Background The reduction and instability of nursing resources represent a growing critical issue in high-acuity hospital care settings, where team continuity, skill mix balance and expert competencies are essential for patient safety and organizational resilience. In these settings, characterized by high complexity and professional interdependence, prolonged absences and permanent exits do not only result in a numerical reduction in staffing levels, but may also lead to care discontinuity, loss of competencies, increased workload and greater organizational vulnerability. Particular relevance is assumed by critical nursing resources, understood as professionals with specialist competencies, consolidated experience or limited short-term replaceability. Objective The objective of this thesis is to map the available evidence on the organizational, professional, educational and care-related consequences of the reduction or instability of nursing resources in high-acuity hospital care settings, with particular attention to the impact on the remaining professionals. Based on the evidence identified, the thesis also proposes an organizational forecasting strategy aimed at monitoring critical nursing resources and supporting the anticipatory assessment of structural vulnerability. **Methods** A scoping review was conducted according to the Joanna Briggs Institute methodological framework and reported in accordance with the PRISMA-ScR criteria. The literature search was carried out in PubMed and CINAHL, including studies published between 2015 and 2025, in English, concerning turnover, staff shortages, workforce instability, prolonged absences and permanent exits in high-acuity hospital care settings. The evidence was analyzed through descriptive and thematic synthesis. **Results** Seventeen studies were included. The evidence shows that the reduction or instability of nursing resources in high-acuity care settings is associated with four main areas of impact: increased care-related and organizational workload for the remaining professionals; worsening of patient outcomes and safety in the presence of inadequate staffing or high workload; loss of competencies, clinical experience and team continuity; and deterioration of professional well-being, expressed in terms of burnout, job dissatisfaction and intention to leave. Overall, the findings describe a possible vicious circle in which the loss of resources increases the workload of those who remain, weakens the skill mix and organizational continuity, and contributes to further conditions of instability. **Conclusions** The reduction or instability of nursing resources in high-acuity care settings is not merely a quantitative issue of staffing coverage, but a complex organizational criticality that may affect care continuity, patient safety, team stability and the sustainability of work for the remaining professionals. The evidence collected supports the need to move beyond an exclusively reactive management of absences and points toward strategies for the anticipatory assessment of organizational vulnerability. The proposal developed in this thesis includes operational tools, such as a data collection sheet, an aggregated structural matrix and a quarterly reference grid, aimed at identifying predictable or formally known events, assigning them different organizational weights and monitoring over time the concentration of criticalities related to critical nursing resources. From this perspective, the forecasting strategy does not aim to eliminate uncertainty, but to make visible what the organization can already know, supporting more informed, timely and care-continuity-oriented planning.
Introduzione La riduzione e l’instabilità delle risorse infermieristiche rappresentano una criticità crescente nei contesti ospedalieri ad alta intensità assistenziale, dove continuità del team, equilibrio dello skill mix e competenze esperte sono essenziali per la sicurezza delle cure e la tenuta organizzativa. In questi setting, caratterizzati da elevata complessità e interdipendenza professionale, le assenze prolungate e le uscite permanenti non comportano solo una riduzione numerica dell’organico, ma anche discontinuità assistenziale, perdita di competenze, aumento del carico di lavoro e maggiore vulnerabilità organizzativa. Particolare rilievo assumono le risorse critiche infermieristiche, ossia professionisti con competenze specialistiche, esperienza consolidata o ridotta sostituibilità nel breve periodo. Obiettivo L’obiettivo della tesi è mappare le evidenze sulle conseguenze organizzative, professionali, formative e assistenziali della riduzione o instabilità delle risorse infermieristiche nei contesti ospedalieri ad alta intensità assistenziale, con particolare attenzione alle ricadute sui professionisti rimanenti. Sulla base delle evidenze, il lavoro propone inoltre una strategia organizzativa previsionale orientata al monitoraggio delle risorse critiche infermieristiche e alla lettura anticipata della vulnerabilità di struttura. Metodi È stata condotta una scoping review secondo il framework metodologico del Joanna Briggs Institute e il reporting PRISMA-ScR. La ricerca è stata effettuata su PubMed e CINAHL, includendo studi pubblicati tra il 2015 e il 2025, in lingua inglese, relativi a turnover, carenza di personale, instabilità della workforce, assenze prolungate e uscite permanenti nei contesti ospedalieri ad alta intensità assistenziale. Le evidenze sono state analizzate mediante sintesi descrittiva e tematica. Risultati Sono stati inclusi 17 studi. Le evidenze mostrano che la riduzione o instabilità delle risorse infermieristiche nei contesti ad alta intensità si associa a quattro principali aree di impatto: aumento del