Perceived barriers and enablers of nursing research in the Italian context: Findings from a systematic review

Two years ago, the whole world celebrated the bicentennial birthday of Florence Nightingale, who was born in Florence (Italy) on 12 May 1820. She developed an ever-widening commitment to redress unjust social policies imperilling human health, by stimulating collaborators, shaping public awareness, and championing the cause of those suffering as a result of unjust policies. Nightingale challenged nurses to promote and develop environments where the health of the population is a realistic expectation (1). Her contribution to research and public health has been acknowledged both inside and outside the nursing discipline, and it has continued to shape both practice and research also during the current pandemic (2).

In the Florence Nightingale heritage, tremendous changes over the years have been implemented at worldwide level with important outcomes achieved in the last two decades. Advancements in education with the establishment of both undergraduate and postgraduate education at university level in several countries have been well recognized (3). Moreover, with the transition of the nursing education from the vocational to academic level, nurses have been educated to place stronger emphasis on nursing research and on establishing consistent production of scientific publication (4, 5). Progress in the practice where nurses have been reported undertaking responsibility for the care influencing patients’ outcomes, have also been underlined (6, 7). Moreover, several care interventions have been assessed on their evidence, increasing health care services equity and accessibility (8). Important achievements have been established at the hospital and community levels, where models of care have been redesigned and implemented, ensuring high organizational performances. Thus, the main message of Florence Nightingale as a creator of the modern nursing discipline (9), implying a continuing strong research foundation of the practice (10), has been implemented and fully followed in promoting research as a method of thinking, practicing and developing the discipline (11). However, despite the celebrations of her bicentenary birthday, the research capacity of nurses has been reported to be still constrained in several countries (12), and not fully implemented in its potentiality due to many factors. Staffing and funding constraints strictly bind nurses to the so-called ‘productive nursing hours’ at patients’ bedside, rendering difficult their active participation in research projects (12). Moreover, limitations in the research budget, as well as the lack of staff, little tradition and culture and no common strategy (13) have been reported as preventing nurses from conducting significant research projects. Summarizing the factors that increase or hinder the research capacity among nurses can inform policies (14), and can trigger strategies aimed at supporting them in conducting or contributing to research advancements. Moreover, given that the research capacity has been defined as ‘the ability to conduct nursing research activities in a sustainable manner in a specific context, and it is normally used at a non-individual level’ (15), the summary has been designed at the Italian level. Therefore, the primary aim of this review was to identify the barriers and enablers of conducting research, as perceived by Italian nurses.

To the best of the authors’ knowledge, this is the first review of literature within the Italian borders on the constraints that prevent and factors that promote Italian nurses’ participation in and conducting of research projects. Two main profiles of studies have emerged: studies based on data collection (14, 19, 20, 21, 22), thus supporting the findings with evidence; and papers based on reflections and/or experiences, as commentaries, experts’ opinions or editorials (13, 23, 24). The majority of them have been published from 2010 to 2017, with more research-based studies in the first five years (14, 20, 21, 22) and more occurrence of editorials in recent years (13, 23). Publications as a concrete output of the efforts conducted in a given discipline such as nursing (19, 20), have been documented as having evident consistent improvement (4) in recent years, suggesting that some barriers have been overcome and a continuing assessment of barriers and facilitators is needed.

The arising barriers and facilitators seem to be two faces of the same coin, and they can be set at the (a) individual, (b) organizational and (c) the system levels, triggering different strategies and policies. As categorized, only some of them have fully considered the concept of research capacity that relies on elements other than individual elements – such as the degree of competences (15) – suggesting that more analysis should be undertaken at the context levels, where factors might promote or hinder research capacity that go beyond an individual competence or ability.

At the individual levels, English language use has been reported as the main research barrier. Research papers are published in English and nurses living in non-speaking English countries have been documented as having increased difficulty in publishing their research outcomes. These difficulties have been reported mainly among senior nurses as compared with their younger colleagues, in terms of the increased attention to English proficiency in the last decades (13, 20, 22, 23). Moreover, low proficiency in English might prevent contacts with international colleagues as mentors and/or research methodology teachers. Reading international papers has been documented as increasing research capacity (20) and publishing significantly more as compared to their colleagues who do not read such journals; moreover, being informed about what is happening abroad seems to improve nurses’ ability to participate in general scientific activities (20, 24). In the same light, participating in international meetings/networks, in order to share ideas (25), to develop international studies and to cooperate, might increase the number and the quality of scientific publications.

