Challenges and Strategies in Internal Communication: Insights from Head of Nursing and Allied Health Professionals

Challenges and Strategies in Internal Communication: Insights from Head of Nursing and Allied Health Professionals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges and Strategies in Internal Communication: Insights from Head of Nursing and Allied Health Professionals Filippo Vella, Maurizio Moreno Fattori, Giulia Marini, Cristina Ferrari, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8671538/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Internal communication is crucial in today's corporate world, ensuring alignment with organizational goals and enhancing performance. However, organizational complexity and lack of standardization may hinder this effectiveness. The transmission of information top-down is a critical element in ensuring effective and timely communication between the various hierarchical levels. The aim of this study was to analyse the process of top-down communication from Heads of Nursing and Allied Health Professionals to Healthcare Workers in hospital care units, with the specific purpose of identifying challenges and strategies that may result in the design of a structured quality improvement project on internal communication. Methods A qualitative descriptive study was conducted between June and July 2024 in a large university hospital in Northern Italy. Nineteen Heads of Nursing and Allied Health Professionals with at least two years of experience were recruited using purposive sampling. Semi-structured interviews were audio-recorded after written consent from the participants, transcribed verbatim, and analysed through content analysis by two independent researchers. Results The analysis highlighted five main categories: (1) use of software applications for the transmission of information, (2) time management for the transmission of information, (3) use of feedback as a verification strategy, (4) contextualization of information in the care unit, and (5) the uncertainty on the effectiveness of official communication channels. The primary channels of communication are formal tools such as email and meetings, while instant messaging apps are employed for the dissemination of urgent alerts. The effective management of time in the transmission of information is regarded as a crucial aspect. Feedback is employed as a strategy for verifying the effective reception and understanding of information. Nevertheless, a sense of uncertainty persists regarding the effectiveness of official channels. Conclusion To enhance internal communication, it is vital to strike a balance between technological efficiency and the well-being of Heads of Nursing and Allied Health Professionals, while guaranteeing the quality of care, adopting structured feedback practices, and contextualising information. An integrated approach that combines informal technologies and traditional methods is essential to address operational challenges and improve information management in the healthcare sector. Nursing Internal communication Nursing management Healthcare leadership Healthcare workers Heads of Nursing and Allied Health Professionals Nursing leadership Information transmission Qualitative research. Figures Figure 1 1. Background Communication is a fundamental element in organizational management and a strategic factor essential for conducting various situations [ 1 , 2 , 3 , 4 ]. The effectiveness of organizational communication significantly influences an organization's success, as it is fundamental to the management of entities [ 5 ]. Furthermore, communication encompasses vital tasks for conveying information, attitudes, ideas, feelings, planning, and decisions [ 6 ]. Internal communication is valuable because an organization evolves through member conversations [ 7 ]. In other words, the organization is not comprised of its members; rather, the organization is a by-product of the actions of and interactions between its members. For communication to occur, an individual uses language to transmit a message through a channel to another individual, who interprets the message. In healthcare, the Heads of Nursing and Allied Health Professionals produce the message, and the staff receive it [ 8 ]. The communication between the heads of Nursing and Allied Health Professionals includes positive and negative behaviors. Despite the inconsistencies in how communication styles are described in the literature, it is acknowledged that aspects such as respect, active listening, appropriate emotional responses, and access to sufficient information are positive. Conversely, negative behaviors include condescension, intimidation, micromanagement, contradictory communication, and an inability to convey information to employees clearly and unambiguously [ 8 ]. The limited literature in health care highlights that organizational communication ensures the efficient exchange of patient care information among HCWs, enhancing nursing effectiveness and improving overall organizational performance [ 9 ]. This type of communication is essential for high-quality healthcare delivery; without it, care quality would decline, leading to increased costs and adverse patient outcomes [ 10 ]. Direct communication between clinical nurses and their nurse managers is often the critical link for significantly impacting patient outcomes [ 11 ], resulting in greater job satisfaction, commitment, and retention for HCWs [ 12 , 13 , 14 , 15 ]. By creating sound internal communication systems, organizations experience greater productivity, greater innovation [ 16 ], reduced absenteeism, and fewer strikes [ 17 ]. Conversely, in poor communication systems, high-quality patient care, health worker satisfaction, collaboration and teamwork, and leaders' commitment to providing resources are lost. This can also hurt healthcare costs [11,18,19,20,21,22,]. Unfortunately, healthcare systems suffer from enormous inadequacies related to poor communication [ 22 , 23 ]. The literature revealed several critical issues contributing to communication difficulties within healthcare organizations. The main factors contributing to poor communication included the absence or ineffectiveness of meetings, limited consultation, and irregular feedback mechanisms, which negatively affected information flow [ 15 ]. Modern healthcare organisations are complex and specialised, requiring collaboration across interprofessional teams. Within this complexity, top-down communication from leaders becomes essential to ensure clarity, alignment, and safe care delivery [ 24 ]. Communication is necessary in healthcare, whether between nurse managers and nurses, physicians, or any other combination of healthcare professionals. However, the communicative relationships between these professionals remain an underexplored area of research [ 25 ]. Much of the existing literature in healthcare communication appears to focus on clinical and operational aspects, neglecting the importance of structured communication strategies to foster internal collaboration, information dissemination, and staff support. This lack of detailed studies makes it difficult for healthcare organizations to develop internal communication models based on empirical evidence, thus limiting the scope for improvement in relationship management and information sharing. Recent literature highlights various analytical and communication strategies to improve healthcare team coordination and internal information flow. Grippa et al. [ 26 ] applied Social Network Analysis to assess how healthcare teams exchange information and rely on brokerage roles. Their findings show that high-performing teams exhibit dense intra-team connections and strong brokers who facilitate information flow across units, supporting timely and targeted communication. Winzer et al. [ 27 ] examined internal crisis communication in a Norwegian tertiary hospital during the COVID-19 pandemic, focusing on the role of channel selection. The study found that communication effectiveness improves significantly when high-bandwidth channels—such as in-person meetings or video calls—convey complex or urgent messages. Conversely, low-bandwidth channels (e.g., e-mail, bulletin boards) were associated with delayed understanding and reduced engagement among staff. From a methodological perspective, Irvanizam and Zahara [ 28 ] introduced an enhanced RAFSI method using single-valued trapezoidal neutrosophic numbers and harmonic/arithmetic mean operators. Their model enables more accurate evaluation of healthcare service quality under uncertain and imprecise conditions, offering a robust decision-making tool for healthcare managers faced with complex multicriteria environments. Mazzei et al. [ 29 ] proposed a contingency-based framework for internal crisis communication strategies. The authors identify key factors—perceived safety, sense of belonging, employee engagement, and mobilization—essential to adopting an “accommodative” communication style. This approach proved particularly effective in enhancing employee trust, reducing anxiety, and promoting organizational resilience during health crises. These studies underscore the importance of integrating technical decision-making frameworks and context-sensitive communication strategies when examining internal information flows in healthcare organizations. Despite the growing body of literature on internal communication in healthcare organizations, empirical evidence remains limited regarding how top-down communication is implemented in everyday clinical practice by Heads of Nursing and Allied Health Professionals. Existing studies have primarily focused on communication channels, crisis contexts, or analytical frameworks, often overlooking the lived experiences, decision-making processes, and strategies adopted by healthcare leaders to transmit information to frontline Healthcare Workers. Moreover, few studies have adopted a qualitative approach aimed at generating practice-oriented evidence that can directly inform structured quality improvement initiatives in internal communication. In line with this perspective, we, therefore, decided to conduct this research to analyse the transmission process of top-down communications from the Head of Nursing and Allied Health Professionals to HCWs in the Care Unit and the factors influencing their diffusion, with the perspective of generating evidence that could serve as the foundation for a structured quality improvement project on internal communication, aimed at enhancing the clarity, timeliness, and effectiveness of information transfer in the hospital setting. 