Nursing Personnel Convention, 1977 (No. 149) - Italy (Ratification: 1985)

Direct Request (CEACR) - adopted 2023, published 112nd ILC session (2024)

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Article 2 of the Convention. National policy concerning nursing services and nursing personnel. The Committee welcomes the detailed information provided by the Government on the application of the Convention, including legislation, collective bargaining agreements and other relevant documents attached. With respect to the application of Article 2 of the Convention, the Committee notes the Government’s indication that the National Health Plan (NHP) (Patto della Salute) 2019–21 aimed to further optimize good governance in the health sector, improve the quality of health services, and equity and universal access to health services. The NHP 2019–21 was approved on 18 December 2019, together with a budget and program, and includes the strengthening of human resources as one of its principal objectives. The Committee notes the Government’s indication that, according to data available from the National Statistics Office (ISTAT), in 2017, there were 406,000 nurses in employment, including paediatric nurses. Despite an increase in the number of nurses employed in different areas of the National Health Service (Servizio Sanitario Nazionale “SSN”), nursing personnel continue to be concentrated in hospital services, where 78 per cent of nurses were employed in 2016. Women continue to outnumber men in the profession, making up almost 75 per cent of the nursing workforce, while men make up only one out of every four nurses. According to the European Observatory on Health Systems and Policies report “Italy: Health System Summary” (December 2022), the acute lack of nurses in the country persists. The number of nurses per 100,000 inhabitants in Italy is considerably lower than the EU average, especially in lower-income regions (626 compared with 835). In addition to shortages, there are also regional imbalances in the numbers of healthcare workers across the country. The report attributes the causes of the shortage to declining investment in health personnel, a reduction in the overall number of health workers, including both physicians and nurses, and a deterioration of working conditions, especially in regions under recovery plans. In respect of gender disparities, the report notes that, with women earning 24 per cent less than men, Italy ranks among the worst EU countries for overall working conditions of female health professionals. Lastly, the report indicates that in terms of health worker mobility, Italy has experienced an increase in outflows, especially among young practitioners, with a simultaneous increase in inflows for certain categories of health professionals, such as nurses, accompanied by attempts to ease the entry process to respond to workforce shortages. As of 2012, foreign nurses made up 10 per cent of the total nursing workforce. Following the multiple challenges faced by the country during the COVID-19 pandemic, the Government submitted a National Recovery and Resilience Plan (NRRP), which was approved by the European Union on 31 July 2021. The NRRP sets out the investment and development priorities for Italy from 2021 through 2026 and identifies six primary missions, one of which (mission 6) focuses wholly on healthcare. The NRRP indicates that the COVID-19 pandemic highlighted the need to strengthen the capacity of the SSN to provide adequate services across the entire country, particularly given the aging of the population, a significant and growing percentage (40 per cent) of whom suffer from chronic diseases. The NRRP aims to make the healthcare service more accessible to citizens, considering homes as the first point of care. To this end, interventions include the creation of 1,228 community homes by 2026 as places of access and care of chronic patients, distributed throughout the country, and strengthening of home care and telemedicine, with a focus on patients over the age of 65 with chronic illnesses. The Committee notes that, in May 2020, the Government formalized the role of “family and community nurses” to strengthen home-based care and support the operation of new special units for continuity of care (Unità Specialli di Continuità Assistenziale), allocating €480 million to hire some 9,600 family and community nurses in 2021. The Committee takes note of these developments with interest as they demonstrate Italy’s recognition of the importance of significantly increasing investment in the health sector with a view to anticipate the rise of the demand for nurses in the near future. In this respect, it notes that, according to the OECD report “Health at a Glance: Europe 2022”, the demand for nurses is expected to continue to rise in coming years, due to the aging population and the retirement of large numbers of nurses in the EU region. In comparison with the EU average of 8.3 nurses per 1,000 population in 2020, the OECD notes that Italy has relatively low numbers of nurses. The Committee requests the Government to provide with its next report detailed updated information, including statistical data disaggregated by sex, age and region, on the nature, scope and impact of measures taken under the NRRP to strengthen the SSN and to indicate whether it is foreseen to carry out an assessment of the situation upon the plan’s expiry in 2026 with a view to feeding into the design of the national policy concerning nursing services and nursing personnel. In particular, the Committee would like the Government to supply information on measures taken or envisaged to invest in education and training and improve working conditions, including career prospects and remuneration, to attract and retain both women and men in the nursing profession as well as to increase the quantity, quality and equitable distribution of health professionals, including nursing personnel.

