Evidence-based pathways to modernise emergency nursing in Italy: autonomy, accountability, and outcomes

Italian emergency nursing has not evolved in step with rising Emergency Department (ED) demand and increasing clinical complexity, contributing to overcrowding, delays, burnout, and inappropriate ED use. This paper synthesizes European models and evidence to outline a modernization agenda centred on professional autonomy, accountability, and outcomes. We propose implementing Advanced Nurse Practitioners to manage low- to moderate-acuity presentations through urgent care pathways, supported by master’s education and a clear scope of practice with audit. For prehospital care, we recommend an advanced practice profile for out-of-hospital emergency nurses enabling assessment, protocolised treatments, non-conveyance decisions, and activation of general practitioner and community services when chronic-care pathways are appropriate. System levers include adoption of a validated national triage system with training and recertification, reconfiguration of night-time demand via alternative community access and telehealth, and investment in nurse-led research networks and university pathways. Finally, competencies and responsibilities should be linked to contractual recognition, remuneration, and sustainable rostering. These actions aim to reduce inappropriate ED attendance, shorten call-to-treatment times, improve patient safety, and strengthen workforce retention, aligning Italy with European standards in emergency care.

1) Franchini R, Malerba P, Ragazzoni L, et al. Exploring the implementation of nurses' advanced competencies in emergency departments: a scoping review. Intern Emerg Med 2026;21:187-203. DOI: https://doi.org/10.1007/s11739-025-04145-5

2) De Raeve P, Davidson PM, Bergs J, et al. Advanced practice nursing in Europe-Results from a pan-European survey of 35 countries. J Adv Nurs 2024;80:377-86. DOI: https://doi.org/10.1111/jan.15775

3) Phillips K, Knowlton M, Riseden J. Emergency department nursing burnout and resilience. Adv Emerg Nurs J 2022;44:54-62. DOI: https://doi.org/10.1097/TME.0000000000000391

4) Kelen GD, Wolfe R, D’Onofrio G, et al. Emergency department crowding: the canary in the health care system. NEJM Catal Innov Care Deliv 2021;5:17.

5) Mason S, Coleman P, O'Keeffe C, Ratcliffe J, Nicholl J. The evolution of the emergency care practitioner role in England: experiences and impact. Emerg Med J 2006;23:435-9. DOI: https://doi.org/10.1136/emj.2005.027300

6) Zaboli A, Turcato G, Brigiari G, et al. Emergency departments in contemporary healthcare: are they still for emergencies? An analysis of over 1 million attendances. Healthcare (Basel) 2024;12:2426. DOI: https://doi.org/10.3390/healthcare12232426

7) Zaboli A, Mocchi T, Brigo F, et al. Enhancing patient safety in alternative emergency pathways: a comparative study of Italian and United Kingdom systems. Intern Emerg Med 2025; doi:10.1007/s11739-025-03997-1 DOI: https://doi.org/10.1007/s11739-025-03997-1

8) State of the world’s nursing 2025: investing in education, jobs, leadership and service delivery. Geneva, Switzerland: World Health Organization; 2025. Accessed November 28, 2025. Available from: https://www.icn.ch/sites/default/files/2025-05/SOWN%202025.pdf

9) Dawood M. The Emergency Practitioner's Handbook: For All Front Line Health Professionals. 1st ed. CRC Press; 2012.

10) Gonçalves-Bradley D, Khangura JK, Flodgren G, et al. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database Syst Rev 2018;2:CD002097. DOI: https://doi.org/10.1002/14651858.CD002097.pub4

11) Zaboli A, Brigo F, Unterholzer F, et al. Discrepancies between emergency transport modality and emergency department outcomes: an epidemiological analysis. J Public Health Manag Pract 2025;31:E338-46. DOI: https://doi.org/10.1097/PHH.0000000000002196

12) van Vliet R, Deddens GJ, Evenhuis R, Moors XRJ. A survey of the current nurse practitioner and physician assistant workforce in Dutch ambulance care. Int J Nurs Stud Adv 2022;4:100099. DOI: https://doi.org/10.1016/j.ijnsa.2022.100099

13) Ebben RH, Vloet LC, van Grunsven PM, et al. Factors influencing ambulance nurses' adherence to a national protocol ambulance care: an implementation study in the Netherlands. Eur J Emerg Med 2015;22:199-205. DOI: https://doi.org/10.1097/MEJ.0000000000000133

14) Holmberg B, Svensson A, Helge A, Bremer A. Self-determination in older patients: Experiences from nurse-dominated ambulance services. J Adv Nurs 2024;80:5018-28. DOI: https://doi.org/10.1111/jan.16152