2. Materials and Methods Study design and setting A qualitative descriptive study [30] was conducted in 2024 in a University Hospital in the North-East of Italy. The setting was a 1500-bed university hospital in Verona, Italy. The hospital has high- and low-complexity units, with 5000 healthcare providers providing direct patient care. The University Hospital is a point of reference for the entire Veneto region, is a hub center, and is recognized as a highly specialized national healthcare center for the activities carried out in various research, care, and training sectors. It is a hub centre [31]. There are approximately 100 Heads of Nursing and Allied Health Professionals. The overall methodological process is summarized in the following flowchart (Fig. 1), which outlines the main steps of the study. Sampling Heads of Nursing and Allied Health Professionals were recruited through purposive sampling to achieve maximum variation in age, sex, education, and experience in the role and to ensure that the participants had direct and significant experience in managing internal communication, as they were responsible for the transmission of information in their Care Units. Participants were selected from different clinical areas (medical, surgical, emergency, obstetrics-gynecology, and diagnostics) with different socio-demographic characteristics (age, gender, and professional seniority) to ensure diversity in experience and perspectives. The participants of this study met the following criteria: they were Heads of Nursing and Allied Health Professions with a minimum of two years of experience in the role, to ensure a consolidated knowledge of communication practices and challenges, and they were willing to participate in the study. Participants were excluded if they had less than two years of experience in the role, did not hold direct responsibility for internal communication within their Care Unit, or were unwilling to provide informed consent. The determination of the sample size was not defined a priori but was based on the richness of the data collected until saturation [32]. The Heads of Nursing and Allied Health Professionals were contacted via email by the principal investigator, who provided them with details of the study and the consent form. Those who indicated their willingness to participate were subsequently contacted to arrange an in-person interview, during which they provided written consent. Data collection Data were collected through face-to-face semi-structured interviews between June 2024 and July 2024 following a semi-structured guide (Table 1) developed through a three-step process. First, the interview questions were developed based on a review of existing literature on internal communication in healthcare and qualitative research frameworks [33]. Second, based on these themes, a preliminary set of open-ended questions was drafted to explore perceptions, strategies, and barriers in communication between leaders and healthcare workers. Finally, the questions were reviewed by a panel of experts, including a senior nurse researcher (F.C.), who assessed content validity, clarity, and relevance. The following data were collected at the beginning of the interview: age, gender, education, role, years of work experience, and work setting. In addition to demographic data, participants were asked about the tools and strategies they use to transmit information within their teams. This included specific questions regarding the use of software applications (e.g., institutional email, instant messaging apps, shared documents, online surveys). Their responses provided detailed qualitative data on each tool's frequency, purpose, perceived effectiveness, and limitations. These qualitative accounts were later grouped thematically during content analysis to assess patterns and preferences in software usage. The interviews were conducted in locations and at times convenient for the participants. All data collected was anonymous and strictly confidential, and the information obtained was used for research purposes only. Interviews were audio recorded and lasted, on average, from 20 to 30 minutes, and were conducted by a nurse attending the second year of the Master’s Degree of Science in Nursing with previous training by a researcher expert in qualitative research. Table 1. Interview guide To ensure the confidentiality of the data, each interviewee was subjected to a recording procedure and assigned an identification code. The verbatim transcripts of the audio recordings of the interviews were identified with this code and can no longer be traced back to the interviewee. Data Analysis The interviews were transcribed verbatim, word for word, by two authors independently. To ensure anonymity and confidentiality of information, participants were assigned an identification code at the time of transcription. A content analysis was conducted on the qualitative data [34], with two authors analyzing each transcription independently. The analytical process consisted of phases: Familiarisation with the source material through multiple readings of the transcriptions. Identification of meaningful textual units: the words and/or significant sentences concerning the research question. Summarise each textual unit with a descriptive label: each significant part of the text was assigned a descriptive label. The arrangement of the labels in patterns is based on similarities and the definition of categories. The analysis process was then reviewed by a third author, and the data were tested for coherence with the labels. At this time, field notes gathered during the interviewing and analysis processes were discussed, and the authors examined how their perceptions contributed to the shape and developed their understanding of the data. Feedback was sought from the participants to increase the validity of the findings, ensuring that their meanings and perspectives were represented and not limited to the researchers’ agenda [35]. No software was used for data analysis. 3. Results Nineteen Heads of Nursing and Allied Health Professionals participated in the study. Most were female (73.7%) and had an average of 10.9 years of experience in their role, ranging from a minimum of 3 years to a maximum of 30 years. Participants interviewed belong to all areas: medical, surgical, emergency-urgency, diagnostic, and obstetrics-gynaecology. Table 3 Characteristics of participants Characteristics of participants n % Number of participants 19 Age (years) 35–50 8 42.1 51–65 11 57.9 Experience in their current positions (years) 3–9 10 52.6 10–20 6 31.6 > 20 3 15.8 Gender Female 14 73.7 Male 5 26.3 Areas Medical 5 26.3 Surgical 5 26.3 Emergency-urgency 3 15.8 Obstetrics-gynaecology 3 15.8 Diagnostics 3 15.8 From the analysis of the interviews, five categories emerged regarding opinions and experiences concerning the internal information transmission process: use of software applications for the transmission of information; Time management for the transmission of information; Use of feedback as a verification strategy; contextualisation of information in the Care Unit; Lived with uncertainty about the effectiveness of official communication channels. Theme 1. Use of software applications for the transmission of information This category includes narrations about the use of software applications to transmit information and is intended for all software applications, from those used as formal channels, such as email, to informal channels, such as social networks and messaging apps. All the leaders interviewed (100%) disseminate information formally via institutional e-mail and through scheduled meetings, with some providing the opportunity to participate remotely using multimedia platforms. This approach ensures that information has been effectively and correctly disseminated, thus enabling accurate tracking and documentation of communications. "...we use the institutional email channels and the communication channel of meetings, also taking advantage of the technologies made available recently..." . Fifteen out of nineteen leaders (79%) reported using instant messaging apps, mainly to draw attention to urgent emails sent through institutional channels. However, the majority of these leaders (10/15, 67%) avoided using apps for transmitting detailed content in order to safeguard confidentiality. ...when I have urgent emails, which I need to be viewed immediately, I write on the WhatsApp group “look at the email I sent you an urgent communication”, I use it in these ways… However, a small proportion (5/15) (33%) of those using instant messaging apps also share content information but do not use it as a preferred method, only for urgent information and always followed by communication through formal channels. This method is chosen for its speed and effectiveness in transmitting messages that require immediate attention while maintaining the formality and completeness of communication through the main institutional channels. This way, leaders can deal with critical situations promptly while ensuring that all official information is archived and accessible through formal channels. “...it's also been used a lot to give service announcements, although it's not a medium that's considered suitable... but maybe things at the last second... I wrote it on WhatsApp after I sent it in the email.” In addition to instant messaging apps, this category includes software applications that allow people to answer online questionnaires and share editable documents. I also did a questionnaire on Google Drive with some answers that gave me an important overview of the level of information there is…also to know how to behave and where I need to focus. However, some of the interviewed state that they do not agree with the use of instant messaging apps for work purposes, as they believe that this channel, being unofficial, could invade the personal sphere of HCWs by creating a continuum even outside working hours. ... WhatsApp means that a person never has the moment where they say ‘I'm done, I've clocked out, I'm home’, you're always involved ... that maybe it's ... a system that forces us never to disconnect. Theme 2. Time management for the transmission of information In the category “time management for the transmission of information”, all labels related to the interviewees' perception of the lack of time for transmitting information were grouped. Many participants (12/19) (63%) emphasized the need to dedicate adequate time to organizing targeted meetings to transmit information. These meetings are crucial to communicating the necessary information and receiving immediate and contextual feedback from the participants. They believe that more effective time management would significantly improve the quality of internal communication. Organizing regular, dedicated information-sharing meetings would help transmit directives clearly and monitor and verify HCWs’ understanding and application of them. ...I would need more time basically because we are overloaded with activities, so sometimes even checking whether information has been understood takes time… The interviews also reveal the leaders' concern about ensuring adequate time spaces for HCWs to receive the information properly. These spaces, excluded from work activities, should allow HCWs to participate peacefully in meetings, thus improving the understanding and application of information. ...it would be ideal to create or set up a time, outside of work activities, to have the serenity to meet, exchange, and share information. In addition to the time required to attend meetings, it was also pointed out that a considerable time commitment is required to handle emails. This includes not only the time to read them but also the time needed to understand their content, which can be particularly demanding due to the large number of messages and the complexity of the information. Moreover, dual-factor authentication for accessing the email application entails additional time commitments. ... so, for email communication certainly the... workload, in my opinion, affects a lot... so if they during the shift... don't have time to look at the email because they are too overloaded to look at it then they don't look at it… The lack of time for transmitting information can be attributed to information overload, making it difficult to establish a degree of importance for each piece of information. This requires time management, as reading, understanding, and responding to each email requires concentration and attention. Not all emails are equally important; distinguishing between urgent and ordinary messages can be challenging. In addition, this information overload also