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Center of Excellence to Build Nursing Scholarship and Improve Health Care in Italy Gennaro Rocco, MSN, RN1 , Dyanne Affonso, PhD, RN, FAAN2 , Linda Mayberry, PhD, RN, FAAN3 , Loredana Sasso, MSN, RN4 , Alessandro Stievano, PhD, MSN, RN5 , & Rosaria Alvaro, MSN, RN6 1 Director, Center of Excellence for Nursing Scholarship, Rome, Italy 2 Honorary President, Center of Excellence for Nursing Scholarship, Rome, Italy 3 Adjunct Associate Professor, New York University, New York, NY, USA 4 Associate Professor, Genoa University, Genoa, Italy 5 Nurse Research Fellow, Center of Excellence for Nursing Scholarship, Rome, Italy 6 Associate Professor, Tor Vergata University, Rome, Italy
Key words Nursing scholarship, nursing research, nursing center infrastructure, conceptual design Correspondence Dr. Alessandro Stievano, Viale Giulio Cesare 78, Center of Excellence for Nursing Scholarship, 00192 Rome, Italy. E-mail: [email protected] Accepted: December 18, 2014 doi: 10.1111/jnu.12125
Abstract Purpose: 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 170
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 Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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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 Italy Understanding 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). Similarly, U.S. nurses capitalized on the proliferation of national health system mergers to activate many nurse-managed clinics across the country in the 1990s (IOM, 2011). In Italy, health care is delivered through a publicinsured, tax-based financed system. A major issue for the nursing profession is that the Italian National Health Service (Servizio Sanitario Nazionale, established in 1978) operate via regional jurisdiction with broad-range autonomy to the health sector in each of Italy’s 20 regions. Italy has relatively fewer nurses employed in comparison to other European countries, 6.3 per 1,000 population according to data issued by the Organisation for Economic Co-operation and Development (OECD) in 2010 (Table S1, available with online version of this article) and 6.4 per 1,000 population for 2012 (OECD, 2013). Regionalization has contributed to the persistence of predominantly hospital-based health care, with less emphasis on the development of more community-oriented care pathways. For example, it has been argued that reforming long-term care of the elderly (a major global healthcare issue) is also linked to federal versus regional fragmentation of resource allocation in Italy (Gabriele & Tediosi, 2014). Confronting the limitations of regionalization amidst efforts to increase the status of the nursing profession on Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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a consistent basis at the national level is a major challenge impacting many countries (Ayala, Fealy, Vanderstraeten, & Bracke, 2014). However, a landmark decision in Italy has helped to address this problem by directly aligning nursing to the regionalized healthcare system via the National Regulatory Board of Nursing known as IPASVI (National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses) (a nonprofit body by public law that includes approximately 100 provincial colleges representing geographic zones as branches of the institution across Italy; National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses [IPASVI], 2014). IPASVI comprises all (422,000) registered nurses licensed to practice in Italy, regulates nursing practice standards (including ethical-legal accountability), and oversees an array of professional programs as one of its primary functions. With a strong organizational infrastructure, the sanction of the federal legislature and Ministry of Health (MOH), and a firm fiscal base, IPASVI has been a catalyst for “C-Change” (defined as innovative approaches to improve the effectiveness and sustainability of major change according to the U.S. Agency for International Development) in transforming the professionalization of Italian nursing (C-Change. Communication for Change, 2014). Integral to this transformation has been the role of IPASVI in facilitating educational reforms on a national level. Countries of Europe (e.g., Finland, Ireland, Norway, Spain, Sweden, United Kingdom), Asia (e.g., Japan, Korea), and North America (Canada and United States) have served as exemplary models of how the introduction of university-based degree programs for nurses has contributed heavily to advancing professionalism over time, particularly expanded roles and scope of practice (Lahtinen, Leino-Kilpi, & Salminen, 2013; Lee, Lee, Wong, Tsang, & Li, 2010). The nursing degree program in Italy is structured according to the credit block system set up by the Bologna Declaration, and this “Bologna impact” (Davies, 2008) has been very positive in terms of overall education improvements. The advancements in nursing education exceed those of some European countries (e.g., Czech Republic, France, Germany, Hungary, Latvia, Lithuania, and others) that do not yet have the undergraduate university degree requirement first established in Italy (1992) and/or employ more than one pathway to becoming a nurse (Lahtinen et al., 2013). The significance of science-based education to support the understanding and study of patient treatment modalities and improved health outcomes was the next major advancement in 2004–2005 via development of a clinically based versus primarily an administrative track master’s degree (as is common in other European 171
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countries) in nursing science. This was followed within 2 years (2006–2007) to the start-up of nursing PhD programs administered by nursing faculty in four universities: Tor Vergata in Rome, University of Genoa in Liguria, University of Florence in Tuscany, and L’AquilaUniversity in the Abruzzo Region. Although nursing education in Italy remains primarily located within the Faculty of Medicine and Surgery, PhD coursework is provided by nursing professors trained mainly in Europe and the United States. Based on the Italian experience, the emergence of these advanced nursing degrees is considered crucial in moving nurses toward the goal of expanding professional practice that includes an increased emphasis on scholarship. With the support of professional organizations such as IPASVI, we found that professional reforms centered on establishing national competencies to guide basic curricula development (Tuning Project, 2012) can subsequently improve clinical practice, enhance nursing faculty capacity building, and eventually lead to increased scholarship. Coinciding with these efforts is the significance of developing strategic plans that can facilitate the ability to conduct research and impact practice directly through evidence generated by nurses and their interdisciplinary colleagues.
