The aim of this quasi-experimental before-after study is to evaluate whether the implementation of the Primary Nursing (PN) pattern of care improves nursing-sensitive outcomes in adult inpatients and nurse-related outcomes across hospital wards in Northern Italy. The main questions it aims to answer are: 1. What is the impact of the PN on inpatients' nursing-sensitive outcomes, including healthcare-associated infections, falls, pressure injuries, functional status, and patient satisfaction? 2. What is the impact of the PN on nurse-related outcomes, including burnout, missed nursing care, job satisfaction, and intention to leave? This study follows a multicentre, uncontrolled before-after design: in the pre-intervention phase, wards operated according to their existing nursing care models (functional or team nursing); this was followed by the implementation of the PN across all participating wards. The PN assigns each patient to a single reference nurse who is responsible for planning, delivering, and evaluating nursing care throughout the entire hospital stay. In the primary nurse's absence, an associate nurse ensures continuity by following the individualised care plan.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
1,708
Primary Nursing is a care delivery model in which each patient is assigned to a single reference nurse who assumes responsibility for planning, delivering, and evaluating nursing care throughout the entire hospital stay. In the primary nurse's absence, an associate nurse ensures continuity by following the individualised care plan. The model emphasises the nurse-patient therapeutic relationship, individual accountability, and active patient participation in care planning.
ASL CN1
Cuneo, Italy
AUSL Ferrara
Ferrara, Italy
AOU Maggiore della Carità
Novara, Italy
Azienda Ospedaliero-Universitaria San Luigi Gonzaga
Orbassano, Italy
Humanitas Gradenigo
Torino, Italy
healthcare-associated infection (HAI)
An infection acquired during hospitalisation, with onset on Day 3 or later, or earlier following an invasive device/procedure on Day 1-2. Patients were monitored for HAIs throughout their stay in the study ward, and the occurrence of HAIs was recorded by the nurse at patient discharge in both the pre- and post-PN implementation phases.
Time frame: From hospital admission to discharge (approximately 10 days)
New pressure injury
Localised damage to the skin and underlying tissue, typically over a bony prominence, resulting from pressure or pressure combined with shear forces. Patients were monitored for pressure injuries throughout their stay in the study ward, and the occurrence of new pressure injuries was recorded by the nurse at patient discharge in both the pre- and post-PN implementation phases.
Time frame: From hospital admission to hospital discharge (approximately 10 days)
Patient fall
Falls were defined as unexpected events in which the patient comes to rest on the ground, floor, or a lower level, excluding intentional changes in position. Patients were monitored for falls throughout their stay in the study ward, and the occurrence of falls was recorded by the nurse at patient discharge in both the pre- and post-PN implementation phases.
Time frame: From hospital admission to hospital discharge (approximately 10 days)
Discharge outcome
Categorised as discharged home, transferred to another facility, or in-hospital death. Discharge disposition was recorded by the nurse at patient discharge in both the pre- and post-PN implementation phases.
Time frame: At hospital discharge (approximately 10 days)
Length of hospital stay
Total number of days between admission to and discharge from the study ward for each patient in both the pre- and post-PN implementation phases.
Time frame: From hospital admission to hospital discharge (approximately 10 days)
Functional status (Barthel Index)
Barthel index: 10-item instrument measuring performance in basic activities of daily living; total scores range from 0 to 100, with higher scores indicating greater independence. The Barthel Index was administered to each patient at admission and at discharge from the study ward in both the pre- and post-PN implementation phases.
Time frame: At hospital admission and at discharge (approximately 10 days)
Patient satisfaction (Caring Behaviours Inventory, CBI)
Patient satisfaction was assessed using the validated Italian version of the Caring Behaviours Inventory (CBI), a 24-item instrument measuring patients' perceptions of nurses' caring behaviours across four dimensions: Assurance, Knowledge and Skill, Respectfulness, and Connectedness. Items are rated on a six-point Likert scale ranging from 1 (never) to 6 (always), with total scores ranging from 24 to 144; higher scores indicate a greater perception of caring behaviours. The CBI was administered to each patient at hospital discharge in both the pre- and post-PN implementation phases.
Time frame: At hospital discharge (approximately 10 days)
Nurse's burnout
Nurses' job-related stress was assessed using the Maslach Burnout Inventory - General Survey (MBI-GS), a 22-item instrument measuring three independent dimensions of burnout syndrome, each rated on a seven-point frequency scale ranging from 0 (never) to 6 (every day): Emotional Exhaustion (9 items): low risk ≤17, intermediate risk 18-29, high risk ≥30 Depersonalization (5 items): low risk ≤5, intermediate risk 6-11, high risk ≥12 Personal Accomplishment (8 items): low risk ≥40, intermediate risk 34-39, high risk ≤33 The MBI-GS was administered to the same nurses before and after PN implementation.
Time frame: baseline (pre-PN) and post-PN (approximately 21 months)
Intention to leave
Assessed using a single dichotomous item (Yes/No). The item was administered to the same nurses before and after PN implementation..
Time frame: baseline (pre-PN) and post-PN (approximately 21 months)
Missed nursing care
Missed nursing care was assessed using the Italian version of the MISSCARE Survey, a self-report questionnaire for nurses. Section A includes 24 nursing care interventions, rated on a 5-point Likert scale indicating how often each element was missed during the nurse's last shift, from 1 (always missed) to 5 (never missed). Section B includes 17 possible reasons for missed care, rated on a 4-point Likert scale from 1 (significant reason) to 4 (not a significant reason). The survey was administered to the same nurses before and after PN implementation.
Time frame: baseline (pre-PN) and post-PN (approximately 21 months)
Job satisfaction
Assessed using a 5-item Likert scale ranging from "totally dissatisfied" to "totally satisfied". The outcome was measured in the same nurses before and after PN implementation.
Time frame: baseline (pre-PN) and post-PN (approximately 21 months)
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