Articles 3 and 4. Nursing education and training. The Government reports that the educational and training requirements for nursing personnel have remained unchanged since the adoption of Ministerial Decree No. 270 in 2004, which introduced a 3+2 approach to training. This approach involves a 3-year degree program to ensure students gain a strong foundation in general scientific topics and specific knowledge, followed by an optional 2-year course for advanced training in specialized fields. Additional qualifications such as specialization diplomas, research doctorates, and master’s degrees are also available. The Government has introduced measures to mandate continued training for nursing personnel to update their professional skills. A new manual on continued training, effective since January 1, 2019, requires health professionals to complete 150 credits of continuing training every three years. Despite a significant shortage of nurses in the country, the Government has increased the number of openings for nursing students through Ministerial Decree No. 616 in July 2019, adding 311 places, bringing the total to 15,069. It is noted that the Ministry of Education, University, and Research had already increased the total openings by 308 the previous year, resulting in a gain of 619 places in two years, which was considered the maximum achievable given the teaching capacity in Italian universities. The Committee requests the Government to continue providing information on the nature and impact of measures taken to progressively increase the number of places available for nursing while at the same time continuing to strengthen and expand the teaching capacity of nursing schools.It requests the Government to provide detailed updated information on ongoing developments with respect to the national system of education and training for nursing personnel, including statistical data on the number of students and the number of graduates, disaggregated by sex and region.

Articles 5 and 6. Collective bargaining in the health sector. The Committee notes the text of the collective bargaining agreement for health sector workers 2016–18 transmitted by the Government. It further notes the information provided by the Government in response to the Committee’s previous comments concerning the procedures governing the resolution of employment disputes in the nursing sector. The Committee requests the Government to continue providing updated information with respect to collective bargaining in the nursing sector, including updates in relation to dispute settlement through negotiations or mechanisms that ensure the confidence of the parties. Please also continue to supply information on how it is ensures that nursing personnel enjoys conditions at least equivalent to the those of other workers, including as regards education, training, occupational safety and health, employment, remuneration and other working conditions.

Article 7. Occupational safety and health of nursing personnel. Noting the significant impacts of the COVID-19 pandemic on health workers, including nursing personnel, during the reporting period, the Committee notes with interest measures taken in the context of the pandemic to provide specific protections for these workers. In particular, the Committee notes the health and safety protocol signed on 25 March 2020 by the Italian General Confederation of Labour (CGIL), the Italian Confederation of Workers’ Trade Unions (CISL) and the Italian Labour Union (UIL) with the Ministry of Health, which sets out standards of protection for health staff, including provision of personal protective equipment and emergency measures aimed at maintaining and increasing staffing. Noting the elevation of the right to safe and healthy working conditions to the rank of a fundamental right at work, the Committee wishes to invite the Government to indicate in its next report how the new national policy concerning nursing services and personnel will be used to continuously adapt national occupational safety and health regulatory framework to the special nature of nursing work and of the environment in which it is carried out so as to better prevent, minimize and address occupational risks for this category of workers.

Direct Request (CEACR) - adopted 2009, published 99th ILC session (2010)

Article 2 of the Convention. National policy concerning nursing services and personnel. The Committee notes the detailed information and attached documents provided by the Government. It notes, in particular, the latest National Health Plan, 2006–08, which outlines, with respect to human resources in the health sector, the reform of nursing education and continuous professional training. It also notes the Government’s indication that the new National Health Plan is based on the premise that the progressive ageing of the population will radically change the demand for goods and services in the health sector and will influence the health professions with the consequent need for more nurses and general practitioners. The National Health Plan continues to strengthen the decentralized structures of the health services while recognizing the fundamental central role of the Ministry of Health. The Committee understands that Italy faces a serious problem of shortage of qualified nurses and this is reflected in recent migration laws which explicitly maintain open entry for nurses and carers for older people. It would be grateful if the Government would continue providing documented information on the implementation of the current National Health Plan, including any specific programmes, initiatives or other activities carried out or planned in the field of education and training of nursing personnel, and the improvement of their employment and working conditions (especially as regards the reorganization of the nursing workforce and professional structure, workload and stress, instability and precarious contractual conditions, career prospects, labour shortage, remuneration levels, etc.). It would also appreciate receiving a copy of the next National Health Plan, 2009–11, once adopted.

Articles 3 and 4. Nursing education and training. The Committee notes the documents provided by the Government, such as the Agreement of 13 March 2003 concerning the objectives and programmes of continuous training or the Agreement of 16 December 2004 concerning the recognition of the university degrees obtained under the previous education system. It requests the Government to continue keeping the Office informed of the progress made in the ongoing reform of the system of education and training of the nursing personnel.