Strategic Planning for Promoting Nursing Scholarship In Italy, the strategies toward achieving these goals were based on three critical drivers. The first was mobilization of organizational funding support to launch an exemplar research project with broad-based interest to a large segment of the nursing population. In this case, IPASVI provided the funds to support the development and conduct of the first large-scale, collaborative study conceptualized, designed, and conducted by nurse teams. In doing so, IPASVI leaders of the Rome Provincial College set in motion an increased emphasis on scholarship that could highlight the research–practice interface via a “patient safety collaborative initiative.” Patient safety as a global health and nursing imperative (IOM, 2001) was introduced at the IPASVI National Congress attended by 5,000 nurses in 2005. This meeting resulted in the design of a “near misses” multisite qualitative study aimed at delineating the characteristics of nearly missed patient care errors in hospitals and clinics (Affonso et al., 2007) that involved nurse participants from the universities and affiliated hospitals and clinics in Rome and Genoa. Funding support for this type of endeavor was considered the first imperative. Nurses in other countries who want to use this strategy should also pay close attention to the importance of mobilizing key partnerships among hospital 172
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administrators, clinical nurse leaders and directors, medical colleagues, and other disciplines to anchor a project of this type as an interdisciplinary healthcare priority to build upon for the future. The second driver was to ensure support for the project at the onset by the MOH. The significance of this strategy cannot be emphasized enough to nurses in other countries who want to be successful in not only cultivating support for future clinical and research projects, but pave the way for advancing the professionalism of nursing in the healthcare system. Specific actions that forged MOH relationships included conducting semiannual workshops jointly on study progress, issues, and updates, with ongoing feedback provided by the MOH. These were the stimulus to subsequent MOH sponsorship of additional annual workshops involving multidisciplinary participants to address diverse healthcare topics relevant to both the medical and nursing professions. Annual reports prepared as formal publications and submitted to the MOH and IPASVI membership were key dissemination strategies of both process and content outcomes of the patient safety near miss study (National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses [IPASVI] Rome, 2008), and were a useful template for future communications about the role of nursing in health care. The launch of the first nursing research project spearheaded by IPASVI was viewed as a starting point that would be difficult to sustain without an infrastructure that could maintain the momentum. Based on the experiences of other countries, it is clear that this type of work is often isolated in separate university “silos” without the communication and operations structure that promotes broader outreach and continued collaboration among nurses. Therefore, we consider the third driver in strategic planning to be expanding scholarship among nursing professionals via the initiation of a CoE. After extensive discourse via consultation with selected global nurse academics and researchers, a decision was made to adapt the U.S. National Institutes of Health (NIH) Program Research (P20) award mechanism (NIH, 2014) as a model infrastructure for the Italian CoE. The goal of the NIH concept of a CoE was to mobilize human and fiscal resources to discover and innovate in the pursuit of health via research, research training, and clinical practice. These essential cores were considered congruent with the goals of the IPASVI CoE. Boyer’s Model of Scholarship was chosen as the conceptual framework for the CoE because it also added the dimension of education to the cornerstones of scholarship (Boyer, 1990). Not only has the utility of Boyer’s model, particularly with regard to curricula reforms and clinical practice innovations, been demonstrated in Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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different scientific fields (American Association of Colleges of Nursing, 1999), but its four domains of scholarship (discovery, integration, application, and teaching) could be translated into pillars of actions or essential cores of the center as shown in Figure S1 (available with online version of this article). The four pillars, built upon Boyer’s expanded definition of scholarship, anchored the CoE’s priority actions within a predefined set of objectives for the years 2010–2014 (Table S2, available with online version of this article).
CoE Pillar Initiatives and Outcomes Evaluation of the CoE varied within each of the pillars, utilizing a combination of quantitative and qualitative approaches. Quantifying designated overall system outcomes included the use of online tracking technologies for the CoE to maintain comprehensive databases of the various projects and studies. Examples of variables that were monitored by the CoE administrative core included program reach, as measured by the total number of nurses participating in CoE projects, research programs, conferences, and training courses. Accessibility defined as nurses’ connection to global literature was also measured by the number of nurses using the digital library system. Productivity was defined by a number of peer-reviewed publications resulting from study findings. Conferences, workshops, and course qualities, as measured by participant self-report responses, were also monitored. As with any infrastructure, we understood that the CoE has to follow a set of clear, measurable actions and associated outcomes stemming from the objectives and placed within a reasonable timeline. Throughout the CoE’s developmental phases of operation (Table S3, available with online version of this article), the four CoE pillars supported multiple initiatives in the form of research studies, education projects, and training courses. Administrative support was important in maintaining seamless communications at all levels (e.g., between research teams and pillar directors). National conferences, staggered throughout the first 4 years, were convened by the CoE administrative core for the purpose of monitoring progress of studies, provision of critique, and exchange of information among pillar leaders and project teams.
Research Pillar The initial developmental phase of research priorities centered on funding broadly focused studies in five key areas: (a) nursing ethics (Sabatino et al., 2014; Stievano, De Marinis, Rocco, Russo, & Alvaro, 2012); (b) quality of life in cardiac patients and families with self-care as a targeted variable (Cocchieri et al., 2013; Vellone, Chung, Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
et al., 2014); (c) patient safety (medication and intravenous therapy); (d) mental health nursing and palliative care; and (e) development of family or community nursing.
Key pillar outcomes. (a) Twenty-five nurse-led funded studies were conducted. (b) The first programs of nursing research were established focusing on cardiac self-care, quality of life, and nursing ethics. (c) A repository toolkit was created composed of new instrumentation and made accessible for use by other researchers, including colleagues of other disciplines. It included the development and preliminary testing of the Stroke Impact Scale (Vellone, Savini, et al., 2014); the European Heart Failure Self-care Behavior Scale (Vellone, Jaarsma, et al., 2014); the Care-giver Contribution to Self-Care of Heart Failure Index (Vellone, Reigel, et al., 2013); and the structural equation model testing the situationspecific theory of heart failure self-care to improve self-care of cardiac patients (Vellone, Cocchieri, et al., 2013). (d) As of June 2014, six combination didactic and online courses were accessed by nurses throughout Italy to address a myriad of topics ranging from nursing research methods to tools for bibliographic research, proposal development, and the art of grantsmanship. (e) An electronic communications network via a digital library system was developed. It included creation of an index of Italian-specific literature on nursing and health-related fields, known as ILISI (Index of Italian Literature on Nursing Sciences; Rocco et al., 2011; Stievano et al., 2011). ILISI currently includes the abstracts of over 4,600 articles (2004 to present) from 25 Italian journals of nursing or health-related disciplines. Other databases, such as the Cumulative Index to Nursing and Allied Health Literature, PubMed, OvidSP, and the Cochrane Databases, were offered as a free consultation through a dedicated digital platform by the CoE to all nurses.