affects HCWs, reducing the time available to provide direct patient care and diverting attention from important information. “You have to consider that if I have too much information, even the most important information might slip through my fingers…”. Theme 3. Use of feedback as a verification strategy In all interviews (100%), the use of feedback as a strategy for verifying the information received emerged. This practice includes various methods, from verbal feedback requests to direct observation, to assess the action's adherence to what was requested. Most interviewees (16/19) (84%) stated that they verify the transmission of information by asking for verbal feedback, explicitly asking whether the information conveyed has been read and understood. This approach allows for immediate and direct feedback on the understanding and accepting the communicated information. Some interviewees also highlighted the usefulness of open-ended questions, which stimulate deeper reflection and offer a more comprehensive view of the level of understanding. It is not enough just to give the information, but to have feedback that the person has understood the information… In addition to verbal feedback, in some cases (5/19) (26%), interviewees use direct observation as a complementary method. They resort to direct observation of clinical practice or patient records to obtain feedback, depending on the information transmitted. This practice involves monitoring employees' behavior and actions to ensure they align with the information received. Direct observation makes it possible to identify discrepancies between the communicated information and the practical implementation, offering the opportunity to intervene promptly to correct any misunderstandings. ...you try to get feedback in the field, see if things are put into practice… Theme 4. Contextualisation of information in the Care Unit Fifty-eight percent of the respondents report that personal insight and analysis of the information received are fundamental to optimizing its contextualization to the coordinated unit. Respondents emphasize that, in addition to receiving information, it is essential to spend time on reflection and analysis, which allows them to identify relevant details, understand the implications of the information, and evaluate how it integrates with the specific dynamics and requirements of their role and in their own unit. ...there are things that come from the top to me as well, but maybe we can adapt them a little bit to our unit and then you just try to readapt them a little bit, that's um... as far as you can. In addition to contextualizing information, many respondents (12/19) (63%) reported synthesizing the information they receive, disseminating only what they consider to be key concepts, or reworking the original information to make it simpler, more immediate, and actionable. This synthesis and simplification process is essential to ensure that information is understood and used effectively within the organization. ... I choose whether by default I have to disseminate it and forward it as it is to my staff or whether I can somehow synthesize it, modify it, to arrive at a communication that can be more immediate and synthesized. Finally, some interviewed leaders (6/19) (32%) stated that they find it useful to establish an order of importance and relevance to the information they receive, even marking with alerts those they consider most important to facilitate the use of the content for HCWs ... and also the placement in a priority order, because as we know, the space for the reception of information, which must be assimilated, is not infinite… Theme 5. The uncertainty on the effectiveness of official communication channels 13 out of the 19 interviews (68%) revealed an experience of uncertainty regarding the real effectiveness of disseminating information through formal channels, especially through institutional e-mails. The perception of the Head of Nursing and Allied Health Professionals is that emails are often not read or, at least, not read quickly. …I have noticed this difficulty in reading the e-mail; I don't know what it is due to, but it is so… To deal with this problem, some leaders (7/19) (37%) reported using email with read confirmation for communications they consider important. However, they found that read confirmations are not received if the emails are read from smartphones, that the HCW may decide not to send the read confirmation even when reading the email, and that, in any case, there is no certainty that the information is read even when the read confirmation is received. As for the emails, at least they opened them with the confirmation. But I don't have the certainty that a person will read it; that's why I told them, " This is your responsibility. In some cases (4/19) (21%), the difficulty in using the applications by the HCWs belonging to the ‘Boomers’ (1946–1964) or ‘X’ (1965–1980) generations emerged as the reason for not reading the information transmitted via email. Gen Y (1981–1984) may be more computer-savvy and technology-ready than the Boomers and Gen X and, therefore, more prepared to work with computing devices [ 36 , 37 , 38 ]. Then it has to be said that not all of them know how to use computers because they are of a certain age they are reluctant, some are reluctant, they don't know how to do it, they don't even want to try, but it's understandable because of their age. A small proportion of respondents (3/19) (16%) also expressed concern that HCWs connected to remote meetings do not closely follow the information being transmitted. ...now, instead of with the fact that you can have meetings with... You are in a meeting with maybe 10 people, and the other 25/30 work remotely from home; you don't know if they are following everything; yes, maybe they are connected, but actually, you don't know if they are there listening or not listening... or they are doing their own thing at home. So maybe they are not completely present at that moment. 4. Discussion The interviews' analysis revealed crucial aspects concerning the internal information transmission process. The five main categories identified provide a detailed picture of leaders' challenges and strategies within the healthcare organization. The quantification of participants' responses further clarifies the extent of certain perceptions and behaviours. For example, while all participants used institutional email, only a third employed instant messaging apps to transmit content-related information. Similarly, although feedback is a common strategy, only a minority validated communication through direct observation. The use of software applications emerged as the most common topic. French-Bravo et al. [ 25 ] showed that Heads of Nursing and Allied Health Professionals employ various methods for disseminating information, including e-mail, meetings, telephone calls, text messages, staff meetings, annual evaluations, and individual meetings. According to the study, all leaders interviewed use formal channels such as institutional e-mails and scheduled meetings, often supported by multimedia platforms. However, using instant messaging apps such as WhatsApp for urgent communications is controversial. Most interviewees (14/19) (74%) limit the use of such apps to avoid privacy violations and to maintain a work-life balance, highlighting the lack of institutional recognition. This reflects a tension between the immediate efficiency offered by informal technologies and the need to maintain a clear separation between work and personal life. Technology is considered one of the main factors influencing employee health and work stress [ 39 , 40 ]. In Italy, the use of instant messaging apps at work is not regulated by specific legislation, but is subject to the principles of privacy, the right to disconnect and the rules on confidentiality of correspondence, with particular attention to the principles of the GDPR and the Italian Criminal Code. Employers cannot access and use private messages or group chats for disciplinary purposes, and employees have the right not to be disturbed outside working hours. The law protects personal data and correspondence, stipulating that any use of these apps for work purposes must be clear, proportionate and respect the user's consent, preferably through a privacy policy or company agreement. Not coincidentally, it turned out that content information is rarely (5/19) (26%) shared via instant messaging apps, mainly used to solicit the attention of HCWs on new urgent information communicated via institutional channels such as e-mail. In this context, the interviews indicated that leaders perceive uncertainty regarding the efficacy of information transmission through institutional channels. The nature of work in healthcare environments is marked by variability and complexity [ 24 ]. The amount of information available has thus become excessive, but it is difficult to assess its quality. As a result, information overload has become a widespread problem and is one of the most frequent stressors in HCWs [ 41 , 42 ]. In addition, our study suggests that difficulties arise not only from the volume of information but also from the complexity of the information and the need for time devoted exclusively to communication. Information overload correlated with a lack of time to manage information, reducing the time available to provide direct patient care and diverting attention from important information. Another relevant finding concerns the generational differences in the use of digital communication tools. In some cases, the failure to read information transmitted via institutional email was linked to difficulties in using digital applications among healthcare workers belonging to the ‘Boomer’ (1946–1964) and ‘Generation X’ (1965–1980) cohorts. Conversely, younger nurse managers appeared more at ease with technology. This aligns with the literature, which highlights how Generation Y (1981–1994) tends to be more computer literate and technologically ready compared to previous generations, and therefore more confident in working with digital devices [ 36 , 37 , 38 ]. The literature highlights the leaders’ consistent effort to understand the challenges participants faced by frequently asking "why." This approach allows the managers to identify barriers to implementing initiatives and actively engage HCWs [ 25 ]. Requesting feedback verbally or by e-mail is common in the interviews. Some leaders also use direct observation of clinical practice or patients' medical records to verify communication effectiveness. Moreover, the need to contextualize and synthesize information about the reality of the Care Unit, highlighting key messages, emerges. Leaders emphasize the importance of adapting communications to the specifics of the work context. This requires a profound understanding of ward dynamics and operational needs to convey relevant and applicable information. This point is also in line with the literature: according to Greenhalgh's [ 43 ] advice, for greater effectiveness, information should be abbreviated, focused, and calibrated to the context. Additionally, it is essential to ensure that the recipient's message is clear and understood. This can be achieved through feedback and validation, as assumptions about the receiver’s understanding can lead to miscommunication and inefficiencies [ 11 ]. Consistent with this, leader behaviors identified as supporting comprehensibility include providing clear instructions, explaining the rationale behind actions, effectively articulating ideas, and maintaining consistency in messaging [ 44 ]. An increasing body of literature