Exploring variables influencing the prevalence of self-employed nurses in the post-pandemic context: A descriptive ecological study
Keywords:
self-employed nurse, regional disparities, territorial careAbstract
Background. The COVID-19 pandemic profoundly reshaped healthcare systems, accelerating ongoing structural transformations and intensifying pre-existing regional disparities in workforce distribution. Understanding the socioeconomic determinants that shape the diffusion of self-employment in nursing is essential, particularly in the post-pandemic phase, to support equitable workforce planning and the reorganization of territorial care envisioned by current national reforms. This study investigates the socio-economic factors influencing self-employed nursing practice and examines its implications for the future of Italy’s healthcare system. Methods: A descriptive ecological observational study was conducted across all 20 Italian regions. Regional-level data were collected from official administrative sources, including ENPAPI, FNOPI, ISTAT, the Ministry of Health, and C.R.E.A. Sanità. The dependent variable was the number of self-employed nurses per 10,000 inhabitants. Independent variables included average per capita income, out-of-pocket health expenditure, hospital beds per 1,000 inhabitants, and the number of National Health Service (NHS) nurses per 1,000 inhabitants. Multiple linear regression was performed, and the study followed the RECORD reporting guidelines. Results: The density of self-employed nurses varied considerably across regions, with higher values in Lombardy, Piedmont, and Aosta Valley. Among the predictors, average per capita income was positively and significantly associated with the number of self-employed nurses (β = 0.739, p = 0.001). Conversely, the number of NHS-employed nurses per 1,000 inhabitants was negatively and significantly associated with the number of self-employed nurse (β = –1.384, p = 0.001). Compared with pre-pandemic evidence, post-COVID trends indicate continuity in socioeconomic gradients but also the emergence of a substitution effect: public recruitment campaigns increased NHS staffing over 7% at the national level, with regional estimates for Lazio approaching 10%, coinciding with a proportional decline in self-employed nurses. Conclusion: Self-employment in nursing appears to operate as a flexible response to workforce shortages rather than a purely autonomous professional choice. Regional socioeconomic disparities continue to shape its distribution, with wealthier areas supporting dual public-private care markets.
References
1. Boccardi V, Mecocci P. Intermediate Care in Italy: Addressing the Challenges and Opportunities for Person-Tailored Care. Geriatrics (Basel). 2023;8(3). doi: 10.3390/geriatrics8030059
2. World Health Organization. State of the world's nursing 2020: investing in education, jobs and leadership. WHO; 2020. Available from: https://iris.who.int/server/api/core/bitstreams/5d564226-7418-4c10-9fb3-08d7e09626ec/content
3. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. Jama. 2003;290(12):1617–23. doi: 10.1001/jama.290.12.1617
4. National Academies of Sciences EM. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021.
5. Dirubbo N. What Does ‘Self-Employed’ Mean? The Nurse Practitioner. 2005;30(2). doi: 10.1097/00006205-200502000-00001
6. Cui N, Yang W, Lu Y, Jin J. The role and value of self-employed nurses in the allocation of nursing human resources: A scoping review. Int J Nurs Sci. 2025;12(5):445–53. doi: 10.1016/j.ijnss.2025.08.005
7. De Raeve P, Davidson PM, Bergs J, Patch M, Jack SM, Castro-Ayala A, et al. Advanced practice nursing in Europe-Results from a pan-European survey of 35 countries. J Adv Nurs. 2024;80(1):377–86. doi: 10.1111/jan.15775
8. Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344:e1717. doi: 10.1136/bmj.e1717
9. De Belvis AG, Meregaglia M, Morsella A, Adduci A, Perilli A, Cascini F, et al. Italy: health system summary 2024. Copenhagen; 2024. Available from: https://iris.who.int/server/api/core/bitstreams/a19431eb-4ea1-4de6-b271-79f5fc08d5e0/content
10. CERGAS Bocconi. Rapporto OASI 2023. Osservatorio sulle Aziende e sul Sistema sanitario Italiano. 2023. Available from: https://cergas.unibocconi.eu/sites/default/files/media/attach/Rapporto_OASI_2023_0.pdf?VersionId=o1QXm9qPi7HP3iz6bXzNpKBUK_CV_hpi
11. Ricciardi W, Tarricone R. The evolution of the Italian National Health Service. The Lancet. 2021;398(10317):2193–206. doi: 10.1016/S0140-6736(21)01733-5