Articles 5 and 6. Collective bargaining in the health-care sector. The Committee notes the Government’s indication that the latest national collective agreement for National Health Service (NHS) personnel was signed on 10 April 2008 and applies to all NHS personnel with an indefinite or fixed-term contract of employment, excluding directors. It would be grateful if the Government would continue providing information concerning collective bargaining in the health sector, and in particular, any specific benefits or standards referring to education, training, or employment and working conditions of nursing personnel.

Article 7. Occupational safety and health of nursing personnel. The Committee notes the Government’s indication that a single act on occupational safety and health (Legislative Decree No. 81 of 9 April 2008) was adopted, which integrates Legislative Decree No. 626 of 24 September 1994 on workers’ safety and health. It also notes the various guidelines issued by the National Institute for Occupational Safety and Prevention (ISPESL) concerning specific risks to nursing staff working in units, such as units using ionizing radiation, first aid units and maternity units. While recognizing the Government’s efforts made in the field of general occupational safety and health, the Committee requests the Government to indicate any specific measures taken or envisaged in order to improve existing laws and regulations on occupational safety and health in view of the particular risks and hazards to which the nursing profession is exposed.

Part V of the report form. Application in practice. The Committee notes that, according to the statistical information provided by the Government, in 2006, there were 265,444 nurses employed in the NHS (64,045 men and 201,399 women). It also notes the number of students who graduated from nursing schools in 2007, as well as the number of nursing personnel by region. The Committee would be grateful if the Government would continue supplying up to date information concerning the application of the Convention in practice.

Direct Request (CEACR) - adopted 2004, published 93rd ILC session (2005)

The Committee takes note of the information provided in the Government’s detailed report and the attached documentation, in particular the adoption of Legislative Decree No. 229 of 19 June 1999 on the rationalization of the National Health Service pursuant to section 1 of Act No. 419 of 30 November 1998, and of Act No. 251 of 10 August 2000 on nursing and related professions.

Article 2, paragraphs 1 and 2, of the Convention. The Committee notes that following the reorganization of the health system, health care planning is assured through the National Health Plan covering a three-year span which specifies the aims and objectives of integrated local authority health and social welfare services, the basic training needs of nursing staff, as well as the development of human resources. According to the Government’s indications, various institutional changes have taken place redefining the responsibilities of the State and the regions in respect of health matters with a view to furthering decentralization and recognizing the fundamental role of the regions in the programming, organization and management of health services. More concretely, under Constitutional Act No. 3/2001 of 8 March 2001 on amendments to Title V of Part Two of the Constitution and the Agreement of 8 August 2001 between the State and the regions on transfer of resources to the regions and local authorities responsible for human health, the State formulates the principles and objectives in matters of public health but their implementation is the exclusive responsibility of the regions. The Committee requests the Government to continue to supply information on the operation of the new decentralized health structures and its practical implications for nursing personnel, especially in terms of work reorganization, workload and stress, career prospects and remuneration.

Article 3. The Committee notes that the National Health Plan 2003-05 places particular emphasis on promoting and intensifying continuous training activities for nursing personnel, while the National Commission on Continuing Training, established in 2000 and extended on 1 February 2002, introduced lifelong training schemes for the health sector paying particular attention to the harmonization of the national training system with European training standards and requirements. The Government reports that university nursing education has been reformed and that the Ministerial Decree of 2 April 2001 on health professions sets out the specific requirements and academic qualifications for the practice of nursing. The Committee would be grateful if the Government would forward a copy of the National Health Plan 2003-05 and elaborate on its practical implementation and the results obtained in terms of improving the quality of nursing care, promoting knowledge and skill enhancement for nursing personnel and ensuring sufficiently rewarding working conditions for the practice of the nursing profession, especially in the light of the Munich Declaration of the European Health Ministers of June 2000 regarding nursing and midwifery and the WHO European Strategy for Nursing and Midwifery Education.

Articles 5 and 6. The Committee notes the terms of the Integrated National Collective Agreement for the health sector of 20 September 2001, and the National Collective Agreement for the health sector for the financial biennium 2000-01, also dated 20 September 2001. The Committee requests the Government to continue supplying concrete information on special arrangements or benefits, as may be provided for in national laws and regulations or collective agreements, especially in relation to remuneration, working time and social security, which are commensurate to the socio-economic needs and responsibilities of nursing personnel and which take account of the constraints and hazards inherent in the profession.