is investigating how existing and emerging information communication technologies impact the health sector, both for patients and HCWs [ 45 ]. What emerged in Category 5 agrees with the literature that successful message delivery does not mean the recipients understood or read the messages [ 11 , 46 ]. One strategy that leaders took to ensure that HCWs understood the messages was to engage in face-to‐face interactions whenever possible [ 46 ]. Primarily for high-priority messages, despite the rapid development of technology, the literature emphasizes the value of direct approaches, such as phone calls or face-to-face communication, that maintain their relevance in the modern world but are often neglected, leaving HCWs needing clarification and support. These methods allow for real-time interaction, providing opportunities for clarification and immediate feedback. For these reasons, there is a need for more face-to-face communication [ 11 , 15 ]. On the other hand, interviewees stated that they always disseminate information formally via e-mail to enable accurate tracking and documentation. Some open issues, only partially explored by the interviews conducted, remain and deserve further investigation. Among these, the group's involvement is a crucial aspect to be considered; some interviews revealed that the transmission of information can vary greatly from the group's involvement in the activities to be performed. Another crucial aspect concerns personal factors such as work stress and motivation. The interviews revealed that, due to the high work stress of HCWs, communications are sometimes not received correctly. The literature highlights how stress can negatively affect the ability to process and transmit information effectively [ 47 ]. Heads of Nursing and Allied Health Professionals face a significant challenge in choosing the most effective communication method to ensure staff members receive and comprehend the intended message. While text messages are widely used for convenience, their volume can quickly become overwhelming, reducing their effectiveness. Consequently, these tools should complement rather than replace routine communication methods [ 11 ]. Thus, it is necessary to combine multiple channels and tools and tailor messages to increase their effectiveness within the company [ 48 ] to promote the involvement and commitment of HCWs [ 49 , 50 ]. Indeed, Heads of Nursing and Allied Health Professionals use multiple communication strategies, disseminating the same information through various channels such as telephone calls, text messages, e-mails, meetings, and noticeboards. This approach addresses the challenge of reaching nurses on different shifts and ensures that all staff receive timely and consistent information [ 46 ]. These insights could serve as a basis for further studies and for developing strategies to improve communication and information management in the healthcare system. Exploring these issues in more depth will provide a more comprehensive view and enable the development of more effective solutions to meet daily operational challenges. 5. Study limitations This study presents some limitations inherent to its qualitative methodology and specific context. The research was based on a relatively small sample of Heads of Nursing and Allied Health Professionals in a single University Hospital in Northern Italy, limiting the generalisability of the results to other healthcare facilities. Additionally, using non-probabilistic sampling methods, such as purposive sampling, further impacts generalisability. However, it is important to note that in qualitative research, the aim is not statistical generalisability but theoretical generalisability, which is the potential to transfer findings to contexts similar to the one studied [ 51 ]. Moreover, the qualitative nature of the interviews introduces potential interpretative biases resulting from the personal experiences and perceptions of both researchers and interviewees, although feedback mechanisms partially mitigate this risk. Lastly, the study exclusively focused on leaders, excluding the perspective of HCWs who receive communication. As a result, the findings might be biased, as they consider only one of the two parties involved in the communication process. Another limitation is the absence of participants under 35 years of age. This may have influenced the results, as younger nurse managers might have different attitudes toward digital communication and hierarchical relationships compared to their older colleagues. 6. Conclusion The analysis of interviews highlights the complexity of internal information transmission in healthcare organizations. The five main categories identified provide a comprehensive view of the challenges and strategies leaders adopt to improve organizational communication. They also require integrated strategies to balance technological efficiency, HCWs’ welfare, and care quality. Challenges such as the use of software applications, information overload, and balancing formal and informal communication methods underscore the need for a multifaceted approach. Integrating multiple communication channels, contextualizing information, and prioritizing face-to-face interactions can enhance clarity, trust, and message comprehension. Future studies should explore the perspectives of healthcare workers, group involvement, and the impact of organizational climate on communication to develop more tailored and effective solutions. In conclusion, an integrated communication approach that balances traditional and informal methods, manages information overload, and dedicates time to communication is vital for improving efficiency and quality. Abbreviations HCWs Healthcare workers GDPR General Data Protection Regulation Gen X Generation X Gen Y Generation Y RAFSI Ranking of Alternatives through Functional mapping of criterion sub-intervals into a Single Interval Declarations According to the institutional policies of the University of Verona, studies focusing on organizational processes and professional perspectives and not involving patients, clinical interventions, or experimental treatments do not require formal approval by an ethics committee. The study was therefore exempt from review by the Ethics Committee of the University of Verona. All participants received written information about the study and provided written informed consent prior to participation. Participation was voluntary, and anonymity and confidentiality were ensured throughout the research process. Ethics approval and consent to participate Before conducting the study, all participants received clear and detailed information about the nature and objectives of the research, which focused exclusively on internal communication practices within the hospital organization. The study did not involve patients, clinical interventions, or experimental treatments. Still, it was instead designed as an organizational quality-oriented initiative aimed at analysing the experiences of Heads of Nursing and Allied Health Professionals and generating evidence to inform a structured improvement project on internal communication. Written informed consent was obtained from each participant, who was fully informed about how the data would be collected, stored, and used. Specific consent was also sought for audio recording of the interviews, which were later transcribed verbatim for analysis. To protect anonymity and confidentiality, identifiers were removed from the transcripts and replaced with participant codes (e.g., Participant 1, 2, etc.), ensuring no individual could be traced from the data. Participants were explicitly informed that they could withdraw from the study at any time, either verbally during the interview or afterwards by email, without justifying and without any negative consequences for their professional role. In accordance with the institutional policies of the University of Verona, projects of this nature—centred on organizational processes and professional perspectives and not involving patients or clinical experimentation—are exempt from the requirement of formal ethics committee approval. Nonetheless, the research team adhered rigorously to the principles of integrity, voluntariness, and respect for participants, ensuring that the study was conducted in line with internationally recognized ethical standards for qualitative research in healthcare. Consent for publication Not applicable. The manuscript does not contain any individual person’s data in any form. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was conducted independently by the authors in their own time, outside of their formal employment duties. No funder or employer had any role in the design of the study, data collection and analysis, interpretation of results, writing of the manuscript, or the decision to submit it for publication. Authors contributions FV: Conceptualization, data collection, data analysis, writing – original draft. Acknowledgments The authors thank Dr. Jessica Longhini for contributing to preliminary data collection and early pilot activities during the initial phase of the project. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to confidentiality agreements with the participants but are available from the corresponding author on reasonable request. References Castro-Martínez A, Diaz-Morilla P, Torres-Martín JL (2022) Internal communication, wellbeing and happiness at work in Spanish hospital institutions during the COVID-19 crisis. Int J Public Relat 12(23):143–162. https://doi.org/10.5783/revrrpp.v12i23.766 Hagen L, Neely S, Scharf R, Keller TE (2020) Social media use for crisis and emergency risk communications during the Zika health crisis. Digit Gov Res Pract 1(2):1–21. https://doi.org/10.1145/3372021 Tworek H, Beacock I, Ojo E (2020) Democratic health communications during Covid-19: a RAPID response. 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PMID: 30935883; PMCID: PMC6590519 Vermeir P, Vandijck D, Degroote S, Peleman R, Verhaeghe R, Mortier E, Hallaert G, Van Daele S, Buylaert W, Vogelaers D (2015) Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract 69(11):1257–1267. 10.1111/ijcp.12686 Epub 2015 Jul 6. PMID: 26147310; PMCID: PMC4758389 Gluyas H (2015) Effective communication and teamwork promotes patient safety. Nurs Stand 29(49):50–57. 10.7748/ns.29.49.50.e10042 Espinoza P, Peduzzi M, Agreli HF, Sutherland MA (2018) Interprofessional team member's satisfaction: a mixed methods study of a Chilean hospital. Hum Resour Health 16(1):30. 10.1186/s12960-018-0290-z PMID: 29996936; PMCID: PMC6042408 French-Bravo M, Nelson-Brantley HV, Williams K, Ford DJ, Manos L, Veazey Brooks J (2020) Exploring nurses' perceptions of nurse managers' communicative relationships that encourage nurses' decisions to buy-in to initiatives that enhance patients' experiences with care. J Nurs Manag 28(3):567–576. 10.1111/jonm.12958 Epub 2020 Mar 20. PMID: 31957125 Grippa F, Bucuvalas J, Booth A, Alessandrini E, Fronzetti Colladon A, Wade LM (2018) Measuring information exchange and brokerage capacity of healthcare teams. Manag Decis 56(10):2239–2251. 10.1108/MD-10-2017-1001 Winzer H, Stevik TK, Scholderer J (2024) Internal crisis communication in hospitals: The choice of communication channels and its impact on effectiveness. J Contingencies Crisis Manag 32(4):1093–1104. 10.1111/1468-5973.70008 Irvanizam ZN (2024) An improved RAFSI method based on single-valued trapezoidal neutrosophic number and its harmonic and arithmetic mean operators for healthcare service quality evaluation. Expert Syst Appl 248:123343. 