Michael Igoumenidis

Background: Instruments measuring autism-related knowledge, attitudes and self-efficacy are widely used with health professionals, but their measurement properties remain unclear when individual scores are considered separately. Methods: We mapped instruments evaluated in health-professional populations and appraised them using COSMIN, treating each total score, subscale and translation as a separate unit of appraisal. Certainty and recommendation categories were then assigned. Results: Across 126 instrument–property cells for fourteen instruments, the 140 rating codes included eight sufficient, three insufficient, thirty-seven indeterminate and seventy-five not-evaluated codes. All appraised instruments were category B in the primary analysis, indicating that evidence supports neither a positive nor a negative recommendation. A reflective-model sensitivity reading placed the Greek KCAHW in category C. The dominant finding is absence rather than inadequacy: measurement error and responsiveness were examined for none, and cross-cultural validity and test–retest reliability for few. Where a result exists it usually cannot be interpreted, because the dimensionality of the score was never established. Content validity was independently examined for a minority of instruments, addressing expert agreement with answer keys rather than comprehensiveness or comprehensibility. Conclusions: Establishing structural validity in the population of use, and evaluating content validity with intended respondents, would address the principal evidence gaps.

Background/Objectives: Quiet quitting, workplace gaslighting, and moral resilience are increasingly recognized as important to employee wellbeing, yet they have rarely been studied together, and evidence from white-collar workforces outside healthcare is scarce. This study examined these three constructs, as well as the associations between them, among white-collar employees of a governmental organization in Greece. Methods: A cross-sectional study was conducted with a self-report questionnaire completed by 433 employees, about 90% of the target population. Quiet quitting, workplace gaslighting, and moral resilience were measured with the Quiet Quitting Scale, the Gaslighting at Work Scale, and the revised Rushton Moral Resilience Scale (RMRS-16). Results: The mean quiet quitting score was 2.26 (SD 0.69), the mean gaslighting score was 1.84 (SD 0.76), and the mean moral resilience score was 3.08 (SD 0.43). In multivariable analysis, higher moral resilience was independently associated with lower quiet quitting (b = −0.52, 95% CI: −0.65 to −0.39) and lower gaslighting (b = −0.49, 95% CI: −0.65 to −0.34). Higher gaslighting was associated with higher quiet quitting (b = 0.27, 95% CI: 0.19 to 0.35). Men and younger employees reported higher levels of both. Conclusions: Moral resilience was independently associated with both lower supervisory gaslighting and lower quiet quitting. These cross-sectional findings cannot establish causality. If confirmed in longitudinal research, interventions that strengthen moral resilience and improve supervisory practices may support employee engagement and wellbeing in white-collar workforces.

The emergence and increasing use of artificial intelligence (AI) in healthcare have paved the way for highly personalized and time-saving approaches in the field of precision medicine. It can be applied to determine a prognosis, diagnosis, and recommended treatment, and may also be used for patient monitoring. As AI applications become more widely available, reliable and easy to use, they are rapidly reshaping the traditional roles of professionals and patients in the therapeutic relationship. On the positive side, professionals may have more time to communicate with patients and provide individualized care, whereas patients may become more empowered and autonomous due to AI-facilitated personalized information and monitoring. On the negative side, AI applications threaten to reduce the role of professionals to a mediating one in clinical decision-making, provide patients with misinformation, and lead to misunderstandings that hinder patients’ autonomy. In this narrative review, we examine the main ethical issues related to the AI-induced shift in roles in the therapeutic relationship, within four inter-related themes: the validity of claims that algorithms outperform humans in certain tasks; the ways in which AI saves time for health professionals but also takes time to properly explain and implement; the issues of trust and accountability, especially if AI suggestions lead to patient harm; and what AI’s alleged cost-effectiveness means for professionals’ employment and remuneration. Across the three roles, we find a common pattern: AI tends to absorb the technical and data-processing parts of clinical work while leaving its relational core to humans. Physicians move toward oversight and interpretation, nurses retain the attentiveness and responsiveness that define care, and patients gain tools for self-management that can widen autonomy or, left unguided, erode it. Whether the overall effect is benign depends less on the technology than on how outperformance is evidenced, how the freed time is used, how trust and accountability are anchored in people, and how cost pressures are managed. The article concludes with some suggestions for prudent use of AI in healthcare, indicating the appropriate measures that can be used to harness the power of AI without damaging the traditional cornerstones of the therapeutic relationship.