Article 7. The Committee notes that the Government refers to Legislative Decree No. 626 of 24 September 1994 on workers’ safety and health which identifies specific risks related to exposure to chemical, physical or biological agents and further indicates that the Higher Institute for Prevention and Safety in the Workplace (ISPESL) has produced risk assessment guidelines for the health sector. The Committee also notes the Government’s indication that by a Ministry of Health Decree of 31 December 2002, the National Commission for the Prevention of AIDS and Emerging and Re-emerging Infectious Diseases was reconstituted for one year, among other things, to monitor epidemiological trends particularly with regard to the spread of infections among risk groups. The Committee would appreciate being kept informed of any new measures or initiatives regarding the adaptation of existing laws and regulations on occupational safety and health to the special nature of nursing work.

Part V of the report form. The Committee would be grateful to the Government for supplying detailed information on the practical application of the Convention, including for instance up-to-date statistics on the number of nurses employed in the public and private sectors, the nurse-to-population ratio, the number of students attending nursing schools, the number of nurses prematurely leaving the profession, copies of official publications or studies (e.g. reports of regional health service agencies (ASSR)) addressing labour and employment issues concerning nursing services and nursing personnel, as well as any practical difficulties encountered in the implementation of the Convention.

Direct Request (CEACR) - adopted 1999, published 88th ILC session (2000)

1. The Committee takes note of the information and legal texts (laws, decrees, regulations and collective bargaining agreements) communicated by the Government in its report concerning Article 1, paragraph 2 (scope of application), Article 1, paragraph 3 (nursing care and services on a voluntary basis), Article 2, paragraph 1 (policy concerning nursing services), Article 2, paragraph 2(a)(b) (education and training and remuneration), Article 2, paragraph 3 (consultation with the employers' and workers' organizations), Article 3, paragraph 1 (nursing education and training), Article 4 (requirements for the practice of nursing), Article 5, paragraph 3 (settlement of disputes) and Article 6 (working conditions).

2. The Committee refers to its previous comments on the following provisions:

Article 2, paragraph 2. The Committee takes note of the information of the Government that:

-- career opportunities in the clinical area and management are scarce;

-- in the next five years demand for nursing personnel will exceed supply by at least 40 per cent; and

-- representatives of professional nurses consider that remunerations are inadequate, especially in relation to the responsibilities borne by middle and senior management.

The Committee recalls that according to this provision measures should be adopted to provide the quantity and quality of nursing care necessary for attaining the highest possible level of health for the population. The Committee therefore requests the Government to continue supplying information on the education and training courses, employment and working conditions, including career prospects and remuneration, which are likely to attract persons to the profession and retain them in it.

Article 2, paragraph 3. The Committee takes note of Legislative Decree No. 115 of 31 March 1998 regulating the organization of the Agency for Regional Sanitary Services and of the information of the Government according to which:

-- the drafting of a national law to ratify the organizational arrangements already implemented in many Italian regions that have autonomous legislative powers with regard to health;

-- nursing services have been set up under this regional legislation which provide for an organizational structure headed by a nurse with management functions; and

-- the bodies responsible for developing and implementing these policies are: (a) for general policies: the Ministry of Health in concert with other ministries concerned as directed by the Council of Ministers; (b) for regional policies: health councils following the same pattern as central government; and (c) for local policies: management boards of individual health institutions.

The Committee hopes that the Government's next report will state that the abovementioned national law has been adopted and that a copy of this text will be communicated.

Article 5. The Committee takes note of the information supplied in the Government's report according to which participation of nursing personnel at the National Health Service level is not regulated yet by the State. However, the Committee recalls that the Government has informed in its previous report that a National Committee was established by decree of the Ministry of Health of 7 November 1991, for verifying and revising the quality of services at the national level, and that nursing personnel were represented by three members from the National Federation (IPASVI). The Committee therefore requests the Government to provide a clarification on this issue. The Committee takes note also of the information contained in the report that some regions have passed legislation on nursing service planning. It requests the Government to communicate copies of this legislation. The Committee recalls that in its previous comments it has requested the Government to provide information on the measures planned or taken to establish working groups to promote the quality of health care at the level of the individual hospitals, in accordance with section 2, subsection 2, of the decree of 13 September 1988. The Committee hopes that the Government will provide information on this issue.