10.1016/j.eswa.2024.123343 Mazzei A, Ravazzani S, Fisichella C, Butera A, Quaratino L (2022) Internal crisis communication strategies: Contingency factors determining an accommodative approach. Public Relat Rev 48(4):102212. 10.1016/j.pubrev.2022.102212 Sandelowski M (2010) What's in a name? Qualitative description revisited. Res Nurs Health. ;33(1):77–84. 10.1002/nur.20362 . PMID: 20014004 Azienda Ospedaliera Universitaria Integrata Verona (2026) Chi siamo? https://www.aovr.veneto.it/azienda/chi-siamo . Accessed 12 Jan Polit DF, Beck CT (2017) Nursing research: generating and assessing evidence for nursing practice, 10th edn. Wolters Kluwer Health, Philadelphia Rezaee R, Zare S, Niknam F, Akbari A, Shirdeli M, Falahati F, Aghajani S (2022) Contributing factors in hospital internal communication based on hospital managers and healthcare personnel’s attitudes: A qualitative study. J Health Sci Surveill Syst 10(3):342–350 Sandelowski M, Barroso J (2002) Reading qualitative studies. Int J Qual Methods 1(1):74–108. 10.1177/160940690200100107 Buus N, Perron A (2020) The quality of quality criteria: Replicating the development of the Consolidated Criteria for Reporting Qualitative Research (COREQ). Int J Nurs Stud 102:103452. 10.1016/j.ijnurstu.2019.103452 Epub 2019 Oct 24. PMID: 31726311 Anderson HJ, Baur JE, Griffith JA, Buckley MR (2017) What works for you may not work for (Gen)me: Limitations of present leadership theories for the new generation. Leadersh Q 28(1):245–260. 10.1016/j.leaqua.2016.08.001 Camp KM, Young M, Bushardt SC (2022) A millennial manager skills model for the new remote work-environment. Manag Res Rev 45:635–648 Pearson JC, Carmon A, Tobola C, Fowler M (2010) Motives for communication: Why the millennial generation uses electronic devices. J Commun Speech Theatre Assoc N Dak 22:45–55 Berg-Beckhoff G, Nielsen G, Ladekjær Larsen E (2017) Use of information communication technology and stress, burnout, and mental health in older, middle-aged, and younger workers - results from a systematic review. Int J Occup Environ Health 23(2):160–171 Epub 2018 Feb 20. PMID: 29460697; PMCID: PMC6060856 Burman R, Goswami TG (2018) A systematic literature review of work stress. Int J Manag Stud 3(9):112–132 Arnold M, Goldschmitt M, Rigotti T (2023) Dealing with information overload: a comprehensive review. Front Psychol 14:1122200. 10.3389/fpsyg.2023.1122200 PMID: 37416535; PMCID: PMC10322198 Meyer B, Zill A, Dilba D, Voermans S (2021) Entspann dich, Deutschland! TK-Stressstudie Greenhalgh T (2017) How to implement evidence-based healthcare. Wiley Blackwell; (Italian translation: Come implementare l’assistenza sanitaria basata sull’evidenza. Il Pensiero scientifico, 2018) Hopkinson SG, Oblea P, Napier C, Lasiowski J, Trego LL (2019) Identifying the constructs of empowering nurse leader communication through an instrument development process. J Nurs Manag 27(4):722–731. 10.1111/jonm.12729 Epub 2019 Feb 20. PMID: 30422364 Janssen A, Robinson T, Brunner M, Harnett P, Museth KE, Shaw T (2018) Multidisciplinary teams and ICT: a qualitative study exploring the use of technology and its impact on multidisciplinary team meetings. BMC Health Serv Res 18(1):444. 10.1186/s12913-018-3242-3 PMID: 29898716; PMCID: PMC6001028 Gan I (2019) How do nurses' work arrangements influence nurse managers' communication? A qualitative study. J Nurs Manag. ;27(7):1366–1373. 10.1111/jonm.12817 . Epub 2019 Jul 11. PMID: 31211906 Vogel S, Kluen LM, Fernández G, Schwabe L (2018) Stress affects the neural ensemble for integrating new information and prior knowledge. NeuroImage 173:176–187. 10.1016/j.neuroimage.2018.02.038 Epub 2018 Feb 21. PMID: 29476913 Cuenca J, Verazzi L (2018) Guía fundamental de la comunicación interna Castro-Martínez A, Díaz-Morilla P (2019) Análisis del ranking Great Place to Work y de los premios del Observatorio de Comunicación Interna: prácticas de comunicación interna en empresas españolas (2014–2018). Prof Inf. ;28(5) Tramontin E, Beuren IM, Gasparetto V (2020) Influência da comunicação interna e do engajamento no desempenho de tarefas de servidores públicos. Rev Int Rel Pub 10(20):179–200. https://doi.org/10.5783/revrrpp.v10i20.662 Mortari L, Zannini L (2017) La ricerca qualitativa in ambito sanitario. La ricerca qualitativa in ambito sanitario. Carocci editore, Rome, pp 1–271 Additional Declarations The authors declare no competing interests. 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Background","content":"\u003cp\u003eCommunication is a fundamental element in organizational management and a strategic factor essential for conducting various situations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The effectiveness of organizational communication significantly influences an organization's success, as it is fundamental to the management of entities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, communication encompasses vital tasks for conveying information, attitudes, ideas, feelings, planning, and decisions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Internal communication is valuable because an organization evolves through member conversations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In other words, the organization is not comprised of its members; rather, the organization is a by-product of the actions of and interactions between its members. For communication to occur, an individual uses language to transmit a message through a channel to another individual, who interprets the message. In healthcare, the Heads of Nursing and Allied Health Professionals produce the message, and the staff receive it [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The communication between the heads of Nursing and Allied Health Professionals includes positive and negative behaviors. Despite the inconsistencies in how communication styles are described in the literature, it is acknowledged that aspects such as respect, active listening, appropriate emotional responses, and access to sufficient information are positive. Conversely, negative behaviors include condescension, intimidation, micromanagement, contradictory communication, and an inability to convey information to employees clearly and unambiguously [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe limited literature in health care highlights that organizational communication ensures the efficient exchange of patient care information among HCWs, enhancing nursing effectiveness and improving overall organizational performance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This type of communication is essential for high-quality healthcare delivery; without it, care quality would decline, leading to increased costs and adverse patient outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Direct communication between clinical nurses and their nurse managers is often the critical link for significantly impacting patient outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], resulting in greater job satisfaction, commitment, and retention for HCWs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. By creating sound internal communication systems, organizations experience greater productivity, greater innovation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], reduced absenteeism, and fewer strikes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Conversely, in poor communication systems, high-quality patient care, health worker satisfaction, collaboration and teamwork, and leaders' commitment to providing resources are lost. This can also hurt healthcare costs [11,18,19,20,21,22,]. Unfortunately, healthcare systems suffer from enormous inadequacies related to poor communication [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature revealed several critical issues contributing to communication difficulties within healthcare organizations. The main factors contributing to poor communication included the absence or ineffectiveness of meetings, limited consultation, and irregular feedback mechanisms, which negatively affected information flow [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Modern healthcare organisations are complex and specialised, requiring collaboration across interprofessional teams. Within this complexity, top-down communication from leaders becomes essential to ensure clarity, alignment, and safe care delivery [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Communication is necessary in healthcare, whether between nurse managers and nurses, physicians, or any other combination of healthcare professionals. However, the communicative relationships between these professionals remain an underexplored area of research [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Much of the existing literature in healthcare communication appears to focus on clinical and operational aspects, neglecting the importance of structured communication strategies to foster internal collaboration, information dissemination, and staff support. This lack of detailed studies makes it difficult for healthcare organizations to develop internal communication models based on empirical evidence, thus limiting the scope for improvement in relationship management and information sharing. Recent literature highlights various analytical and communication strategies to improve healthcare team coordination and internal information flow. Grippa et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] applied Social Network Analysis to assess how healthcare teams exchange information and rely on brokerage roles. Their findings show that high-performing teams exhibit dense intra-team connections and strong brokers who facilitate information flow across units, supporting timely and targeted communication.\u003c/p\u003e \u003cp\u003eWinzer et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] examined internal crisis communication in a Norwegian tertiary hospital during the COVID-19 pandemic, focusing on the role of channel selection. The study found that communication effectiveness improves significantly when high-bandwidth channels\u0026mdash;such as in-person meetings or video calls\u0026mdash;convey complex or urgent messages. Conversely, low-bandwidth channels (e.g., e-mail, bulletin boards) were associated with delayed understanding and reduced engagement among staff. From a methodological perspective, Irvanizam and Zahara [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] introduced an enhanced RAFSI method using single-valued trapezoidal neutrosophic numbers and harmonic/arithmetic mean operators. Their model enables more accurate evaluation of healthcare service quality under uncertain and imprecise conditions, offering a robust decision-making tool for healthcare managers faced with complex multicriteria environments. Mazzei et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] proposed a contingency-based framework for internal crisis communication strategies. The authors identify key factors\u0026mdash;perceived safety, sense of belonging, employee engagement, and mobilization\u0026mdash;essential to adopting an \u0026ldquo;accommodative\u0026rdquo; communication style. This approach proved particularly effective in enhancing employee trust, reducing anxiety, and promoting organizational resilience during health crises.\u003c/p\u003e \u003cp\u003eThese studies underscore the importance of integrating technical decision-making frameworks and context-sensitive communication strategies when examining internal information flows in healthcare organizations.