Research Training Pillar A series of training courses designed specifically to increase new investigator’s skill capacity in research methodologies and knowledge of research proposal development was a top priority. This was a first step in developing a cadre of research fellows to begin participating in an ongoing training “laboratory” that could bring together funded nurse researchers with those less experienced, including doctoral students.
Key training outcomes. (a) Six research training courses or workshops were conducted onsite at IPASVIRome headquarters, specifically tailored for nurses. (b) A 173
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doctoral seminar series specific to research training was instituted and attended by PhD student cohorts from all four of the universities. (c) Two nursing research laboratories were established at IPASVI-Rome—one on qualitative methods, particularly use of focus groups, the other on clinical research methods. (d) A series of English proficiency courses specifically geared to nurses were conducted annually.
Clinical Practice Pillar The clinical practice pillar’s initial developmental priority centered on multiple strategies for infusing knowledge about evidence-based practice (EBP) into the hospital clinical arena and the initiation of several evaluation projects.
Key pillar outcomes. Six EBP projects were funded: (a) An EBP evaluation study on treatment to prevent oral mucositis in women receiving chemotherapy for breast cancer with propolis was conducted. (b) Two EBP evaluation studies on documentation of specific nursing outcomes and on staff perceptions of clinical nursing complexities were conducted. (c) A targeted training program on the principles of EBP and methods for evaluation was conducted. (d) A project designed to conduct several systematic reviews on pertinent clinical topics was completed.
Education Pillar Two major projects were undertaken that addressed objectives related to curricular reforms and the conduct of faculty studies aimed at improving undergraduate education learning. European countries served as educational models in designing these two projects. The first project centered on a 5-year study to assess core competencies for undergraduate nursing education, adapted from the European Tuning Project (2005, 2012). This study, which included collaboration with three universities and a total of 40 nursing schools, found significant variations and a lack of accountability to core competencies across nursing programs in Italy. The second project, initiated in 2012 and adapted from a Swedish nursing education study ´ Wallin, & Gustavsson, 2010), (Rudman, Omne-Ponten, was a 3-year longitudinal analysis of undergraduate nursing education and the impact of variables such as stress, burnout, and depression on baccalaureate student performance.
Key education pillar outcomes. (a) A new standard of core competencies for the licensure examination of baccalaureate nursing students was tested and 174
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instituted in 2013 in the Lazio (Rome) Region based on study findings. (b) New courses considered high priority for changes in the current undergraduate curriculum in Italian nursing schools were piloted to address ethics, risk management for patient safety, core dimensions of the helping relationship, nursing the imprisoned person, and suicide training. (c) A series of strategic planning sessions involving university deans and representatives from the MOH were convened and resulted in three new academic nursing positions at regional universities. It should be noted that the impact of the CoE went beyond the original objectives in several ways. For example, an initial aim of the digital library system was to increase awareness of current global nursing reforms and clinical practice advancements, but the free access via individual password entry also served to magnify the importance of research in changing clinical practice at the unit level since more nurses, even at the staff clinician level, could now more easily read about nursing research. Visibility of nurse-led studies at the unit level also helped to build a stronghold of collaborative partnerships that have since sparked the development of new clinical research projects, in addition to follow-up projects to the original funded studies. An unanticipated but extremely important outcome of the visibility of active nursing research projects and educational programs coincided with strong lobbying efforts on the part of CoE leaders. This outcome was funding by the MOH in 2013 to begin developing guidelines for the education and standardization of the family–community nurse role. The type of role functions that family–community nurses typically perform has been visible sporadically throughout Italy, particularly in the northern regions, and specialty courses focused on community and family health began in 2000. Now, cost containment strategies associated with the economic crisis in Italy have facilitated efforts to obtain governmental commitments to the family–community nurse role. For this reason, the CoE leadership views this as an opportune time to place a major focus in the next 5 years on the development and testing of a new prototype for community-based advanced practice nursing in Italy.