12. Bagnasco A, Alvaro R, Lancia L, Manara D, Rasero L, Rocco G, et al. Assistenza Infermieristica Domiciliare in Italia AIDOMUS-IT: i dati preliminari. L'Infermiere. 2023;60(2):e75 – e96. doi: 10.57659/SSI.2023.008
13. Jazieh AR, Kozlakidis Z. Healthcare Transformation in the Post-Coronavirus Pandemic Era. Front Med (Lausanne). 2020;7:429. doi: 10.3389/fmed.2020.00429
14. Scerbo F, Rocco G, Stievano A, Vellone E, Maurici M, Cammarano A, et al. Socio-demographic analysis of free-lance nurses in a non-institutional employment regimen. Ann Ig. 2020;32(6):599–607. doi: 10.7416/ai.2020.2381
15. Sasso L, Bagnasco A, Catania G, Zanini M, Aleo G, Watson R. Push and pull factors of nurses' intention to leave. J Nurs Manag. 2019;27(5):946–54. doi: 10.1111/jonm.12745
16. Nicholls SG, Quach P, von Elm E, Guttmann A, Moher D, Petersen I, et al. The REporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) Statement: Methods for Arriving at Consensus and Developing Reporting Guidelines. PLoS One. 2015;10(5):e0125620. doi: 10.1371/journal.pone.0125620
17. National Welfare and Assistance Authority for the Nursing Profession. 2024 financial statement. 2024. Available from: https://www.enpapi.it/wp-content/uploads/2025/05/Bilancio-Consuntivo-2024.pdf
18. Italian National Institute of Statistics. Italian Statistical Yearbook 2024. 2024. Available from: https://www.istat.it/wp-content/uploads/2024/12/ASI_2024.pdf
19. Spandonaro F, D’Angela D, Polistena B. 18th Health Report. Without reforms and growth, NHS on the brink of crisis. 2022. Available from: https://www.creasanita.it/wp-content/uploads/2023/04/CREASanita_RapportoSanita_2022_Volume.pdf
20. Ministry of Health. Statistical Yearbook of the National Health Service: Organizational Structure, Activities, and Production Factors of the NHS. 2022. Available from: https://www.salute.gov.it/new/sites/default/files/imported/C_17_pubblicazioni_3299_allegato.pdf
21. Vainieri M, Taddeucci L. Rapporto Professioni Infermieristiche. Pisa: Edizioni Campano; 2025. Available from: www.fnopi.it/wp-content/uploads/2025/05/Rapporto-FNOPI-S.ANNA-ok.pdf
22. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2023: OECD Indicators. Paris: OECD Publishing; 2023. Available from:
23. World Health Organization. Global Spending on Health: A World in Transition. Ginevra: World Health Organization; 2019. Available from: https://iris.who.int/server/api/core/bitstreams/7a5d850e-a278-46ad-a697-52db7a88402a/content
24. Buchan J, Duffield C, Jordan A. 'Solving' nursing shortages: do we need a New Agenda? J Nurs Manag. 2015;23(5):543–5. doi: 10.1111/jonm.12315
25. Glorioso V, Subramanian SV. Equity in access to health care services in Italy. Health Serv Res. 2014;49(3):950–70. doi: 10.1111/1475-6773.12128
26. Notarnicola I, Duka B, Grosha E, Gioiello G, Zega M, Caruso R, et al. Regional Inequities in the Distribution of the Nursing Workforce in Italy. Nurs Rep. 2025;15(7). doi: 10.3390/nursrep15070235
27. Franzini L, Giannoni M. Determinants of health disparities between Italian regions. BMC Public Health. 2010;10:296. doi: 10.1186/1471-2458-10-296
28. Brieger S.A., Kruse S, Potter J. The job quality of self-employment in Europe: A longitudinal perspective. Paris: OECD SME and Entrepreneurship Papers; 2025. Available from: https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/07/the-job-quality-of-self-employment-in-europe_af6d4bce/646e6778-en.pdf
29. Bagnasco A, Alvaro R, Lancia L, Manara DF, Rasero L, Rocco G, et al. Working conditions, missed care and patient experience in home care nursing in Italy: An observational study. Public Health Nurs. 2024;41(4):709–22. doi: 10.1111/phn.13320
30. Dante A, Marcotullio A, Checchi A, Caponnetto V, Masotta V, Paoli I, et al. Behind closed doors: Freelance nurses and the reality of unmet care needs in Italian home care setting. Insight from a phenomenological descriptive study. Ann Ig. 2025;37(4):425–34. doi: 10.7416/ai.2024.2668
31. Causio FA, Golinelli D, Diedenhofen G, Silenzi A, Ferro D, Baglivo F. Fragmented but evolving: a response to the editorial "the Italian health data system is broken". Lancet Reg Health Eur. 2025;51:101256. doi: 10.1016/j.lanepe.2025.101256
32. O'Dowd A. NHS temporary staffing bill "skyrockets" to pound10.4bn. BMJ. 2024;384:q140. doi: 10.1136/bmj.q140
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Francesco Scerbo, Bartolomeo Verduci, Giovanni Cangelosi, Ippolito Notarnicola, Massimo Maurici, Alessandro Stievano, Gennaro Rocco, Rosaria Alvaro, Gabriele Caggianelli, Rocco Mazzotta (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.