A Mur decree in the Senate introduces three clinical master’s degrees for nurses: more autonomy, recipes for devices and new emergency skills. Doctors in revolt: “confusing roles, who is responsible if it goes wrong?”.
They are not doctors. But they won’t even be “just” nurses anymore. They will be able to prescribe, decide and act in (partial) autonomy, without the approval of a white coat with a medical degree. A decree from the Ministry of University and Research which is being examined by the Senate begins to redraw the map of power in Italian hospitals, and introduces three new clinically oriented master’s degrees for the nursing profession: giving life to a hybrid and controversial figure. A quasi-doctor? A deputy doctor? The debate is heated.
The staffing crisis and the urgency of community houses
What is certain is that in Italy there is a shortage of 65 thousand nurses, and having to “fill” the Community housesto these numbers we will need to add at least another 20 thousand. The profession, which today can be practiced after a three-year degree, is no longer attractive: competitions are deserted and more and more nurses decide to go to work in countries such as the United Arab Emirates, the United Kingdom or Canada. The reform therefore arises from a structural need.
Three new clinical master’s degrees
The aim is to create professionals with advanced clinical specializations, capable of intervening in complex contexts with hitherto unprecedented levels of autonomy, and the hope would be to encourage more and more young people to undertake a nursing career. Guaranteeing them, through these new degrees, more qualified and better paid top careers. The decree mentions three profiles: «the specialist nurse in primary, family and community care, the specialist nurse in intensive and emergency care and the specialist nurse in neonatal and pediatric care».
The doctors’ protest: “we will build barricades”
Up to this point there would be nothing to object to: but the operation has a very high professional price. «We doctors will stand on the barricades, because with this reform we are going to touch, in an unclear way, a whole series of roles, skills and responsibilities», Guido Quici, president of Cimo, the Italian Confederation of hospital doctors, tells Panorama. «It is stated in the decree that specialist nurses will be able to independently prescribe only health aids, but the prescription is never an isolated act free from risks: it presupposes a diagnosis, which can only be made by a doctor, and full clinical responsibility. Who is responsible if something goes wrong? Who really evaluated that patient? There is a risk of growing confusion of roles and levels of responsibility in an already fragmented system.”
Recipes yes, but for principals: yet the boundaries are not clear
In truth, the decree establishing these degrees states that the “new” nurses will only be able to make prescriptions for health products such as ostomy bags, diabetes sticks, advanced dressings, incontinence devices: therefore exclusively materials related to their care activity. But in the part dedicated to the specialist degree to train nurses in the emergency and intensive care sector there are passages that are not very clear, where the boundaries are not defined.
In fact, when it is said that specialist nurses will be able to «plan care interventions in accordance with the guidelines and validated protocols, for patients in conditions of instability or potential clinical instability, who require intensive care to support or replace vital functions» and also that they will be able to «autonomously manage the pathways of patients with low clinical complexity in the various first aid settings», well, this means everything and the opposite of everything. Also that they could be entitled, for example in an emergency room, to evaluate the outcomes of these interventions and paths, and proceed accordingly? «It’s not made explicit. Precisely for this reason we strongly contest the decree”, concludes Quici. «It lacks clarity, and leads to a downward leveling: it will become increasingly difficult to distinguish the role of the doctor from that of the nurse, and when the skills become too close a problem of unpacking clinical management arises».
The silence of the departments and the voice of those who work in the emergency room
No one from the emergency departments wants to talk about this scenario: the few head doctors who would be willing to do so are blocked – before the interviews – by the general management. Clear sign of how divisive and hot the topic is. Only Fabio De Iaco, former president of Simeu and head of the emergency room of Maria Vittoria in Turin, is exposed. «We must start from reality: the world moves forward and we must face the problems. The basic nursing degree is often not sufficient, in the face of new challenges relating to health: it must be integrated with more or less specialized training. I am not conceptually against the institution of master’s degrees: but obviously without dramatically expanding the scope of action.”
The real issue: drugs and “field invasion”
The real burning issue is the prescription of drugs. If the reform establishes the transition from a predominantly “executive” nursing figure to a more clinically autonomous professional with specialized skills, is it reasonable to expect a sort of “field invasion” soon also in terms of drug prescriptions, and not just devices? Is it likely that patients can leave a hospital with prescriptions filled only by nurses? This is precisely the great fear of doctors: that the decree is a first step towards a sort of “drift” in the granting of skills. On this the wall is insurmountable.
Fnomceo: diagnosis and therapies must remain with doctors
«Modern medicine is based on team work. If doctors and nurses don’t work together, healthcare doesn’t work: however, roles and boundaries need to be clarified extremely precisely”, Toti Amato, national councilor of Fnomceo with delegation for Foreign Affairs and president of the Order of Palermo, tells Panorama. «Diagnosis and prescription of therapies are areas that must remain exclusive to doctors: it is not a corporatist defense, but one of skills. The training course of a doctor is not comparable to that of nursing, however serious the latter may be. They are different professions, and they must remain so.”
The lack of concertation and the reform that dissatisfies everyone
The crux of the issue, according to Amato, arises from the lack of consultation: «We doctors were not consulted, despite being parties to the matter: when it was decided to carry forward the decree on specialist degrees, the ministry went ahead without discussion. But how can we redefine the skills that nurses will have in the departments or clinics, without interlocution with doctors? We trust there is still room for dialogue.”
In short, at the moment it seems that this reform has succeeded in displeasing almost everyone. University courses have not yet started (if the process proceeds quickly they could start in 2027) and critical issues are already emerging: at the centre, as often happens, there is money.
NurSind: recognition yes, but funds and positions are needed
“There is no doubt that specialist degrees are a first step towards greater recognition of our work,” says Andrea Bottega, national secretary of the NurSind nurses’ union. «But then it will be necessary to carry out competitions and selections for these new specialists: adequate funds are therefore needed to guarantee them the positions for which they studied. And in the future, the experience of other countries such as the United Kingdom or the United States could be taken as an example, where there are nursing figures called advanced practice nurses, also trained to prescribe medicines.”
Almost autonomous, almost doctors: rewriting the heart of healthcare
Moreover, in the very popular series The Pitt, set in an American emergency room, the head doctor defines the head nurse Dana as “the true director of our circus”, ordering the young doctors to “do what she says, when she says so”. But fiction aside, there is little to joke about, because by “touching” the topic of drug prescriptions we are already at the crucial point: the stakes are very high and the battle between doctors and nurses promises to be long and not painless. Not only for the categories involved, but for the very idea of public health. Almost doctors, almost self-employed? Redefining who decides, who prescribes and who takes responsibility for care means rewriting the heart of the healthcare system. And changing the names probably won’t be enough to make it work.