\u003c/p\u003e \u003cp\u003eDespite the growing body of literature on internal communication in healthcare organizations, empirical evidence remains limited regarding how top-down communication is implemented in everyday clinical practice by Heads of Nursing and Allied Health Professionals. Existing studies have primarily focused on communication channels, crisis contexts, or analytical frameworks, often overlooking the lived experiences, decision-making processes, and strategies adopted by healthcare leaders to transmit information to frontline Healthcare Workers. Moreover, few studies have adopted a qualitative approach aimed at generating practice-oriented evidence that can directly inform structured quality improvement initiatives in internal communication.\u003c/p\u003e \u003cp\u003eIn line with this perspective, we, therefore, decided to conduct this research to analyse the transmission process of top-down communications from the Head of Nursing and Allied Health Professionals to HCWs in the Care Unit and the factors influencing their diffusion, with the perspective of generating evidence that could serve as the foundation for a structured quality improvement project on internal communication, aimed at enhancing the clarity, timeliness, and effectiveness of information transfer in the hospital setting.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive study [30] was conducted in 2024 in a University Hospital in the North-East of Italy.\u003c/p\u003e\n\u003cp\u003eThe setting was a 1500-bed university hospital in Verona, Italy. The hospital has high- and low-complexity units, with 5000 healthcare providers providing direct patient care.\u003c/p\u003e\n\u003cp\u003eThe University Hospital is a point of reference for the entire Veneto region, is a hub center, and is recognized as a highly specialized national healthcare center for the activities carried out in various research, care, and training sectors. It is a hub centre [31]. There are approximately 100 Heads of Nursing and Allied Health Professionals. The overall methodological process is summarized in the following flowchart (Fig.\u0026nbsp;1), which outlines the main steps of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHeads of Nursing and Allied Health Professionals were recruited through purposive sampling to achieve maximum variation in age, sex, education, and experience in the role and to ensure that the participants had direct and significant experience in managing internal communication, as they were responsible for the transmission of information in their Care Units.\u003c/p\u003e\n\u003cp\u003eParticipants were selected from different clinical areas (medical, surgical, emergency, obstetrics-gynecology, and diagnostics) with different socio-demographic characteristics (age, gender, and professional seniority) to ensure diversity in experience and perspectives. The participants of this study met the following criteria: they were Heads of Nursing and Allied Health Professions with a minimum of two years of experience in the role, to ensure a consolidated knowledge of communication practices and challenges, and they were willing to participate in the study. Participants were excluded if they had less than two years of experience in the role, did not hold direct responsibility for internal communication within their Care Unit, or were unwilling to provide informed consent. The determination of the sample size was not defined a priori but was based on the richness of the data collected until saturation [32].\u003c/p\u003e\n\u003cp\u003eThe Heads of Nursing and Allied Health Professionals were contacted via email by the principal investigator, who provided them with details of the study and the consent form. Those who indicated their willingness to participate were subsequently contacted to arrange an in-person interview, during which they provided written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face semi-structured interviews between June 2024 and July 2024 following a semi-structured guide (Table\u0026nbsp;1) developed through a three-step process. First, the interview questions were developed based on a review of existing literature on internal communication in healthcare and qualitative research frameworks [33]. Second, based on these themes, a preliminary set of open-ended questions was drafted to explore perceptions, strategies, and barriers in communication between leaders and healthcare workers. Finally, the questions were reviewed by a panel of experts, including a senior nurse researcher (F.C.), who assessed content validity, clarity, and relevance.\u003c/p\u003e\n\u003cp\u003eThe following data were collected at the beginning of the interview: age, gender, education, role, years of work experience, and work setting.\u003c/p\u003e\n\u003cp\u003eIn addition to demographic data, participants were asked about the tools and strategies they use to transmit information within their teams. This included specific questions regarding the use of software applications (e.g., institutional email, instant messaging apps, shared documents, online surveys). Their responses provided detailed qualitative data on each tool\u0026apos;s frequency, purpose, perceived effectiveness, and limitations. These qualitative accounts were later grouped thematically during content analysis to assess patterns and preferences in software usage.\u003c/p\u003e\n\u003cp\u003eThe interviews were conducted in locations and at times convenient for the participants.\u003c/p\u003e\n\u003cp\u003eAll data collected was anonymous and strictly confidential, and the information obtained was used for research purposes only.\u003c/p\u003e\n\u003cp\u003eInterviews were audio recorded and lasted, on average, from 20 to 30 minutes, and were conducted by a nurse attending the second year of the Master\u0026rsquo;s Degree of Science in Nursing with previous training by a researcher expert in qualitative research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Interview guide\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img1769592524.png\"\u003e\u003c/p\u003e\n\u003cdiv\u003eTo ensure the confidentiality of the data, each interviewee was subjected to a recording procedure and assigned an identification code. The verbatim transcripts of the audio recordings of the interviews were identified with this code and can no longer be traced back to the interviewee.\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were transcribed verbatim, word for word, by two authors independently. To ensure anonymity and confidentiality of information, participants were assigned an identification code at the time of transcription.\u003c/p\u003e\n\u003cp\u003eA content analysis was conducted on the qualitative data [34], with two authors analyzing each transcription independently. The analytical process consisted of phases:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\n \u003cp\u003eFamiliarisation with the source material through multiple readings of the transcriptions.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIdentification of meaningful textual units: the words and/or significant sentences concerning the research question.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSummarise each textual unit with a descriptive label: each significant part of the text was assigned a descriptive label.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe arrangement of the labels in patterns is based on similarities and the definition of categories.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe analysis process was then reviewed by a third author, and the data were tested for coherence with the labels. At this time, field notes gathered during the interviewing and analysis processes were discussed, and the authors examined how their perceptions contributed to the shape and developed their understanding of the data.\u003c/p\u003e\n\u003cp\u003eFeedback was sought from the participants to increase the validity of the findings, ensuring that their meanings and perspectives were represented and not limited to the researchers\u0026rsquo; agenda [35].\u003c/p\u003e\n\u003cp\u003eNo software was used for data analysis.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eNineteen Heads of Nursing and Allied Health Professionals participated in the study. Most were female (73.7%) and had an average of 10.9 years of experience in their role, ranging from a minimum of 3 years to a maximum of 30 years. Participants interviewed belong to all areas: medical, surgical, emergency-urgency, diagnostic, and obstetrics-gynaecology.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience in their current positions (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency-urgency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrics-gynaecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFrom the analysis of the interviews, five categories emerged regarding opinions and experiences concerning the internal information transmission process: use of software applications for the transmission of information; Time management for the transmission of information; Use of feedback as a verification strategy; contextualisation of information in the Care Unit; Lived with uncertainty about the effectiveness of official communication channels.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1. Use of software applications for the transmission of information\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis category includes narrations about the use of software applications to transmit information and is intended for all software applications, from those used as formal channels, such as email, to informal channels, such as social networks and messaging apps.\u003c/p\u003e \u003cp\u003e All the leaders interviewed (100%) disseminate information formally via institutional e-mail and through scheduled meetings, with some providing the opportunity to participate remotely using multimedia platforms. This approach ensures that information has been effectively and correctly disseminated, thus enabling accurate tracking and documentation of communications.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"...we use the institutional email channels and the communication channel of meetings, also taking advantage of the technologies made available recently...\"\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eFifteen out of nineteen leaders (79%) reported using instant messaging apps, mainly to draw attention to urgent emails sent through institutional channels. However, the majority of these leaders (10/15, 67%) avoided using apps for transmitting detailed content in order to safeguard confidentiality.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...when I have urgent emails, which I need to be viewed immediately, I write on the WhatsApp group \u0026ldquo;look at the email I sent you an urgent communication\u0026rdquo;, I use it in these ways\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e However, a small proportion (5/15) (33%) of those using instant messaging apps also share content information but do not use it as a preferred method, only for urgent information and always followed by communication through formal channels. This method is chosen for its speed and effectiveness in transmitting messages that require immediate attention while maintaining the formality and completeness of communication through the main institutional channels. This way, leaders can deal with critical situations promptly while ensuring that all official information is archived and accessible through formal channels.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;...it's also been used a lot to give service announcements, although it's not a medium that's considered suitable... but maybe things at the last second... I wrote it on WhatsApp after I sent it in the email.