Lessons Learned and Global Implications Our experiences with the new Italian nursing CoE revealed important lessons learned applicable to nurses in other countries who may want to create a similar entity to advanced nursing scholarship. Working from a defined structure such as IPASVI for such a large undertaking was crucial, and starting with a broad mission coupled with specific objectives was essential. Early alignments developed successfully with key stakeholders such as the Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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MOH and most of the universities through the IPASVI connection. Inclusivity at all levels of nursing, rather than only the doctoral level, was also important. Accessing these relationships had an unexpectedly rapid impact on orchestrating project development (e.g., progress in determining educational priorities and instituting an increased focus on EBP among clinician groups). Without having a well-established organizational structure with national recognition and a strong financial base upon which to draw, it would have been very difficult to develop and manage the many projects in such a short period of time. We also found that the increased communications occurring via the IPASVI CoE structure were instrumental in shaping the collegiality necessary to bridge the advocacy efforts targeting new university nursing faculty positions in Italy, an objective that at first seemed unrealistic during the developmental years of the CoE. Therefore, a vital step in considering a CoE is to examine the realities of context. In Italy, the availability of working through a national organization such as IPASVI was an effective approach because the connection among the entire population of nurses was already well established and the leadership included a cross-section of clinical, administrative, and education nurses motivated to advance nursing’s drive for scholarship. Similar national structures exist in other countries (e.g., Croatia, Greece, Ireland, Romania, Spain, United Kingdom), and while each has unique features associated with the national context, their shared goals target professional quality standards leading to the protection of the general public. Other countries worldwide may consider alternatives to a national-based CoE and initiate operations in either a university, government agency, or smaller, but well-established, nursing specialty organization. The key is to anticipate what kind of human and financial resources will be necessary to achieve realistic objectives and to identify the key individuals to be involved, even when beginning at the local or regional levels. Before the CoE was instituted, many nurses were stymied by the inability to quickly access available published research studies. Even with access, however, many nurses were confronted by the difficulties in obtaining appropriate reviews and engaging in discussion of study findings due to the wide variability in English competencies. Thus, the introduction of English courses as part of the education pillar was very important. We are aware of this issue in other non-English-speaking countries and emphasize the significance of assessing this component as a strategy to capacity building in nursing scholarship. Future work by the CoE will center on strengthening the availability of English competency courses to Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
undergraduate students, nurse clinicians, and academic faculty members. The scope of the CoE objectives and related activities was another issue. Looking back, consideration to a more narrow focus as to the specific topic priorities for funding in each of the pillars, in the first phase of development, was a lesson learned. Specifically, ensuring more precise criteria for fielding the quality and scope of studies at the start could have been a higher priority, not just because the goal was to fund the best studies, but as an approach to identifying earlier on which investigators might have benefited from additional assistance via mentoring and consultation coordinated by the CoE. Innovations that were introduced early on in the CoE, such as the digital library system, coupled with multiple research training opportunities, were viewed as well worth the financial investment toward achieving the secondary gains of strengthening communication and collaborations among nurse researchers, practitioners, and educators. Initially, the concept of a CoE and projected benefits were questioned by nurses (Rocco et al., 2014), but positive responses to these nurse-focused strategies demonstrated the significance of timeliness and strong recognition of the social context in determining which activities should be brought to fruition early on in response to specific issues or problems. Finally, we believe that CoE efforts in the future will need to center even more prominently on the development of important connections with other European partners. Alliances with nurses from other countries have been possible in the past through the European Federation of Nurse Educators, the European Nurse Director Association, and the European Academy of Nursing Science. The research network associated with the European Union has funding opportunities for nurses, and Italian nurses are now in a better position to compete for these based on strides made in relation to scholarship contributions to date.
Conclusions Based on the sheer quantity and broad scope of pillar initiatives launched during the first phase timeframe of the CoE, it is clear that the concept was a proven success toward achieving the mission of expanding nursing scholarship in Italy. Challenges such as maintaining research funding in the long term will remain an issue faced by nurses in Italy, but this is no different from the current situation worldwide. Forging interdisciplinary partnerships and engaging government agencies at the local and national levels will continue to be the common thread for nurses internationally. We learned 175
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that application of the CoE concept for building nursing scholarship has merit when based on the specific needs and issues confronting improvements in nursing care within the country context.
Acknowledgments Gratitude and appreciation is expressed to all collaborating partners who developed this project. This article was partially supported by a grant from the Center of Excellence for Nursing Scholarship (CoENS 2.13.1).
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Center of Excellence for Nursing Scholarship: http://www.centrodieccellenza.eu European Academy of Nursing Science: http:// www.european-academy-of-nursing-science.com/ European Council of Nursing Regulators: http:// www.fepi.org/ European Federation of Nurse Educators: http:// www.fine-europe.eu/?lang=en European Nurse Director Association: http://www. enda-europe.com/en/home-34.html Regulatory Board of Registered Nurses, Health Visitors and Pediatric Nurses (IPASVI): http://www. ipasvi.it/
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Rocco, G., Bonfigli, A., Bruno, E., Fanfera, E., Finocchi, G., Montevecchi, A., . . . Turci, C. (2011). A new resource for the bibliography research: Project experience ILISI(R) Index of Italian Literature on Nursing Sciences [Italian]. Professioni Infermieristiche, 64(1), 22–32. ´ M., Wallin, L., & Gustavsson, P. Rudman, A., Omne-Ponten, J. (2010). Monitoring the newly qualified nurses in Sweden: The Longitudinal Analysis of Nursing Education (LANE) study. Human Resources for Health, 8, 10. doi:10.1186/1478-4491-8-10 ¨ A. M., Rocco, G., Sabatino, L., Stievano, A., Kallio, H., Pietila, & Kangasniemi, M. (2014). The dignity of the nursing profession: A meta-synthesis of qualitative research. Nursing Ethics. doi:10.1177/0969733013513215 Stievano, A., Bonfigli, A., Fanfera, E., Finocchi, G., R Montevecchi, A., Nappini, P., . . . Rocco, G. (2011). ILISI digital index of the Italian scientific literature of nursing. Nurse Education Today, 31(3), 294–298. doi:10.1016/j.nedt.2010.11.019 Stievano, A., De Marinis, M. G., Rocco, G., Russo, M. T., & Alvaro, R. (2012). Professional dignity in nursing in clinical and community workplaces. Nursing Ethics, 19(6), 341–356. doi:10.1177/0969733011414966 Tuning Project. (2005). Tuning educational structures in Europe. Retrieved from http://www.unideusto.org/ tuningeu/ Tuning Project. (2012). Nursing specific competences. Retrieved from http://www.unideusto.org/tuningeu/ competences/specific/nursing.html Vellone, E., Chung, M. L., Cocchieri, A., Rocco, G., Alvaro, R., & Riegel B. (2014). Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: Testing dyadic dynamics using the actor-partner interdependence model. Journal of Family Nursing, 20(1), 120–141. doi:10.1177/1074840713510205 Vellone, E., Cocchieri, A., D’Agostino, F., Fida, R., Rocco, G., & Alvaro R. (2013). Structural equation model testing the situation-specific theory of heart failure self-care. Journal of Advanced Nursing, 69(11), 2481–2492. doi:10.1111/jan.12126 ˚ ¨ Vellone, E., Jaarsma, T., Stromberg, A., Fida, R., Arestedt, K., Rocco, G., . . . Alvaro R. (2014). The European heart failure