Ethics education constitutes a fundamental component of nursing development, shaping practitioners capable of sound moral judgment, responsible action, and ethically grounded clinical decision-making. Despite long-standing written ethical codes within the nursing profession, substantial gaps persist between theoretical instruction and real-world practice, leading to fragmented moral competence among nursing students and nurses. This discussion paper synthesizes evidence from the “Promoting a Morally Competent Nurse” project, insights derived from an international blended intensive program to examine the multifaceted challenges that hinder effective nursing ethics education, and expert contributions. Identified challenges include complexity of ethics theories; inconsistencies in the nursing curricula; the misalignment between formal and hidden curriculum; lack of resources and time dedicated to ethics education; inconsistencies in the training methods; and issues related to ethical leadership. The paper argues that cultivating moral competence requires more than the transmission of theoretical knowledge -it demands experiential learning, role modelling, and ethically supportive environments. A roadmap is proposed outlining complementary roles for academic nurses and nurse managers in strengthening ethics education across educational and clinical settings. Enhancing ethical leadership, harmonizing curricula, and investing in educator preparation are critical steps toward building an ethically resilient nursing workforce The paper concludes that ethical competence is not a static achievement but a lifelong developmental process that must be nurtured through intentional, coordinated, and context-sensitive strategies.

Aim: To describe the prevalence of Missed Nursing Care and its predictors in Greek public hospitals. Background: Missed Nursing Care is defined as any aspect of required patient care that is omitted or delayed. Despite the available studies, little is still known in countries with significant nursing shortages, such as Greece, where 2.23 registered and assistant nurses per 1000 population have been reported, significantly below the EU‐27 average. Methods: A national cross‐sectional study was conducted in 28 of 124 public hospitals in Greece. Nurses and nursing assistants working in medical or surgical units, providing direct care to adult patients, and with at least 3 months of experience were eligible. The MISSCARE Survey Part A (5‐point Likert scale; 1 = never, 5 = always missed), Part B (reasons, four‐point Likert scale; 1 = not significant, 4 = significant reason) and the Practice Environment Scale of the Nurse Work Index (4‐point Likert scale; 1 = totally agree, 4 = totally disagree) were used. Descriptive and inferential statistics were applied. Results: A total of 676 nurses participated. The Missed Nursing Care Part A total score was 2.06 (±0.65), with patients’ daily activities (mean = 2.32 ± 0.73) receiving higher scores than activities related to health status and treatments (mean = 1.80 ± 0.63). The overall score on the Practice Environment Scale of the Nurse Work Index was 2.53 (±0.49). Multiple linear regression analysis showed that issues in nursing care standards for quality of care, staffing adequacy and communication within the team were the most significant predictors of Missed Nursing Care. Conclusion: Missed Nursing Care is a major problem in Greek hospitals. Inadequate staffing is a key factor in missed care according to nurses’ perceptions. Increasing nursing staff, along with implementing standards for nursing care and improving communication among team members, will enhance the quality of health services in Greece. Implications for Nursing Management: Strengthening staffing levels and reinforcing nursing standards are essential strategies for reducing Missed Care in Greek public hospitals.

