The contribution of nursing doctoral schools to the development of evidence 10 years after their establishment in Italy: An exploratory descriptive survey of former and current doctoral students’ publications

Abstract Aim To analyse through an exploratory descriptive survey how former and current doctoral students’ publications have contributed to the development of evidence between the establishment of the doctoral schools of nursing in 2006–2015. Design An exploratory descriptive survey. Methods We analysed the papers published in peer‐reviewed journals by the four Italian PhD Schools of Nursing between 2006–2015. Additional missing information was retrieved from Web of Science. Results We identified 478 scientific papers. The papers increased from 12 in 2006–110 in 2015. Most are published in 29 journals, of which 15 had an impact factor ranging between 0.236–3.755. These results show the increasingly significant contribution of nursing doctoral programmes to the production of evidence, which can be used to improve the quality of nursing and inform health policies. Nursing doctoral schools deserve a greater recognition, especially by Italian funding agencies and political institutions.

to earn a master's degree in a specialty and obtain more clinical experience before pursuing PhD education (Ellembecker & Kazmi, 2014).
The new and challenging prospects of nursing are the result of research and innovation conducted by senior lecturers and researchers, who are now playing strategic education roles to determine the lines of future development in the social and healthcare fields in synergy with the new generations of professionals (Cheraghi, Jasper, & Vaismoradi, 2014;Holland, 2015).
Nurses who access the highest levels of academic education, such as doctoral students, are called on by the international scientific community to take an active part in the production of new knowledge and to promote the culture of evidence-based practice through project development competencies, critical analysis and innovative ideas that adequately respond to the emerging needs of the health system (Begley, McCarron, Huntley-Moore, Condell, & Higgins, 2014). Supporting and fostering the production of scientific publications means creating innovation, quality, more opportunities for international cooperation, more interdisciplinary collaboration and making a discipline more appealing for members inside and outside the same profession. This involves the development of a culture of research, which in the field of nursing requires the attainment of a substantial number of nurses with a doctoral degree, financial support and a strong local and national leadership (Begley et al., 2014).

| Background
The Initially, nursing research was part of the National Institutes of Health, but then it established its own National Institute for Nursing Research (NINR) (Ketefian, Davidson, Daly, Chang, & Srisuphan, 2005). In fact, the NINR in the United States has funded nursing research through educational programmes to support research and researchers to study phenomena associated with health care directly provided to the person, through the same funding systems of the National Institutes of Health (AACN, 2016). Therefore, in the United States, thanks to the scientific rigour and methodological soundness of the research conducted by the doctoral schools of nursing, these now play a key role for the funding system of the US health policies.
Also, in Europe, the nursing profession is increasing its level of education, professional competencies and its role in research (Bressan et al., 2016). Just like any other health profession, the development of the culture of research requires the attainment of PhDs, funding and support at a national level and leadership and vision at the academic level (Begley et al., 2014). Indeed, several studies have shown how appropriate preparation and acquisition of knowledge in the field of research through doctoral programmes can facilitate the development of clinical competencies and bring nursing practice to a higher level (Begley et al., 2014;Bressan et al., 2016). Through research, the creation of databases and the validation of tools, doctoral programmes offer clinical nurses the opportunity to increase their knowledge and, consequently, provide them with the potential to ensure higher standards of patient safety (Cheraghi et al., 2014).
With regard to the Italian context, a "doctorate" is defined as the level of education that "provides the necessary competencies to conduct high-quality research for public and private bodies, as well as to practice as independent professionals, contributing to the accomplishment of the European Higher Education Area and to the European Research Area" (Decree of the Italian Ministry of Education, University, & Research, 2013).
Access to a doctoral programme is ruled by admission criteria and tests designed to select highly prepared candidates, who can innovate. These characteristics imply the willingness and the ability to complete a complex and difficult programme, which will enable students to achieve the highest level of education available today. After completing the PhD programme, students will have the competencies to contribute to national and international scientific projects and be competitive in the labour market by having access to high-level job positions in all the available fields of a profession (Stiwne & Alves, 2010). This reinforces the roles played by Italian nurse academics, who are ensuring that nurses develop increasingly higher research competencies (Bagnasco, Ghirotto, & Sasso, 2014).
In the past, publications in the field of nursing research were very few, and in many cases, these studies were not conducted by nurses, but by other health professionals. Instead, recently the number of studies and scientific papers published by Italian nurses has steadily increased (Marucci et al., 2013). Advanced competencies in the field of research are needed to publish scientific papers that show the international scientific community the value of the studies conducted, share new scientific evidence and ultimately enable to highlight the importance of PhD schools through their publications, which have become a measure of the quality of academic excellence (Langer, 2017).
Since, the doctoral nursing programmes were launched in Italy for the first time in 2006, after 10 years we felt that it would be important to analyse and highlight how nursing research has developed through the work of all of the four PhD Schools of Nursing in Italy.
This would provide the scientific evidence necessary to facilitate, for instance, discussions with healthcare policymakers and help to bring nursing practice to a higher level. Therefore, the research question of this study was: "How have nursing doctoral schools contributed to the development of nursing research in the last 10 years?"

