BackgroundThe nursing workforce is a key determinant of health system resilience, quality, and sustainability. In Italy, nurses receive significantly lower salaries compared to the OECD average, and the country has one of the lowest nurse-to-population ratios in Europe. This study examines the Italian nursing pay gap as a systemic vulnerability in health policy, with implications for the National Health Service's (NHS) capacity to deliver safe and continuous care.MethodsThis study follows a descriptive policy analysis approach integrated with comparative data analysis. Salary and workforce data were obtained from Organisation for Economic Co-operation and Development (OECD) datasets (2015-2024) and complemented with national and international institutional sources. The analysis was guided by Walt and Gilson's Policy Triangle and the Nursing Theory of Complex Adaptive Systems (NTCAS).ResultsItaly reports an average nursing salary of approximately USD 48,000 (PPP), about 21% lower than the OECD average, and a density of 6.2 nurses per 1,000 inhabitants compared with 9.4 internationally. In the selected country comparison, higher salary levels co-occurred with higher nurse density, while the policy analysis identified persistent constraints in remuneration, career development, workforce planning, and retention. Theoretical interpretation frames the pay gap as a systemic variable with potential consequences for quality, safety, and equity.DiscussionThe Italian pay gap reflects structural weaknesses in workforce governance rather than an isolated issue. Limited career pathways, migration, and workforce shortages further increase system vulnerability.ConclusionAddressing the nursing pay gap is a strategic priority to strengthen retention, reduce inequalities, and ensure the long-term sustainability of the NHS.

The specific quantitative relationship between the calculated mean total nursing hours per patient-day (derived from National Health Insurance Form 9) and in-hospital mortality in Japanese acute-care settings remains largely unexamined. This study aims to evaluate the clinical relevance and patient safety impact of actual nursing care hours by identifying practical thresholds below which patient mortality risk substantially increases. This retrospective, multicentre study included 75,708 patients admitted to general hospital beds between April 1, 2019, and March 31, 2020, across nine acute-care hospitals in Japan. Patients from Intensive Care Units and High Care Units were excluded to focus on general ward care. The main outcome measure was in-hospital mortality (dichotomous outcome). The mean daily nursing hours per patient was 3.88 h (median: 3.75 h). Mixed-effects logistic regression analysis showed that while higher nursing hours generally correlated with lower mortality, this risk reduction plateaued beyond 4.5 h. Compared to the 4.5-5.0 h care category (reference), patients receiving less than 4.0 h of care experienced a substantial increase in the odds of in-hospital mortality, with the risk elevating by 34%-52% (adjusted odds ratios ranging from 1.34 to 1.52). Our study provides evidence of a significant inverse association between actual nursing care hours and in-hospital mortality in Japanese acute care hospitals, suggesting that a minimum threshold of 4.0 h of actual daily nursing care may serve as a practical safety boundary for patient survival. These findings suggest that current staffing standards in Japan may warrant careful reconsideration from the perspective of patient safety.

IntroductionActive involvement of nurse leaders in policy advancement is considered crucial, particularly in Africa, where nurses constitute most of the health workforce. This review was conducted to determine factors that influence African nurse leaders' participation in policy development.MethodThe databases CINAHL and MEDLINE were searched to answer the review question. The search parameters were adjusted to include studies in English and between 2012 and 2025. The review partially followed the JBI methodology for evidence synthesis. Two reviewers conducted data extraction and independently assessed all included studies. The PRISMA guideline guided study selection reporting. Results were thematically analysed.ResultsSeven studies were identified. The review reveals a spectrum of challenges and opportunities impacting nurse leaders' involvement in policy development. The main theme that emerged from the included studies was enablers and constraints in health policy development, with four subthemes. Namely: enablers of nurse leaders' engagement, perceived value, knowledge and gendered influences, limited and peripheral participation, structural, organisational and individual barriers.ConclusionPersonal, structural and institutional factors were enablers and bottlenecks that limit involvement of African nurse leaders in health policy. Implementing strategies such as leadership support, education, professional recognition, organisational empowerment, and governmental support could elevate the role of nurse leaders in policy development, contributing to a more robust and inclusive healthcare policymaking landscape in Africa. Additional case studies and longitudinal research are needed to examine the factors influencing nurse leaders' involvement in policy development across different African contexts.

Forty-one states in the United States that adopted Medicaid expansion through the Affordable Care Act reached historically low rates of uninsured that have endured through 2025. The One Big Beautiful Bill Act (OBBBA) signed into law on 4 July 2025 contains numerous provisions that place Medicaid expansion coverage at risk. Resulting changes to Medicaid expansion include work requirements, a decrease in federal match funds for expansion programs, cost-sharing fees for recipients, stricter eligibility requirements, more frequent re-enrollment periods, and limitations on family planning services provided by organizations that also provide abortion services. Because each state with Medicaid expansion has implemented this program differently, states will be impacted differently and with various timelines. The impact of OBBBA on Medicaid expansion in the state of New Hampshire is discussed in detail and examined from the perspective of a community mental health center. Nursing implications are discussed within the framework of Fawcett and Russell's conceptual model of nursing and health policy. Recommendations for advocacy and the nurse's role as an important stakeholder are discussed.