carico assistenziale e organizzativo per i professionisti rimanenti; peggioramento degli esiti e della sicurezza delle cure in presenza di staffing inadeguato o workload elevato; perdita di competenze, esperienza clinica e continuità del team; deterioramento del benessere professionale, espresso in termini di burnout, insoddisfazione lavorativa e intention to leave. Nel complesso, i risultati descrivono un possibile circolo vizioso in cui la perdita di risorse aumenta il carico su chi rimane, indebolisce lo skill mix e la continuità organizzativa, favorendo ulteriori condizioni di instabilità. Conclusioni La riduzione o instabilità delle risorse infermieristiche nei contesti ad alta intensità assistenziale non rappresenta soltanto un problema quantitativo di copertura dell’organico, ma una criticità organizzativa complessa, capace di incidere sulla continuità assistenziale, sulla sicurezza delle cure, sulla stabilità del team e sulla sostenibilità del lavoro dei professionisti rimanenti. Le evidenze raccolte sostengono la necessità di superare una gestione esclusivamente reattiva delle assenze e orientano verso strategie di lettura anticipata della vulnerabilità organizzativa. La proposta elaborata nella tesi prevede strumenti operativi, quali scheda di rilevazione, matrice aggregata di struttura e griglia trimestrale di riferimento, finalizzati a raccogliere eventi prevedibili o formalmente noti, attribuire loro un diverso peso organizzativo e monitorare nel tempo la concentrazione di criticità riferite alle risorse critiche infermieristiche. In questa prospettiva, la strategia previsionale non mira a eliminare l’incertezza, ma a rendere visibile ciò che l’organizzazione può già conoscere, supportando una programmazione più consapevole, tempestiva e orientata alla continuità delle cure.
Perdite di risorse infermieristiche nei contesti ad alta intensità assistenziale: dalla criticità organizzativa alla lettura anticipata della vulnerabilità
TARULLI, CRISTINA
2025/2026
Abstract
Background The reduction and instability of nursing resources represent a growing critical issue in high-acuity hospital care settings, where team continuity, skill mix balance and expert competencies are essential for patient safety and organizational resilience. In these settings, characterized by high complexity and professional interdependence, prolonged absences and permanent exits do not only result in a numerical reduction in staffing levels, but may also lead to care discontinuity, loss of competencies, increased workload and greater organizational vulnerability. Particular relevance is assumed by critical nursing resources, understood as professionals with specialist competencies, consolidated experience or limited short-term replaceability. Objective The objective of this thesis is to map the available evidence on the organizational, professional, educational and care-related consequences of the reduction or instability of nursing resources in high-acuity hospital care settings, with particular attention to the impact on the remaining professionals. Based on the evidence identified, the thesis also proposes an organizational forecasting strategy aimed at monitoring critical nursing resources and supporting the anticipatory assessment of structural vulnerability. **Methods** A scoping review was conducted according to the Joanna Briggs Institute methodological framework and reported in accordance with the PRISMA-ScR criteria. The literature search was carried out in PubMed and CINAHL, including studies published between 2015 and 2025, in English, concerning turnover, staff shortages, workforce instability, prolonged absences and permanent exits in high-acuity hospital care settings. The evidence was analyzed through descriptive and thematic synthesis. **Results** Seventeen studies were included. The evidence shows that the reduction or instability of nursing resources in high-acuity care settings is associated with four main areas of impact: increased care-related and organizational workload for the remaining professionals; worsening of patient outcomes and safety in the presence of inadequate staffing or high workload; loss of competencies, clinical experience and team continuity; and deterioration of professional well-being, expressed in terms of burnout, job dissatisfaction and intention to leave. Overall, the findings describe a possible vicious circle in which the loss of resources increases the workload of those who remain, weakens the skill mix and organizational continuity, and contributes to further conditions of instability. **Conclusions** The reduction or instability of nursing resources in high-acuity care settings is not merely a quantitative issue of staffing coverage, but a complex organizational criticality that may affect care continuity, patient safety, team stability and the sustainability of work for the remaining professionals. The evidence collected supports the need to move beyond an exclusively reactive management of absences and points toward strategies for the anticipatory assessment of organizational vulnerability. The proposal developed in this thesis includes operational tools, such as a data collection sheet, an aggregated structural matrix and a quarterly reference grid, aimed at identifying predictable or formally known events, assigning them different organizational weights and monitoring over time the concentration of criticalities related to critical nursing resources. From this perspective, the forecasting strategy does not aim to eliminate uncertainty, but to make visible what the organization can already know, supporting more informed, timely and care-continuity-oriented planning.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/27041