| Design
This is an exploratory descriptive survey conducted on a national level that analysed publications produced from 2006-March 2016 by current and former doctoral students of the four PhD Schools of Nursing across Italy.

| Sample
The sample of this study was a convenience sample of the publications of current and former doctoral students from all four PhD Schools of Nursing in Italy.

| Data collection
We involved all four PhD Schools of Nursing present in Italy by email and invited current and former PhD nursing students to complete a questionnaire consisting of 25 items, which was specifically designed by our research team for this study.
Participants were asked to provide data regarding the year they started their doctoral programme (i.e. cycle), the date they completed it, specifying if they had finished on time or if they were overdue, their publications before, during and after their doctoral studies and job positions covered before and after completing their PhD programme.
For each author, a table was built to collect data on the respective publications, such as authorship, if the journals were peer-reviewed, number of citations, impact factors and number of publications on national and international journals with an impact factor. We preliminarily contacted the coordinators of all the PhD Schools of Nursing by phone asking them to provide the lists of all their current and former PhD students and their mailing lists. Then, we contacted the students asking them to provide within 10 days a copy of their curriculum vitae containing a detailed list of all their publications.
We sent two invitations to obtain the highest possible number of participants. Finally, we checked all the publication lists sent by the PhD students with those available in Web of Science to add extra information regarding the journal impact factor, year of publication and authorship.

| Data analysis
Through the online survey, all the data were automatically collected into a table created by the online survey software. Afterwards, the data were entered into an Excel file, which included also the additional data we collected from Web of Science. The database con-

| Statistical analysis
Statistical analysis was conducted using Microsoft Excel 2010 and the Statistical Package for Social Science (SPSS for Windows, IBM, New York) version 21.0. To study the statistical distribution of the areas under investigation, we adopted the descriptive statistics methodology (mean and standard deviation). Conference proceedings and duplicates were excluded. All the remaining publications were grouped together according to the PhD School they belonged to and then analysed.

| Sample
The total number of respondents was 79. Of these, 48 were from the PhD School of Rome, 19 from Genoa, seven from Florence and five from L'Aquila. The characteristics of the respondents are shown in Table 1.

| Publications in journals with and without impact factor
To highlight the quality of the scientific output of nursing research in Italy, papers were ranked according to the journal name and their impact factor (Table 2)

| Publication topics
Most   (Table 4).    showing In Europe, Canada and Australia nursing research studies mainly tended to focus nurses themselves, whereas in Asia and the United States the focus was mainly on patients. Polit and Beck (2009) also found that in Europe, countries like the United Kingdom, Norway and Sweden nursing research mainly adopted qualitative methods.

| D ISCUSS I ON
This interesting finding was also confirmed by Meleis (2011)

| Limitations
Since, it was not possible to have the full mailing list of all the students who had completed the doctoral programme from the various doctoral schools, we were unable to conduct a precise calculation of the response rate. However, after checking Web of Science, we subsequently found that the response rate was very good.
Another limit is that we did not include papers of those who did not accept to participate. Finally, although in Italy there is very little funding for nursing research, an interesting aspect we did not analyse was how many studies received funding and by whom.

| CON CLUS IONS
In the last 10 years, nursing doctoral schools have greatly contributed to the development of nursing research, not only in terms of academic excellence, but also in producing a wealth of scientific evidence that is relevant and applicable to Italian clinical settings.
However, academic nurse leaders need to identify strategies to obtain more funds for nursing research projects. For instance, universities could form partnerships with healthcare institutions to conduct research and support them to design and develop studies to meet the demands of clinical services, patient outcomes and the quality and safety of care. In these cases, grant applications for projects with a clinical focus are instrumental (Wilkes, Cummings, Ratanapongleka, & Carter, 2015).
However, the availability of funding and resources for nursing research in Italy are still scarce. This is mainly due to the persistence of a culture that gives little priority to nursing research and this constitutes a barrier to the further development of nursing studies. This requires doctoral schools to develop more studies that focus on policies and on the financial impact and economic value of nursing, which until now have been very few (only 10). In this way, nursing research projects could have more chances of attracting funding from Italian governmental and health institutions. In other countries, such as the USA and several North European countries, the role of doctoral schools is greatly valued and many institutions and agencies fund nursing research projects that produce better patient outcomes and constantly improve the quality of health care.
Many studies are also used as benchmarks and provide indicators that enable to improve healthcare standards and are instrumental to identify and develop new lines of future research. Italian nursing doctoral schools now have the potential to become an integral part of a national funding system for the improvement of health care and boosting a widespread recognition of the inestimable value of their work.

CO N FLI C T O F I NTE R E S T
None.

PATI E NT CO N S E NT S TATE M E NT
No patient consent was required for this study.