Background: U.S. state licensing restrictions requiring written practice agreements for certified nurse-midwives (CNMs) lack evidence of improved patient safety and instead contribute to maternity care workforce shortages. The objective of this study was to examine restrictive state licensing and practice policies for CNMs to identify the problem they were intended to solve. Methods: This was a qualitative content analysis of state policies that require CNMs to obtain written practice agreements, collected in January 2022, using the "What's the Problem Represented to be" framework. Analysis was completed by two midwife researchers with interpretation assistance from a panel of expert midwives. Results: Variation in written practice agreement requirements across states demonstrated that the regulations echoed historical physician complaints about the "midwife problem" first articulated in 1912. Effects of this problemization are inaccurate workforce data and persistent maternity care shortages. The problemization is maintained by the physician organization's advocacy against midwifery autonomy. The COVID-19 pandemic policy modifications demonstrated that states could eliminate restrictions when prioritizing access without compromising safety. Conclusions: Restrictive CNM licensing regulations perpetuate professional gatekeeping rather than ensuring public safety, directly contributing to maternity care shortages. State legislatures should eliminate written practice agreement requirements for CNMs and adopt evidence-based criteria focused on practitioner qualifications rather than supervisory relationships. National nursing organizations should advocate for regulatory reform, prioritizing healthcare access. Removing these barriers can expand the maternity care workforce and improve access to reproductive healthcare, particularly in underserved communities.

Nurses are central to palliative care, yet their community contributions remain undervalued. This study aimed to clarify how political and professional documents conceptualize nursing autonomy in community palliative care. Using the READ (Reading materials, Extracting data, Analyzing data, Distilling findings) methodology, a comparative documentary analysis was conducted in the Netherlands, Portugal, Spain, and the United Kingdom. Sixty-eight strategic documents, identified through systematic searches and expert consultation, underwent targeted qualitative content analysis, combining deductive coding with inductive theme generation. Results reveal a multilevel framework of professional representation: (1) micro-level interventions; (2) meso-level contextual determinants; and (3) macro-level systemic dimensions. A critical tension exists between technical visibility and formal authority. In Portugal and Spain, robust taxonomic infrastructures provide high clinical visibility, yet legal frameworks prioritize "system breadth" over specialized nursing roles. The UK and the Netherlands emphasize "vertical career trajectories," where specialty recognition and advanced education act as levers for clinical agency and nurse-led care. While all country policies prioritize home-based care, differences in how they improve autonomy may influence workforce sustainability and professional migration. These findings suggest that failing to formalize-specialized roles creates "gray zones" of responsibility. Strengthening the structural conditions that support nursing autonomy, including clear role recognition and aligned policy mechanisms, is essential for ensuring timely access to care and the long-term viability of community-based models. This study provides a roadmap for policymakers to reconcile professional agency with the universal right to high-quality care at the end-of-life.

Fuel2Flourish is a nurse-led initiative designed to center the voices of nurses, who are active leaders within the National Association of Hispanic Nurses (NAHN), as trusted messengers and role models in advancing the nutritional and emotional well-being of school-age children. Operating across nine local chapters in different states, this community-rooted program was built in partnership with national policy stakeholders and community leaders to respond to what children and families need most: support they can trust from people who understand their lived experiences. This study employed qualitative methods to gain feedback from chapter program leads to examine implementation processes and early perceived impacts. Through bilingual education toolkits, culturally relevant storytelling, and nurse-led workshops, nurses engaged directly with students, parents, and educators to create safe, inclusive spaces for learning and connection. Despite limited budgets and varied local conditions, Fuel2Flourish thrived by aligning clinical nursing expertise with community insight and action. This article describes the partnerships formed, and the early signs of impact seen on the ground. Fuel2Flourish shows what's possible when nurses are equipped and empowered to lead, bringing creative, locally tailored solutions to the forefront of child health promotion.