Background: The relationship between moral resilience, moral distress, and moral injury among nurses during the COVID-19 pandemic has been widely investigated; however, the literature in the post-COVID-19 era is scarce. Research aim: To examine the impact of moral resilience on moral distress and moral injury among nurses after the COVID-19 pandemic. Research design: Cross-sectional study. Participants and research context: We obtained a convenience sample of 1118 nurses in Greece. We collected demographic data (gender, age) and work-related data (understaffed wards, shift work, clinical experience). We measured moral resilience with the revised “Rushton Moral Resilience Scale”, moral distress with the “Moral Distress Thermometer”, and moral injury with the “Moral Injury Symptom Scale-Healthcare Professionals” version. We adjusted all multivariable models for demographic variables. Ethical considerations: The Ethics Committee of the Faculty of Nursing, National and Kapodistrian University of Athens approved our study protocol (approval number; 474, approved: November 2023). Our study followed the Declaration of Helsinki. Findings/results: Multivariable linear regression analysis showed that moral resilience reduced moral distress and moral injury. In particular, we found that increased response to moral adversity was associated with decreased moral distress (adjusted coefficient beta = −1.81, 95% confidence interval [CI] = −2.07 to −1.54). Moreover, we found that increased response to moral adversity (adjusted coefficient beta = −8.24, 95% CI = −9.37 to −7.10) and increased moral efficacy (adjusted coefficient beta = −3.24, 95% CI = −5.03 to −1.45) were associated with reduced moral injury. Conclusions: Moral resilience can reduce the level of moral distress and moral injury among nurses. However, the persistence of moderate moral resilience among Greek nurses does not guarantee its sustainability. To ensure that this resilience is maintained and potentially enhanced, it is imperative for nurse leaders and policymakers to strategically design interventions to address issues at the organizational, team, and individual levels.

Ethics is a foundational competency in healthcare inherent in everyday nursing practice. Therefore, the promotion of qualified nurses’ and nursing students’ moral competence is essential to ensure ethically high-quality and sustainable healthcare. The aim of this integrative literature review is to identify the factors contributing to the promotion of qualified nurses’ and nursing students’ moral competence. The review has been registered in PROSPERO (CRD42023386947) and reported according to the PRISMA guideline. Focusing on qualified nurses’ and nursing students’ moral competence, a literature search was undertaken in January 2023 in six scientific databases: CINAHL, Cochrane Library, PsycINFO, PubMed Medline, Scopus and Web of Science. Empirical studies written in English without time limitation were eligible for inclusion. A total of 29 full texts were retrieved and included out of 5233 citations. Quality appraisal was employed using Joanna Briggs Institute checklists and the Mixed Method Appraisal Tool. Data were analysed using inductive content analysis. Research about the factors contributing to the promotion of qualified nurses’ and nursing students’ moral competence is limited and mainly explored using descriptive research designs. The contributing factors were identified as comprising two main categories: (1) human factors, consisting of four categories: individual, social, managerial and professional factors, and ten sub-categories; and (2) structural factors, consisting of four categories: educational, environmental, organisational and societal factors, and eight sub-categories. This review provides knowledge about the factors contributing to the promotion of qualified nurses’ and nursing students’ moral competence for the use of researchers, nurse educators, managers, organisations and policymakers. More research about the contributing factors is needed using complex intervention, implementation and multiple methods designs to ensure ethically sustainable healthcare.

Background: Over the years, national and international nurses’ organisations have drawn up Codes of Conduct and Codes of Ethics. A new differentiation has emerged over time between mandatory and aspirational approaches underlying how nurses can be supported by documents with rules to be respected (mandatory ethics) or by incentives (aspirational ethics). However, to date, no research has applied these approaches to analyse available Codes and to identify which approach are predominantly used. Methods: In this case study, the Italian Nursing Code of Conduct (NCC), published in 2019, composed of 53 articles distributed in eight chapters, was first translated, and then analysed using a developed matrix to identify the articles that refer to mandatory or aspirational ethics. A nominal group technique was used to minimise subjectivity in the evaluation process. Results: A total of 49 articles addressing the actions of the individual nurse were considered out of 53 composing the NNC. Articles were broken down into 97 units (from one to four for each article): 89 units (91.8%) were attributed to a unique category, while eight (8.2%) to two categories according to their meaning. A total of 38 units (39.2%) were categorised under the mandatory ethics and 58 (59.8%) under the aspirational ethics; however, one (1.0%) reflected both mandatory and aspirational ethics. Conclusions: According to the findings, the Italian Professional Body (FNOPI) has issued a modern code for nursing professionals in which an aspirational perspective is dominant offering a good example for other nursing organisations in the process of updating their codes when aimed at embodying an aspirational ethics.