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self-care behaviour scale: New insights into factorial structure, reliability, precision and scoring procedure. Patient Education and Counseling, 94(1), 97–102. doi:10.1016/j.pec.2013.09.014 Vellone, E., Riegel, B., Cocchieri, A., Barbaranelli, C., D’Agostino, F., Glaser, D., . . . Alvaro, R. (2013). Validity and reliability of the caregiver contribution to self-care of heart failure index. Journal of Cardiovascular Nursing, 28(3), 245–255. doi:10.1097/JCN.0b013e318256385e Vellone, E., Savini, S., Fida, R., Dickson, V. V., Melkus, G., Carod-Artal, F. J., . . . Alvaro, R. (2014). Psychometric evaluation of the Stroke Impact Scale 3.0. Journal of Cardiovascular Nursing. doi:10.1097/JCN.0000000000000145 World Health Organization. (2009). Global standards for the initial education of professional nurses and midwives. Retrieved from http://www.who.int/hrh/nursing midwifery/hrh global standards education.pdf World Health Organization. (2010). The WHO global code of practice on the international recruitment of health personnel. Retrieved from http://www.who.int/hrh/ migration/code/code en.pdf?ua=1 World Health Organization. (2014). A global strategy on human resources for health. Retrieved from http://www. who.int/workforcealliance/media/news/2014/public consultations GHWA Synthesis Paper Towards GSHRH 21Jan15.pdf?ua=1
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Figure S1. Essential cores of the Center of Excellence for Nursing Scholarship in Italy. Table S1. Practising nurses per 1 000 population, 2010 or nearest year–OECD Health Data 2012. Table S2. Center of Excellence: Pillar objectives. Table S3. CoE timeline–Developmental phases and milestones.
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Center of Excellence to Build Nursing Scholarship and Improve Health Care in Italy Gennaro Rocco, MSN, RN1 , Dyanne Affonso, PhD, RN, FAAN2 , Linda Mayberry, PhD, RN, FAAN3 , Loredana Sasso, MSN, RN4 , Alessandro Stievano, PhD, MSN, RN5 , & Rosaria Alvaro, MSN, RN6 1 Director, Center of Excellence for Nursing Scholarship, Rome, Italy 2 Honorary President, Center of Excellence for Nursing Scholarship, Rome, Italy 3 Adjunct Associate Professor, New York University, New York, NY, USA 4 Associate Professor, Genoa University, Genoa, Italy 5 Nurse Research Fellow, Center of Excellence for Nursing Scholarship, Rome, Italy 6 Associate Professor, Tor Vergata University, Rome, Italy
Key words Nursing scholarship, nursing research, nursing center infrastructure, conceptual design Correspondence Dr. Alessandro Stievano, Viale Giulio Cesare 78, Center of Excellence for Nursing Scholarship, 00192 Rome, Italy. E-mail: [email protected] Accepted: December 18, 2014 doi: 10.1111/jnu.12125
Abstract Purpose: 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 170
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 Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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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 Italy Understanding 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). Similarly, U.S. nurses capitalized on the proliferation of national health system mergers to activate many nurse-managed clinics across the country in the 1990s (IOM, 2011). In Italy, health care is delivered through a publicinsured, tax-based financed system. A major issue for the nursing profession is that the Italian National Health Service (Servizio Sanitario Nazionale, established in 1978) operate via regional jurisdiction with broad-range autonomy to the health sector in each of Italy’s 20 regions. Italy has relatively fewer nurses employed in comparison to other European countries, 6.3 per 1,000 population according to data issued by the Organisation for Economic Co-operation and Development (OECD) in 2010 (Table S1, available with online version of this article) and 6.4 per 1,000 population for 2012 (OECD, 2013). Regionalization has contributed to the persistence of predominantly hospital-based health care, with less emphasis on the development of more community-oriented care pathways. For example, it has been argued that reforming long-term care of the elderly (a major global healthcare issue) is also linked to federal versus regional fragmentation of resource allocation in Italy (Gabriele & Tediosi, 2014). Confronting the limitations of regionalization amidst efforts to increase the status of the nursing profession on Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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a consistent basis at the national level is a major challenge impacting many countries (Ayala, Fealy, Vanderstraeten, & Bracke, 2014). However, a landmark decision in Italy has helped to address this problem by directly aligning nursing to the regionalized healthcare system via the National Regulatory Board of Nursing known as IPASVI (National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses) (a nonprofit body by public law that includes approximately 100 provincial colleges representing geographic zones as branches of the institution across Italy; National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses [IPASVI], 2014). IPASVI comprises all (422,000) registered nurses licensed to practice in Italy, regulates nursing practice standards (including ethical-legal accountability), and oversees an array of professional programs as one of its primary functions. With a strong organizational infrastructure, the sanction of the federal legislature and Ministry of Health (MOH), and a firm fiscal base, IPASVI has been a catalyst for “C-Change” (defined as innovative approaches to improve the effectiveness and sustainability of major change according to the U.S. Agency for International Development) in transforming the professionalization of Italian nursing (C-Change. Communication for Change, 2014). Integral to this transformation has been the role of IPASVI in facilitating educational reforms on a national level. Countries of Europe (e.g., Finland, Ireland, Norway, Spain, Sweden, United Kingdom), Asia (e.g., Japan, Korea), and North America (Canada and United States) have served as exemplary models of how the introduction of university-based degree programs for nurses has contributed heavily to advancing professionalism over time, particularly expanded roles and scope of practice (Lahtinen, Leino-Kilpi, & Salminen, 2013; Lee, Lee, Wong, Tsang, & Li, 2010). The nursing degree program in Italy is structured according to the credit block system set up by the Bologna Declaration, and this “Bologna impact” (Davies, 2008) has been very positive in terms of overall education improvements. The advancements in nursing education exceed those of some European countries (e.g., Czech Republic, France, Germany, Hungary, Latvia, Lithuania, and others) that do not yet have the undergraduate university degree requirement first established in Italy (1992) and/or employ more than one pathway to becoming a nurse (Lahtinen et al., 2013). The significance of science-based education to support the understanding and study of patient treatment modalities and improved health outcomes was the next major advancement in 2004–2005 via development of a clinically based versus primarily an administrative track master’s degree (as is common in other European 171
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countries) in nursing science. This was followed within 2 years (2006–2007) to the start-up of nursing PhD programs administered by nursing faculty in four universities: Tor Vergata in Rome, University of Genoa in Liguria, University of Florence in Tuscany, and L’AquilaUniversity in the Abruzzo Region. Although nursing education in Italy remains primarily located within the Faculty of Medicine and Surgery, PhD coursework is provided by nursing professors trained mainly in Europe and the United States. Based on the Italian experience, the emergence of these advanced nursing degrees is considered crucial in moving nurses toward the goal of expanding professional practice that includes an increased emphasis on scholarship. With the support of professional organizations such as IPASVI, we found that professional reforms centered on establishing national competencies to guide basic curricula development (Tuning Project, 2012) can subsequently improve clinical practice, enhance nursing faculty capacity building, and eventually lead to increased scholarship. Coinciding with these efforts is the significance of developing strategic plans that can facilitate the ability to conduct research and impact practice directly through evidence generated by nurses and their interdisciplinary colleagues.