Systemic discrimination within nursing and healthcare institutions continues to shape inequitable workforce experiences and leadership opportunities for 2SLGBTQI+, Indigenous, and Black nurses. These inequities have implications not only for the nursing profession but also for health system performance and the delivery of culturally safer care. In 2024, the Registered Nurses' Association of Ontario (RNAO) established the Health Equity Consortium (HEC) to coordinate collective action across three equity-focused nursing interest groups. This paper argues that the HEC constitutes a policy-relevant organizational response to structural inequities in nursing, demonstrating how professional associations can operationalize equity, diversity, and inclusion through governance, advocacy, and capacity-building mechanisms. Guided by Critical Social Theory, the analysis draws on the concepts of liberation and conscientization to examine how shared experiences of marginalization are mobilized into coordinated policy and practice interventions. The paper highlights key outcomes associated with the HEC, including the advancement of anti-racism initiatives, the integration of equity-focused content into professional development and education, and the creation of leadership pathways for underrepresented nurses. It further illustrates how collective advocacy within a formal organizational structure can influence policy priorities, strengthen accountability, and support system-level change. The HEC provides a transferable model for embedding equity within professional governance and health policy frameworks. Its approach underscores the role of nursing leadership in advancing structural change and offers insights for policymakers and health organizations seeking to address workforce inequities and improve the inclusiveness of healthcare systems.

The United States continues to struggle with the opioid crisis, exacerbated by shifting political priorities and the aftermath of the COVID-19 pandemic. This critical review analyzes the One Big Beautiful Bill Act (OBBBA) and its implications for opioid use disorder (OUD) treatment through the lens of the Multiple Streams Framework. Drawing on Medicaid data, and evidence from state-level implementation, most notably Arkansas, this article evaluates how work requirements and administrative restructuring threaten access to medications for opioid use disorder (MOUD), harm reduction services, and continuity of care. Medicaid expansion has been influential in increasing treatment availability, reducing overdose deaths, and supporting rural health systems; however, OBBA's mandated community engagement requirements threaten the progress made in combatting this epidemic. These restrictions are projected to cause 11.8 million Americans to lose health insurance, disproportionately affecting individuals with OUD who already encounter significant barriers to care. Prior evidence demonstrates that similar policies failed to increase employment, generated widespread confusion, and produced significant losses in coverage. The losses in coverage lead to delayed care, medication interruptions, and worsened health outcomes. There are also substantial financial and operational burdens associated with national implementation, including an estimated $200 million in administrative costs, diversion of resources away from clinical services, and reduced capacity for evidence-based treatment. This analysis concludes that OBBBA is likely to undermine progress in reducing overdose mortality, amplify health disparities, and place added strain on healthcare systems, particularly in rural communities, which have experienced the most significant effects of the opioid epidemic.

AimIn the United States, 82% of American Indian/Alaska Native (AI/AN) women face violence during their lifetimes, compared to 45.1% of women from all other racial groups. We examined the evolution and impact of the Violence Against Women Act (VAWA) on AI/AN women.Design and MethodsA policy analysis of VAWA and its impact on AI/AN women survivors of violence was completed through the lens of the Tribal Critical Race Theory.ResultsThe findings identified that prior to VAWA (2013), there were significant legal gaps regarding the prosecution of non-Native offenders on tribal lands. Following multiple reauthorizations of VAWA, there has been a reported increase in services for AI/AN women, yet challenges persist due to limited data and jurisdictional complexities. While VAWA has made strides in addressing violence against AI/AN women, systemic issues such as historical trauma, racism, and invisibility continue to hinder effective responses. The complexity of jurisdictional frameworks further complicates law enforcement efforts on tribal lands.ConclusionThis policy analysis underscores the need for continued advocacy for comprehensive data collection and more robust legislative measures that prioritize the unique circumstances of AI/AN communities. Additionally, the analysis can inform policymakers, community leaders, and advocacy groups on the necessity of addressing systemic factors that contribute to violence against AI/AN women, such as the jurisdictional complexities on sovereign Native lands. To enhance policy effectiveness, we must take a collaborative approach with tribal communities and ensure that AI/AN voices are integral to the conversation on violence against women.

Nurses' involvement in public and policy debates is increasingly recognised as essential for shaping health care systems, yet their voices remain largely invisible. When nurses do engage publicly, they may act as public opinion leaders, using their professional expertise and credibility to influence policy discussions. Little is known, however, about how public opinion leadership (POL) manifests in practice and what motivates nurses to take on such a role. A proposed health care reform in the Netherlands, known as the BIG2 proposal, triggered an unexpected wave of nurses speaking up in national media and on social platforms. This study explores how POL manifested during this reform and what motivated nurses to raise their voices. A qualitative design was used, combining a thematic and abductive approach. Twelve semi-structured interviews were conducted with Dutch nurses who publicly responded to the reform through newspapers or social media. The findings show that nurses who engaged in POL acted from moral conviction and professional credibility, rather than formal authority. Their motivation stemmed from feeling misunderstood or undervalued, which evoked emotions such as frustration and anger. Responsibility, encouragement, and solidarity sustained their engagement. Nurses used social and traditional media to connect with peers, journalists, and politicians, making their leadership visible and collective. POL appeared as a collective process grounded in moral conviction, professional expertise, and mutual support. These findings highlight how nurses can extend their influence beyond clinical settings and contribute to shaping health policy debates.