15) Wästerhed J, Ekenberg E, Hagiwara MA. Ambulance nurses' experiences as the sole caregiver with critical patients during long ambulance transports: an interview study. Scand J Trauma Resusc Emerg Med 2024;32:6. DOI: https://doi.org/10.1186/s13049-024-01178-1

16) Mannion R, Exworthy M, Wiig S, Braithwaite J. The power of autonomy and resilience in healthcare delivery. BMJ 2023;382:e073331. DOI: https://doi.org/10.1136/bmj-2022-073331

17) Halo Group. Understanding NHS ambulance clinical roles: a guide to UK ambulance trusts. Halo Medical Group website. Published August 22, 2025. Accessed November 28, 2025. Available from: https://halogroup.uk/understanding-nhs-ambulance-clinical-roles-a-guide-to-uk-ambulance-trusts/

18) Schröder H, Beckers SK, Borgs C, et al. Long-term effects of a prehospital telemedicine system on structural and process quality indicators of an emergency medical service. Sci Rep 2024;14:310. DOI: https://doi.org/10.1038/s41598-023-50924-5

19) Dalla Valle Z, Ricciardi GE, Signorelli C, Renzi C. Variations in avoidable hospital admissions and emergency visits by primary care characteristics: an ecological study in Italy. Ann Ig 2024;36:227-33.

20) Tuasikal H, Dhamanti I, Mahmudah M. Nurses’ autonomy and its determinants in clinical practice: a scoping review. Health Leadership Qual Life 2025;4:700. DOI: https://doi.org/10.56294/hl2025700

21) Wietecha M. Rapid, accurate triage in ED crucial for patient outcomes. Emergency Nurses Association website. Published May 21, 2025. Accessed November 28, 2025. Available from: https://www.ena.org/news-publications/newsroom/rapid-accurate-triage-ed-crucial-patient-outcomes

22) Zaboli A, Brigo F, Cipriano A, et al. Assessing triage efficiency in Italy: a comparative study using simulated cases among nurses. Intern Emerg Med 2025;20:1167-76. DOI: https://doi.org/10.1007/s11739-024-03735-z

23) Zachariasse JM, van der Hagen V, Seiger N, et al. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019;9:e026471. DOI: https://doi.org/10.1136/bmjopen-2018-026471

24) Hinson JS, Martinez DA, Cabral S, et al. Triage performance in emergency medicine: a systematic review. Ann Emerg Med 2019;74:140-52. DOI: https://doi.org/10.1016/j.annemergmed.2018.09.022

25) Lingas EC. A narrative review of the carcinogenic effect of night shift and the potential protective role of melatonin. Cureus 2023;15:e43326. DOI: https://doi.org/10.7759/cureus.43326

26) Kasvi A, Iirola T, Nordquist H. Rethinking non-urgent EMS conveyance to ED during night-time - a pilot study in Southwest Finland. BMC Emerg Med 2023;23:95. DOI: https://doi.org/10.1186/s12873-023-00872-0

27) National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. NICE Guideline No. 94. London, England: National Institute for Health and Care Excellence (NICE); March 2018. Chapter 16, Emergency department opening hours.

28) Barbadoro P, Di Tondo E, Menditto VG, et al. Emergency department non-urgent visits and hospital readmissions are associated with different socio-economic variables in Italy. PLoS One 2015;10:e0127823. DOI: https://doi.org/10.1371/journal.pone.0127823

29) Joseph MJ, Summerscales M, Yogesan S, et al. The use of kiosks to improve triage efficiency in the emergency department. NPJ Digit Med 2023;6:19. DOI: https://doi.org/10.1038/s41746-023-00758-2

30) Dickson SJ, Dewar C, Richardson A, et al. Agreement and validity of electronic patient self-triage (eTriage) with nurse triage in two UK emergency departments: a retrospective study. Eur J Emerg Med 2022;29:49-55. DOI: https://doi.org/10.1097/MEJ.0000000000000863

31) Levin S, Toerper M, Hamrock E, et al. Machine-learning-based electronic triage more accurately differentiates patients with respect to clinical outcomes compared with the emergency severity index. Ann Emerg Med 2018;71:565-74.e2. DOI: https://doi.org/10.1016/j.annemergmed.2017.08.005

32) Gosselin M, Mabire C, Pasquier M, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med 2022;17:1803-12. DOI: https://doi.org/10.1007/s11739-022-03005-w

33) OECD. Remuneration of nurses. In: Health at a Glance 2025: OECD Indicators. Paris, France: OECD Publishing; 2025. Accessed November 28, 2025. Available from: https://www.oecd.org/en/publications/health-at-a-glance-2025_8f9e3f98-en/full-report/remuneration-of-nurses_9b98c70c.html

34) National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. Washington, DC: National Academies Press; 2021. Chapter 3, The nursing workforce.