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition to instant messaging apps, this category includes software applications that allow people to answer online questionnaires and share editable documents.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI also did a questionnaire on Google Drive with some answers that gave me an important overview of the level of information there is\u0026hellip;also to know how to behave and where I need to focus.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some of the interviewed state that they do not agree with the use of instant messaging apps for work purposes, as they believe that this channel, being unofficial, could invade the personal sphere of HCWs by creating a continuum even outside working hours.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e... WhatsApp means that a person never has the moment where they say \u0026lsquo;I'm done, I've clocked out, I'm home\u0026rsquo;, you're always involved ... that maybe it's ... a system that forces us never to disconnect.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2. Time management for the transmission of information\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the category \u0026ldquo;time management for the transmission of information\u0026rdquo;, all labels related to the interviewees' perception of the lack of time for transmitting information were grouped.\u003c/p\u003e \u003cp\u003e Many participants (12/19) (63%) emphasized the need to dedicate adequate time to organizing targeted meetings to transmit information. These meetings are crucial to communicating the necessary information and receiving immediate and contextual feedback from the participants. They believe that more effective time management would significantly improve the quality of internal communication. Organizing regular, dedicated information-sharing meetings would help transmit directives clearly and monitor and verify HCWs\u0026rsquo; understanding and application of them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...I would need more time basically because we are overloaded with activities, so sometimes even checking whether information has been understood takes time\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe interviews also reveal the leaders' concern about ensuring adequate time spaces for HCWs to receive the information properly. These spaces, excluded from work activities, should allow HCWs to participate peacefully in meetings, thus improving the understanding and application of information.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...it would be ideal to create or set up a time, outside of work activities, to have the serenity to meet, exchange, and share information.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to the time required to attend meetings, it was also pointed out that a considerable time commitment is required to handle emails. This includes not only the time to read them but also the time needed to understand their content, which can be particularly demanding due to the large number of messages and the complexity of the information. Moreover, dual-factor authentication for accessing the email application entails additional time commitments.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e... so, for email communication certainly the... workload, in my opinion, affects a lot... so if they during the shift... don't have time to look at the email because they are too overloaded to look at it then they don't look at it\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe lack of time for transmitting information can be attributed to information overload, making it difficult to establish a degree of importance for each piece of information. This requires time management, as reading, understanding, and responding to each email requires concentration and attention. Not all emails are equally important; distinguishing between urgent and ordinary messages can be challenging. In addition, this information overload also affects HCWs, reducing the time available to provide direct patient care and diverting attention from important information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You have to consider that if I have too much information, even the most important information might slip through my fingers\u0026hellip;\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3. Use of feedback as a verification strategy\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn all interviews (100%), the use of feedback as a strategy for verifying the information received emerged. This practice includes various methods, from verbal feedback requests to direct observation, to assess the action's adherence to what was requested.\u003c/p\u003e \u003cp\u003e Most interviewees (16/19) (84%) stated that they verify the transmission of information by asking for verbal feedback, explicitly asking whether the information conveyed has been read and understood. This approach allows for immediate and direct feedback on the understanding and accepting the communicated information. Some interviewees also highlighted the usefulness of open-ended questions, which stimulate deeper reflection and offer a more comprehensive view of the level of understanding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt is not enough just to give the information, but to have feedback that the person has understood the information\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e In addition to verbal feedback, in some cases (5/19) (26%), interviewees use direct observation as a complementary method. They resort to direct observation of clinical practice or patient records to obtain feedback, depending on the information transmitted. This practice involves monitoring employees' behavior and actions to ensure they align with the information received. Direct observation makes it possible to identify discrepancies between the communicated information and the practical implementation, offering the opportunity to intervene promptly to correct any misunderstandings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...you try to get feedback in the field, see if things are put into practice\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4. Contextualisation of information in the Care Unit\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFifty-eight percent of the respondents report that personal insight and analysis of the information received are fundamental to optimizing its contextualization to the coordinated unit. Respondents emphasize that, in addition to receiving information, it is essential to spend time on reflection and analysis, which allows them to identify relevant details, understand the implications of the information, and evaluate how it integrates with the specific dynamics and requirements of their role and in their own unit.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...there are things that come from the top to me as well, but maybe we can adapt them a little bit to our unit and then you just try to readapt them a little bit, that's um... as far as you can.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to contextualizing information, many respondents (12/19) (63%) reported synthesizing the information they receive, disseminating only what they consider to be key concepts, or reworking the original information to make it simpler, more immediate, and actionable. This synthesis and simplification process is essential to ensure that information is understood and used effectively within the organization.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e... I choose whether by default I have to disseminate it and forward it as it is to my staff or whether I can somehow synthesize it, modify it, to arrive at a communication that can be more immediate and synthesized.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, some interviewed leaders (6/19) (32%) stated that they find it useful to establish an order of importance and relevance to the information they receive, even marking with alerts those they consider most important to facilitate the use of the content for HCWs\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e... and also the placement in a priority order, because as we know, the space for the reception of information, which must be assimilated, is not infinite\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5. The uncertainty on the effectiveness of official communication channels\u003c/b\u003e \u003c/p\u003e \u003cp\u003e13 out of the 19 interviews (68%) revealed an experience of uncertainty regarding the real effectiveness of disseminating information through formal channels, especially through institutional e-mails. The perception of the Head of Nursing and Allied Health Professionals is that emails are often not read or, at least, not read quickly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip;I have noticed this difficulty in reading the e-mail; I don't know what it is due to, but it is so\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo deal with this problem, some leaders (7/19) (37%) reported using email with read confirmation for communications they consider important. However, they found that read confirmations are not received if the emails are read from smartphones, that the HCW may decide not to send the read confirmation even when reading the email, and that, in any case, there is no certainty that the information is read even when the read confirmation is received.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAs for the emails, at least they opened them with the confirmation. But I don't have the certainty that a person will read it; that's why I told them, \" This is your responsibility.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn some cases (4/19) (21%), the difficulty in using the applications by the HCWs belonging to the \u0026lsquo;Boomers\u0026rsquo; (1946\u0026ndash;1964) or \u0026lsquo;X\u0026rsquo; (1965\u0026ndash;1980) generations emerged as the reason for not reading the information transmitted via email.\u003c/p\u003e \u003cp\u003eGen Y (1981\u0026ndash;1984) may be more computer-savvy and technology-ready than the Boomers and Gen X and, therefore, more prepared to work with computing devices [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThen it has to be said that not all of them know how to use computers because they are of a certain age they are reluctant, some are reluctant, they don't know how to do it, they don't even want to try, but it's understandable because of their age.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA small proportion of respondents (3/19) (16%) also expressed concern that HCWs connected to remote meetings do not closely follow the information being transmitted.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...now, instead of with the fact that you can have meetings with... You are in a meeting with maybe 10 people, and the other 25/30 work remotely from home; you don't know if they are following everything; yes, maybe they are connected, but actually, you don't know if they are there listening or not listening... or they are doing their own thing at home. So maybe they are not completely present at that moment.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe interviews' analysis revealed crucial aspects concerning the internal information transmission process. The five main categories identified provide a detailed picture of leaders' challenges and strategies within the healthcare organization. The quantification of participants' responses further clarifies the extent of certain perceptions and behaviours. For example, while all participants used institutional email, only a third employed instant messaging apps to transmit content-related information. Similarly, although feedback is a common strategy, only a minority validated communication through direct observation.