Strategic Planning for Promoting Nursing Scholarship In Italy, the strategies toward achieving these goals were based on three critical drivers. The first was mobilization of organizational funding support to launch an exemplar research project with broad-based interest to a large segment of the nursing population. In this case, IPASVI provided the funds to support the development and conduct of the first large-scale, collaborative study conceptualized, designed, and conducted by nurse teams. In doing so, IPASVI leaders of the Rome Provincial College set in motion an increased emphasis on scholarship that could highlight the research–practice interface via a “patient safety collaborative initiative.” Patient safety as a global health and nursing imperative (IOM, 2001) was introduced at the IPASVI National Congress attended by 5,000 nurses in 2005. This meeting resulted in the design of a “near misses” multisite qualitative study aimed at delineating the characteristics of nearly missed patient care errors in hospitals and clinics (Affonso et al., 2007) that involved nurse participants from the universities and affiliated hospitals and clinics in Rome and Genoa. Funding support for this type of endeavor was considered the first imperative. Nurses in other countries who want to use this strategy should also pay close attention to the importance of mobilizing key partnerships among hospital 172
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administrators, clinical nurse leaders and directors, medical colleagues, and other disciplines to anchor a project of this type as an interdisciplinary healthcare priority to build upon for the future. The second driver was to ensure support for the project at the onset by the MOH. The significance of this strategy cannot be emphasized enough to nurses in other countries who want to be successful in not only cultivating support for future clinical and research projects, but pave the way for advancing the professionalism of nursing in the healthcare system. Specific actions that forged MOH relationships included conducting semiannual workshops jointly on study progress, issues, and updates, with ongoing feedback provided by the MOH. These were the stimulus to subsequent MOH sponsorship of additional annual workshops involving multidisciplinary participants to address diverse healthcare topics relevant to both the medical and nursing professions. Annual reports prepared as formal publications and submitted to the MOH and IPASVI membership were key dissemination strategies of both process and content outcomes of the patient safety near miss study (National Regulatory Board of Registered Nurses, Health Visitors, and Pediatric Nurses [IPASVI] Rome, 2008), and were a useful template for future communications about the role of nursing in health care. The launch of the first nursing research project spearheaded by IPASVI was viewed as a starting point that would be difficult to sustain without an infrastructure that could maintain the momentum. Based on the experiences of other countries, it is clear that this type of work is often isolated in separate university “silos” without the communication and operations structure that promotes broader outreach and continued collaboration among nurses. Therefore, we consider the third driver in strategic planning to be expanding scholarship among nursing professionals via the initiation of a CoE. After extensive discourse via consultation with selected global nurse academics and researchers, a decision was made to adapt the U.S. National Institutes of Health (NIH) Program Research (P20) award mechanism (NIH, 2014) as a model infrastructure for the Italian CoE. The goal of the NIH concept of a CoE was to mobilize human and fiscal resources to discover and innovate in the pursuit of health via research, research training, and clinical practice. These essential cores were considered congruent with the goals of the IPASVI CoE. Boyer’s Model of Scholarship was chosen as the conceptual framework for the CoE because it also added the dimension of education to the cornerstones of scholarship (Boyer, 1990). Not only has the utility of Boyer’s model, particularly with regard to curricula reforms and clinical practice innovations, been demonstrated in Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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different scientific fields (American Association of Colleges of Nursing, 1999), but its four domains of scholarship (discovery, integration, application, and teaching) could be translated into pillars of actions or essential cores of the center as shown in Figure S1 (available with online version of this article). The four pillars, built upon Boyer’s expanded definition of scholarship, anchored the CoE’s priority actions within a predefined set of objectives for the years 2010–2014 (Table S2, available with online version of this article).
CoE Pillar Initiatives and Outcomes Evaluation of the CoE varied within each of the pillars, utilizing a combination of quantitative and qualitative approaches. Quantifying designated overall system outcomes included the use of online tracking technologies for the CoE to maintain comprehensive databases of the various projects and studies. Examples of variables that were monitored by the CoE administrative core included program reach, as measured by the total number of nurses participating in CoE projects, research programs, conferences, and training courses. Accessibility defined as nurses’ connection to global literature was also measured by the number of nurses using the digital library system. Productivity was defined by a number of peer-reviewed publications resulting from study findings. Conferences, workshops, and course qualities, as measured by participant self-report responses, were also monitored. As with any infrastructure, we understood that the CoE has to follow a set of clear, measurable actions and associated outcomes stemming from the objectives and placed within a reasonable timeline. Throughout the CoE’s developmental phases of operation (Table S3, available with online version of this article), the four CoE pillars supported multiple initiatives in the form of research studies, education projects, and training courses. Administrative support was important in maintaining seamless communications at all levels (e.g., between research teams and pillar directors). National conferences, staggered throughout the first 4 years, were convened by the CoE administrative core for the purpose of monitoring progress of studies, provision of critique, and exchange of information among pillar leaders and project teams.