3. Article 7. The Committee takes note with interest of the information provided by the Government in its report according to which in matters of occupational safety and health in general, and, with particular reference to biological risks and the risk of accidental exposure to the HIV virus, the Government and the regional and local authorities may take primary prevention measures, run information campaigns and issue specific regulations to safeguard, as far as possible, the work of nursing personnel. It also takes note of the various texts communicated by the Government with its report on this matter such as the informative brochure on biological risks for nursing personnel; Act No. 5 of 5 June 1990 approving the programme of urgent intervention on prevention and measures to combat AIDS, and Decree No. 235 of the Ministry of Health of 28 September 1990 on protection against occupational exposure to HIV within the structure of the Health Service in both the public and private sectors. In relation to its general observation of 1990, reiterated in 1994, the Committee requests the Government to continue providing information on the measures taken or contemplated regarding the working conditions of the nursing personnel who are infected or considered to be infected by HIV.

Direct Request (CEACR) - adopted 1994, published 81st ILC session (1994)

The Committee notes the information in the Government report concerning Article 1, paragraph 3, of the Convention (voluntary nursing personnel), Article 2, paragraph 2(b) (employment and working conditions), Article 3 (nursing education and training) and Article 7 (adaptation of laws to the special nature of nursing work). It also notes the observation received from the Trade Union Association for Petrochemical and Allied Enterprises with State Participation (ASAP), concerning the general working conditions of nursing personnel in undertakings. It requests the Government to provide additional information on the following points:

Article 1, paragraph 2, of the Convention. The Committee notes that the status of nursing personnel of health institutions that do not, or only partly, come under collective agreements, is regulated under private law, by the Act on Labour Relations and by the Statute of Workers, as far as applicable. Furthermore, these workers have to observe the regulations of the individual curative institutions. The Committee asks the Government to provide samples of such regulations.

Article 2, paragraph 3. The Committee notes from the Government report that the National Health Council has been partly superseded by the "State-Region Conference" attached to the Presidency of the Council of Ministers. Please indicate how and to what extent the organizations of employers and workers are consulted in this body. The Committee further notes that another part of the former Council's functions will be transferred to the "Agency for Regional Sanitary Services". The Committee asks the Government to communicate the Decree of the Minister of Health, regulating the organization of this Agency. It further requests the Government to provide information on the mechanisms for future consultations with the employers' and workers' organizations within the new Agency.

Article 5. The Committee notes the information on the committees for verification and revision of the quality of services at the national and regional level. It asks the Government to indicate what measures are planned or taken to establish, in accordance with section 2, subsection 2, of the Decree of 13 September 1988, working groups to promote the quality of health care at the level of the individual hospitals, and to indicate the procedures governing the participation of nursing personnel in these bodies.

Direct Request (CEACR) - adopted 1990, published 77th ILC session (1990)

The Committee takes note of the Government's first report. It requests the Government to provide additional information on the following points.

Article 1, paragraph 2, of the Convention. The Committee requests the Government to provide information on the status of the nursing personnel of health institutions that do not come under collective agreements, institutions that have not obtained or requested classification as per Act No. 132 of 12 February 1968 concerning hospital establishments and hospital care, or mutual benefit society health institutions.

Article 1, paragraph 3. The Committee requests the Government to provide information on the agreements which, within the framework of the health programme and national legislation, govern the relationship between the local health units and the associations of volunteers freely established to assist the National Health Service.

Article 2, paragraph 2(b). The Committee requests the Government to provide information on the measures taken or contemplated concerning employment and working conditions, particularly in respect of career prospects and remuneration likely to attract persons to the profession and retain them in it.

Article 2, paragraph 3. The Committee notes that, by virtue of section 8 of Act No. 833 of 23 December 1978 to establish the National Health Council, the Council shall include amongst its members ten health experts appointed by the National Council for the Economy and Labour. The Committee requests the Government to provide particulars of the procedures for appointing these representatives and to indicate the number of representatives of the employers' and workers' organisations concerned who participate in the above Council.

Article 3, paragraph 1. The Committee requests the Government to provide a copy of the text of the Decree of 15 February 1972 to modify the curricula of schools for nurses and auxiliary nurses, if it is still applied. If this text is no longer applied, please indicate the provisions that apply to the training of auxiliary nurses.

Article 5, paragraph 1. The Committee notes that section 2, subsection 2, of the Decree of 13 September 1988 to issue the hospital staff rules, provides for various working groups to be set up in each hospital with a view to promoting the quality of health care. The Committee requests the Government to indicate the procedures governing the participation of nursing personnel in the working groups established in hospitals.

Article 7. The Committee notes from the Government's report that the general provisions of the legislation governing health and work apply to nursing personnel. It requests the Government to provide information on the measures taken or under consideration to adapt these measures on health and safety, which apply to all workers, to the special nature of nursing work.

The Committee requests the Government to continue to provide information on agreements concerning nursing personnel.