At the organizational levels, library and technology accessibility has been documented as a barrier (13, 23), especially at the unit level, which is consistent with international data (26), and encountering such barriers might discourage nurses from their active participation in research activities. However, the recent progress in technologies developed in response to the COVID-19 pandemic, which has increased skills in the use of computer tools, or continuing education through video-conferencing and open online courses, have reduced this constraint. Moreover, there is a sort of agreement that understaffing, time constraints and the lack of organizational culture are three major barriers in preventing nurses from participating in research activities (13, 14, 21, 22, 23). Similar barriers have also been reported in other countries, such as Slovenia (27).

In addition to processes at the organizational level, consideration should also be given to the fact that the lack of managerial support as well as the lack of leadership and authority to negotiate and overcome constraints of nursing research development in Italy (13, 14, 21, 22, 23) have been reported. Nurse managers should be supported and educated in changing value systems regarding nursing research by promoting collaboration and creating structural conditions to allow research opportunities and resources. On the other hand, conducting multidisciplinary journal clubs, allowing time for nurses to participate both passively and actively, might also promote research capacity. Furthermore, establishing a unit for research within the hospital (22, 23) has been reported to promote research capacity in line with international literature. Consequently, sensitizing leaders at various levels to create supportive environments for nursing research seems to be strategic.

At the system level, designing and promoting PhD education has been widely recognized as fundamental (28). The first Italian PhD programme was established in 2006 and the number of nurses with PhDs has increased over the years, although numbers remain limited (13, 22, 23). However, universities capable of supporting clinical nurses by involving them in defining research priorities or research protocols has been proved to increase research capacity. Academics’ and clinicians’ collaboration, as encouraged by studies included in this review (13, 19, 22, 23, 24), has the power to improve the quality of research, as well as helping to detect problems that emerge in everyday clinical practice. Therefore, strong partnerships are recommended between clinicians and academics.

At the system level, the lack of available economic resources has been underlined as an important factor hindering research capacity. Although the nursing discipline should access grants available to all researchers, in other countries, too, the lack of specific funding or high competition has been underlined as a critical factor in the nursing field. When research studies are supported financially, an increase in nurses’ participation, a growing cooperation with international projects as well as increased effectiveness have been documented.

The access of resources seems to be strictly associated with another barrier documented at the system level: the regional ethics committees have been documented as often refusing nursing studies because the study design is not pertinent to interventional research (13). Nursing representatives are required to be part of the ethical committees’ boards also to value the peculiarities of nursing research, when, for example, qualitative studies are submitted. Overcoming ethical committee issues might increase the access to national and international resources and international publications (13). Therefore, the relationship between the ethical committee and researchers should be based on an intensive dialogue, as ‘provocative allies’ (29), to ensure the appropriate support for the nursing discipline and good clinical practice, and not presented as an insuperable bureaucratic structure.

This systematic review provides an initial framework of the constraints that prevent, and the factors that promote, Italian nurses’ active participation in research projects. Factors preventing effective nursing research might have long-term public health consequences, in two directions: on the one hand, the perception of being limited in research might trigger a brain drain, by increasing the intention to leave the profession and/ or the country; on the other hand, limiting the research capacity might prevent patients from receiving the best care. Therefore, the identification of factors hindering or promoting research might support the defining of policies; moreover, detecting these factors at the country level by also comparing the findings, might also harmonize strategies promoting international cooperation in the nursing research field.

A large number of obstacles that limit Italian nursing research have emerged at the individual, organizational and system-wide levels. Most are broadly consistent with the findings available in the international literature, such as poor knowledge of English, lack of managerial support and limited access to libraries and information technologies. Some of them might have paradoxically benefited from the pandemic crisis (such as the development and accessibility of digital solutions), whereas others might have been further threatened, such as the lack of organizational support. In this context, universities creating research units within hospitals and promoting international collaboration, which have been already recognized as facilitators, might increase in importance in the post-pandemic era. To promote the development of nursing research in the Italian context, the following are recommended: to enhance the influence of institutional leaders both within healthcare facilities and in universities aimed at nursing research development; to foster strong partnerships between academics and clinicians; to develop researchers’ managerial skills to identify effective national and/or international funding and collaborations; and to build good relationships with ethics committees, and ask for specialist support when necessary.