Research Pillar The initial developmental phase of research priorities centered on funding broadly focused studies in five key areas: (a) nursing ethics (Sabatino et al., 2014; Stievano, De Marinis, Rocco, Russo, & Alvaro, 2012); (b) quality of life in cardiac patients and families with self-care as a targeted variable (Cocchieri et al., 2013; Vellone, Chung, Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
et al., 2014); (c) patient safety (medication and intravenous therapy); (d) mental health nursing and palliative care; and (e) development of family or community nursing.
Key pillar outcomes. (a) Twenty-five nurse-led funded studies were conducted. (b) The first programs of nursing research were established focusing on cardiac self-care, quality of life, and nursing ethics. (c) A repository toolkit was created composed of new instrumentation and made accessible for use by other researchers, including colleagues of other disciplines. It included the development and preliminary testing of the Stroke Impact Scale (Vellone, Savini, et al., 2014); the European Heart Failure Self-care Behavior Scale (Vellone, Jaarsma, et al., 2014); the Care-giver Contribution to Self-Care of Heart Failure Index (Vellone, Reigel, et al., 2013); and the structural equation model testing the situationspecific theory of heart failure self-care to improve self-care of cardiac patients (Vellone, Cocchieri, et al., 2013). (d) As of June 2014, six combination didactic and online courses were accessed by nurses throughout Italy to address a myriad of topics ranging from nursing research methods to tools for bibliographic research, proposal development, and the art of grantsmanship. (e) An electronic communications network via a digital library system was developed. It included creation of an index of Italian-specific literature on nursing and health-related fields, known as ILISI (Index of Italian Literature on Nursing Sciences; Rocco et al., 2011; Stievano et al., 2011). ILISI currently includes the abstracts of over 4,600 articles (2004 to present) from 25 Italian journals of nursing or health-related disciplines. Other databases, such as the Cumulative Index to Nursing and Allied Health Literature, PubMed, OvidSP, and the Cochrane Databases, were offered as a free consultation through a dedicated digital platform by the CoE to all nurses.
Research Training Pillar A series of training courses designed specifically to increase new investigator’s skill capacity in research methodologies and knowledge of research proposal development was a top priority. This was a first step in developing a cadre of research fellows to begin participating in an ongoing training “laboratory” that could bring together funded nurse researchers with those less experienced, including doctoral students.
Key training outcomes. (a) Six research training courses or workshops were conducted onsite at IPASVIRome headquarters, specifically tailored for nurses. (b) A 173
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doctoral seminar series specific to research training was instituted and attended by PhD student cohorts from all four of the universities. (c) Two nursing research laboratories were established at IPASVI-Rome—one on qualitative methods, particularly use of focus groups, the other on clinical research methods. (d) A series of English proficiency courses specifically geared to nurses were conducted annually.
Clinical Practice Pillar The clinical practice pillar’s initial developmental priority centered on multiple strategies for infusing knowledge about evidence-based practice (EBP) into the hospital clinical arena and the initiation of several evaluation projects.
Key pillar outcomes. Six EBP projects were funded: (a) An EBP evaluation study on treatment to prevent oral mucositis in women receiving chemotherapy for breast cancer with propolis was conducted. (b) Two EBP evaluation studies on documentation of specific nursing outcomes and on staff perceptions of clinical nursing complexities were conducted. (c) A targeted training program on the principles of EBP and methods for evaluation was conducted. (d) A project designed to conduct several systematic reviews on pertinent clinical topics was completed.
Education Pillar Two major projects were undertaken that addressed objectives related to curricular reforms and the conduct of faculty studies aimed at improving undergraduate education learning. European countries served as educational models in designing these two projects. The first project centered on a 5-year study to assess core competencies for undergraduate nursing education, adapted from the European Tuning Project (2005, 2012). This study, which included collaboration with three universities and a total of 40 nursing schools, found significant variations and a lack of accountability to core competencies across nursing programs in Italy. The second project, initiated in 2012 and adapted from a Swedish nursing education study ´ Wallin, & Gustavsson, 2010), (Rudman, Omne-Ponten, was a 3-year longitudinal analysis of undergraduate nursing education and the impact of variables such as stress, burnout, and depression on baccalaureate student performance.
Key education pillar outcomes. (a) A new standard of core competencies for the licensure examination of baccalaureate nursing students was tested and 174
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instituted in 2013 in the Lazio (Rome) Region based on study findings. (b) New courses considered high priority for changes in the current undergraduate curriculum in Italian nursing schools were piloted to address ethics, risk management for patient safety, core dimensions of the helping relationship, nursing the imprisoned person, and suicide training. (c) A series of strategic planning sessions involving university deans and representatives from the MOH were convened and resulted in three new academic nursing positions at regional universities. It should be noted that the impact of the CoE went beyond the original objectives in several ways. For example, an initial aim of the digital library system was to increase awareness of current global nursing reforms and clinical practice advancements, but the free access via individual password entry also served to magnify the importance of research in changing clinical practice at the unit level since more nurses, even at the staff clinician level, could now more easily read about nursing research. Visibility of nurse-led studies at the unit level also helped to build a stronghold of collaborative partnerships that have since sparked the development of new clinical research projects, in addition to follow-up projects to the original funded studies. An unanticipated but extremely important outcome of the visibility of active nursing research projects and educational programs coincided with strong lobbying efforts on the part of CoE leaders. This outcome was funding by the MOH in 2013 to begin developing guidelines for the education and standardization of the family–community nurse role. The type of role functions that family–community nurses typically perform has been visible sporadically throughout Italy, particularly in the northern regions, and specialty courses focused on community and family health began in 2000. Now, cost containment strategies associated with the economic crisis in Italy have facilitated efforts to obtain governmental commitments to the family–community nurse role. For this reason, the CoE leadership views this as an opportune time to place a major focus in the next 5 years on the development and testing of a new prototype for community-based advanced practice nursing in Italy.
