Competence, performance evaluation, and educational needs of middle nurse managers in the Italian healthcare system: A qualitative study

Abstract

Background Existing literature highlights the essential role of middle nurse managers (MNMs) in ensuring communication, coordination, and quality within healthcare organisations, demonstrating the need for deeper insight into their competencies, educational needs, and evaluation processes. Objectives This study aimed to explore MNMs' perceptions of the competencies they use, their training needs, and the systems used to evaluate their performance. Methods A qualitative descriptive design was used, guided by the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist. Thirty-one MNMs from diverse Italian healthcare settings participated in seven focus groups conducted between March and June 2024. A semistructured interview guide was used to facilitate discussion. All focus groups were audio-recorded, transcribed verbatim, and analysed using inductive content analysis. Codes, subcategories, and main categories were developed through an iterative process of comparison and triangulation. Results Analysis generated 115 codes grouped into 38 subcategories and 3 main categories: operational and financial management capabilities, relational leadership and professional development, evaluation processes and organisational constraints. MNMs demonstrated consistent use of American Organization for Nursing Leadership–aligned competencies, particularly in staffing, communication, conflict management, and organisational decision-making. Participants reported significant training gaps in leadership, digital skills, and strategic management. Performance evaluations were viewed as superficial, inconsistent, and poorly aligned with actual responsibilities. Perceived organisational barriers included insufficient time, limited recognition, inadequate support from top management, and fragmented evaluation processes. Discussion MNMs rely on a wide range of managerial and relational competencies but face structural and organisational barriers that hinder their effectiveness. The results support literature calling for stronger competency-based evaluation, improved educational pathways, and enhanced institutional support to strengthen the MNM role within the Italian healthcare system.

The authors' abstract, as published at the source. Collegian Journal of the Royal College of Nursing Australia, 2026 · DOI ↗