but through this system it is difficult to accurately control costs if the specific costs are unknown.2 In this regard, Needleman3 pointed to the ‘invisibility’ of a significant portion of nursing today, which explains why this discipline in many countries around the world is still not fully recognised by administrators, policymakers and the public. Invisible work includes monitoring patients, educating patients and families, preparing discharge plans, providing psychological support to patients who are seriously ill and their family members, and advocating for their patients. In the last few decades, the decreasing lengths of hospital stay of increasingly acute inpatients have been putting strong pressure in terms of time and intensity of care on nurses and this is inevitably leading to missed care.4 5 Missed care is an error of omission, defined as ‘any aspect of required care that is omitted either in part or in whole, or delayed.’6 In 2009, Kalisch and Williams also developed and validated a tool to measure missed care.6 Therefore, missed care is linked to the concept of ‘Complexity Compression,’7 which has been described as ‘what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.’8 …

Background Patient safety, including safe drug administration, is an essential component of the nursing profession. Mathematical competence is considered an essential skill for nurses. Drug administration is among the principle duties of nurses, therefore it is essential that nurses are able to carry out, drug dosage calculations, to assure patient safety. Nursing research indicates that a poor medication calculation skill is an international issue for the nursing profession. Aim To verify if calculator use in the written Maths Skill Test (MST) reduces errors in the test and improves undergraduate nursing students’ performance. Methods This study compares the test results of the second year nursing students randomized into two groups: an experimental and a control group, respectively with and without a calculator, to understand if the calculator helps students to reduce mathematical errors. Results The range of the scores was different between the two groups. The experimental group had scores ranging from 16.15 to 29.25 out of a possible 30, the average score was 24.30 (SD 3.34) and the control group had scores ranging from 12.80 to 27.25, the average was 22.73 (SD 4.38). Conclusions Our study shows mathematical deficiencies in both groups, despite the use of a calculator. Implications for practice An integrated approach of several strategies will improve drug calculation skills of nursing students and ensure patient safety

Background: One of the most crucial palliative care challenges is in determining how patient’ needs are defined and assessed. Assessing quality of life has been defined as a priority in palliative care, and it has become a central concept in palliative care practice. Aim: To determine to what extent interventions focused on measuring quality of life in palliative care practice are effective in improving outcomes in palliative care patients. Design: Systematic review according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and hand searches. Data sources: MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library were searched for articles published until June 2012, and through hand searching from references lists of included articles. Only studies that included adult palliative care patients, in any palliative care clinical practice setting of care, and with an experimental, quasi-experimental, or observational analytical study design were eligible for inclusion. All studies were independently reviewed by two investigators who scored them for methodological quality by using the Edwards Method Score. Results: In total, 11 articles (of 8579) incorporating information from 10 studies were included. Only three were randomized controlled trials. The quality of the evidence was found from moderate to low. Given a wide variability among patients’ outcomes, individual effect size (ES) was possible for 6 out of 10 studies, 3 of which found a moderate ES on symptoms (ES = 0.68) and psychological (ES = 0.60) and social (ES = 0.55) dimensions. Conclusion: Effectiveness of interventions focused on quality-of-life assessment is moderate. Additional studies should explore the complexity of the real palliative care world more accurately and understand the effects of independent variables included in complex palliative care interventions.

Aim To validate the Staff Attitudes to Nutritional Nursing Care Geriatric scale in Italian, a tool created in Sweden to measure nurses' attitudes towards nutritional care in older people. Background Malnutrition in institutionalized older people is a serious problem having negative impact on patient outcomes. It is reported in the literature that nurses have negative attitudes towards nutritional care. Methods Forward and back-translation were carried out to build the Italian version of the tool. Content and face validity were then examined by pilot study. Test-retest reliability with Spearman's rho (rs) correlation, intraclass correlation (ICC) and internal consistency reliability with Cronbach's α were assessed. Differences between test-rest were assessed by t-test. Results Linguistic and semantic adaptation of the tool into Italian was successful. Thirty-three nurses skilled in caring for older patients did pilot testing and 46 test-retesting. SANN-G GITA-scale achieved good content and face validity, good internal consistency reliability (Cronbach's α = 0.85) and acceptable stability [rs = 0.75, P = 0.001; ICC = 0.76, 95% confidence interval (CI) 0.63–0.86; P = 0.001]. The t-test showed no significant difference between test and retest results, confirming stability of the tool (t(64) = −0.98; P = 0.33). Discussion The process of adaptation of the scale from Swedish to Italian language was successful. Thus, the SANN-GITA scale can be useful to assess attitudes of nursing staff to nutritional care in the Italian context. Conclusions This tool will allow the identification of areas where Italian nurses have negative attitudes and where to implement strategies to improve overall nutritional care.

Aim To describe a protocol for a quantitative systematic review, to identify critique and summarize factors that influence self-management education. Background Self-management education enables patients to manage their condition successfully and it is associated with better self-care, good control over lifestyle and leading the best possible quality of life, notwithstanding the presence of a chronic disease. Type II Diabetes is a chronic disease that requires lifestyle adjustments and disease management to keep glycaemia and long-term complications under control. Education has to be customized and based on an assessment that includes factors influencing self-management, such as personal characteristics that can optimize the educational intervention. Design The protocol for the systematic review was conducted according to the guidelines of the Centre for Reviews and Dissemination, York (UK). Method The review question was defined in terms of population, interventions, comparators, outcomes and study designs. The protocol included decisions about the review question, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination. Funding for the review was confirmed on January 2011 by the Centre of Excellence for Nursing Scholarship in Rome. Discussion An initial summary will be made by tabulating the data; the review will be reported in a narrative style and be developed according to the PRISMA guidelines. The protocol for the systematic review will allow us to identify, among the factors influencing self-management in people with Type II diabetes, the personal characteristics most relevant to the factors of motivation and empowerment. In addition, the systematic review will also identify an appropriate self-management model.