Lessons Learned and Global Implications Our experiences with the new Italian nursing CoE revealed important lessons learned applicable to nurses in other countries who may want to create a similar entity to advanced nursing scholarship. Working from a defined structure such as IPASVI for such a large undertaking was crucial, and starting with a broad mission coupled with specific objectives was essential. Early alignments developed successfully with key stakeholders such as the Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
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MOH and most of the universities through the IPASVI connection. Inclusivity at all levels of nursing, rather than only the doctoral level, was also important. Accessing these relationships had an unexpectedly rapid impact on orchestrating project development (e.g., progress in determining educational priorities and instituting an increased focus on EBP among clinician groups). Without having a well-established organizational structure with national recognition and a strong financial base upon which to draw, it would have been very difficult to develop and manage the many projects in such a short period of time. We also found that the increased communications occurring via the IPASVI CoE structure were instrumental in shaping the collegiality necessary to bridge the advocacy efforts targeting new university nursing faculty positions in Italy, an objective that at first seemed unrealistic during the developmental years of the CoE. Therefore, a vital step in considering a CoE is to examine the realities of context. In Italy, the availability of working through a national organization such as IPASVI was an effective approach because the connection among the entire population of nurses was already well established and the leadership included a cross-section of clinical, administrative, and education nurses motivated to advance nursing’s drive for scholarship. Similar national structures exist in other countries (e.g., Croatia, Greece, Ireland, Romania, Spain, United Kingdom), and while each has unique features associated with the national context, their shared goals target professional quality standards leading to the protection of the general public. Other countries worldwide may consider alternatives to a national-based CoE and initiate operations in either a university, government agency, or smaller, but well-established, nursing specialty organization. The key is to anticipate what kind of human and financial resources will be necessary to achieve realistic objectives and to identify the key individuals to be involved, even when beginning at the local or regional levels. Before the CoE was instituted, many nurses were stymied by the inability to quickly access available published research studies. Even with access, however, many nurses were confronted by the difficulties in obtaining appropriate reviews and engaging in discussion of study findings due to the wide variability in English competencies. Thus, the introduction of English courses as part of the education pillar was very important. We are aware of this issue in other non-English-speaking countries and emphasize the significance of assessing this component as a strategy to capacity building in nursing scholarship. Future work by the CoE will center on strengthening the availability of English competency courses to Journal of Nursing Scholarship, 2015; 47:2, 170–177. C 2015 Sigma Theta Tau International
undergraduate students, nurse clinicians, and academic faculty members. The scope of the CoE objectives and related activities was another issue. Looking back, consideration to a more narrow focus as to the specific topic priorities for funding in each of the pillars, in the first phase of development, was a lesson learned. Specifically, ensuring more precise criteria for fielding the quality and scope of studies at the start could have been a higher priority, not just because the goal was to fund the best studies, but as an approach to identifying earlier on which investigators might have benefited from additional assistance via mentoring and consultation coordinated by the CoE. Innovations that were introduced early on in the CoE, such as the digital library system, coupled with multiple research training opportunities, were viewed as well worth the financial investment toward achieving the secondary gains of strengthening communication and collaborations among nurse researchers, practitioners, and educators. Initially, the concept of a CoE and projected benefits were questioned by nurses (Rocco et al., 2014), but positive responses to these nurse-focused strategies demonstrated the significance of timeliness and strong recognition of the social context in determining which activities should be brought to fruition early on in response to specific issues or problems. Finally, we believe that CoE efforts in the future will need to center even more prominently on the development of important connections with other European partners. Alliances with nurses from other countries have been possible in the past through the European Federation of Nurse Educators, the European Nurse Director Association, and the European Academy of Nursing Science. The research network associated with the European Union has funding opportunities for nurses, and Italian nurses are now in a better position to compete for these based on strides made in relation to scholarship contributions to date.
Conclusions Based on the sheer quantity and broad scope of pillar initiatives launched during the first phase timeframe of the CoE, it is clear that the concept was a proven success toward achieving the mission of expanding nursing scholarship in Italy. Challenges such as maintaining research funding in the long term will remain an issue faced by nurses in Italy, but this is no different from the current situation worldwide. Forging interdisciplinary partnerships and engaging government agencies at the local and national levels will continue to be the common thread for nurses internationally. We learned 175
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that application of the CoE concept for building nursing scholarship has merit when based on the specific needs and issues confronting improvements in nursing care within the country context.
Acknowledgments Gratitude and appreciation is expressed to all collaborating partners who developed this project. This article was partially supported by a grant from the Center of Excellence for Nursing Scholarship (CoENS 2.13.1).
Clinical Resources
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Center of Excellence for Nursing Scholarship: http://www.centrodieccellenza.eu European Academy of Nursing Science: http:// www.european-academy-of-nursing-science.com/ European Council of Nursing Regulators: http:// www.fepi.org/ European Federation of Nurse Educators: http:// www.fine-europe.eu/?lang=en European Nurse Director Association: http://www. enda-europe.com/en/home-34.html Regulatory Board of Registered Nurses, Health Visitors and Pediatric Nurses (IPASVI): http://www. ipasvi.it/
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web site: Figure S1. Essential cores of the Center of Excellence for Nursing Scholarship in Italy. Table S1. Practising nurses per 1 000 population, 2010 or nearest year–OECD Health Data 2012. Table S2. Center of Excellence: Pillar objectives. Table S3. CoE timeline–Developmental phases and milestones.
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