\u003c/p\u003e \u003cp\u003eThe use of software applications emerged as the most common topic. French-Bravo et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] showed that Heads of Nursing and Allied Health Professionals employ various methods for disseminating information, including e-mail, meetings, telephone calls, text messages, staff meetings, annual evaluations, and individual meetings. According to the study, all leaders interviewed use formal channels such as institutional e-mails and scheduled meetings, often supported by multimedia platforms. However, using instant messaging apps such as WhatsApp for urgent communications is controversial. Most interviewees (14/19) (74%) limit the use of such apps to avoid privacy violations and to maintain a work-life balance, highlighting the lack of institutional recognition. This reflects a tension between the immediate efficiency offered by informal technologies and the need to maintain a clear separation between work and personal life. Technology is considered one of the main factors influencing employee health and work stress [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In Italy, the use of instant messaging apps at work is not regulated by specific legislation, but is subject to the principles of privacy, the right to disconnect and the rules on confidentiality of correspondence, with particular attention to the principles of the GDPR and the Italian Criminal Code. Employers cannot access and use private messages or group chats for disciplinary purposes, and employees have the right not to be disturbed outside working hours. The law protects personal data and correspondence, stipulating that any use of these apps for work purposes must be clear, proportionate and respect the user's consent, preferably through a privacy policy or company agreement. Not coincidentally, it turned out that content information is rarely (5/19) (26%) shared via instant messaging apps, mainly used to solicit the attention of HCWs on new urgent information communicated via institutional channels such as e-mail. In this context, the interviews indicated that leaders perceive uncertainty regarding the efficacy of information transmission through institutional channels. The nature of work in healthcare environments is marked by variability and complexity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The amount of information available has thus become excessive, but it is difficult to assess its quality. As a result, information overload has become a widespread problem and is one of the most frequent stressors in HCWs [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In addition, our study suggests that difficulties arise not only from the volume of information but also from the complexity of the information and the need for time devoted exclusively to communication. Information overload correlated with a lack of time to manage information, reducing the time available to provide direct patient care and diverting attention from important information.\u003c/p\u003e \u003cp\u003eAnother relevant finding concerns the generational differences in the use of digital communication tools. In some cases, the failure to read information transmitted via institutional email was linked to difficulties in using digital applications among healthcare workers belonging to the \u0026lsquo;Boomer\u0026rsquo; (1946\u0026ndash;1964) and \u0026lsquo;Generation X\u0026rsquo; (1965\u0026ndash;1980) cohorts. Conversely, younger nurse managers appeared more at ease with technology. This aligns with the literature, which highlights how Generation Y (1981\u0026ndash;1994) tends to be more computer literate and technologically ready compared to previous generations, and therefore more confident in working with digital devices [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature highlights the leaders\u0026rsquo; consistent effort to understand the challenges participants faced by frequently asking \"why.\" This approach allows the managers to identify barriers to implementing initiatives and actively engage HCWs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Requesting feedback verbally or by e-mail is common in the interviews. Some leaders also use direct observation of clinical practice or patients' medical records to verify communication effectiveness. Moreover, the need to contextualize and synthesize information about the reality of the Care Unit, highlighting key messages, emerges. Leaders emphasize the importance of adapting communications to the specifics of the work context. This requires a profound understanding of ward dynamics and operational needs to convey relevant and applicable information. This point is also in line with the literature: according to Greenhalgh's [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] advice, for greater effectiveness, information should be abbreviated, focused, and calibrated to the context. Additionally, it is essential to ensure that the recipient's message is clear and understood. This can be achieved through feedback and validation, as assumptions about the receiver\u0026rsquo;s understanding can lead to miscommunication and inefficiencies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Consistent with this, leader behaviors identified as supporting comprehensibility include providing clear instructions, explaining the rationale behind actions, effectively articulating ideas, and maintaining consistency in messaging [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn increasing body of literature is investigating how existing and emerging information communication technologies impact the health sector, both for patients and HCWs [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. What emerged in Category 5 agrees with the literature that successful message delivery does not mean the recipients understood or read the messages [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. One strategy that leaders took to ensure that HCWs understood the messages was to engage in face-to‐face interactions whenever possible [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Primarily for high-priority messages, despite the rapid development of technology, the literature emphasizes the value of direct approaches, such as phone calls or face-to-face communication, that maintain their relevance in the modern world but are often neglected, leaving HCWs needing clarification and support. These methods allow for real-time interaction, providing opportunities for clarification and immediate feedback. For these reasons, there is a need for more face-to-face communication [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. On the other hand, interviewees stated that they always disseminate information formally via e-mail to enable accurate tracking and documentation.\u003c/p\u003e \u003cp\u003eSome open issues, only partially explored by the interviews conducted, remain and deserve further investigation. Among these, the group's involvement is a crucial aspect to be considered; some interviews revealed that the transmission of information can vary greatly from the group's involvement in the activities to be performed. Another crucial aspect concerns personal factors such as work stress and motivation. The interviews revealed that, due to the high work stress of HCWs, communications are sometimes not received correctly. The literature highlights how stress can negatively affect the ability to process and transmit information effectively [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHeads of Nursing and Allied Health Professionals face a significant challenge in choosing the most effective communication method to ensure staff members receive and comprehend the intended message. While text messages are widely used for convenience, their volume can quickly become overwhelming, reducing their effectiveness. Consequently, these tools should complement rather than replace routine communication methods [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, it is necessary to combine multiple channels and tools and tailor messages to increase their effectiveness within the company [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] to promote the involvement and commitment of HCWs [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Indeed, Heads of Nursing and Allied Health Professionals use multiple communication strategies, disseminating the same information through various channels such as telephone calls, text messages, e-mails, meetings, and noticeboards. This approach addresses the challenge of reaching nurses on different shifts and ensures that all staff receive timely and consistent information [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese insights could serve as a basis for further studies and for developing strategies to improve communication and information management in the healthcare system. Exploring these issues in more depth will provide a more comprehensive view and enable the development of more effective solutions to meet daily operational challenges.\u003c/p\u003e"},{"header":"5. Study limitations","content":"\u003cp\u003eThis study presents some limitations inherent to its qualitative methodology and specific context. The research was based on a relatively small sample of Heads of Nursing and Allied Health Professionals in a single University Hospital in Northern Italy, limiting the generalisability of the results to other healthcare facilities. Additionally, using non-probabilistic sampling methods, such as purposive sampling, further impacts generalisability. However, it is important to note that in qualitative research, the aim is not statistical generalisability but theoretical generalisability, which is the potential to transfer findings to contexts similar to the one studied [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, the qualitative nature of the interviews introduces potential interpretative biases resulting from the personal experiences and perceptions of both researchers and interviewees, although feedback mechanisms partially mitigate this risk. Lastly, the study exclusively focused on leaders, excluding the perspective of HCWs who receive communication. As a result, the findings might be biased, as they consider only one of the two parties involved in the communication process. Another limitation is the absence of participants under 35 years of age. This may have influenced the results, as younger nurse managers might have different attitudes toward digital communication and hierarchical relationships compared to their older colleagues.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe analysis of interviews highlights the complexity of internal information transmission in healthcare organizations. The five main categories identified provide a comprehensive view of the challenges and strategies leaders adopt to improve organizational communication. They also require integrated strategies to balance technological efficiency, HCWs\u0026rsquo; welfare, and care quality.\u003c/p\u003e \u003cp\u003eChallenges such as the use of software applications, information overload, and balancing formal and informal communication methods underscore the need for a multifaceted approach. Integrating multiple communication channels, contextualizing information, and prioritizing face-to-face interactions can enhance clarity, trust, and message comprehension.\u003c/p\u003e \u003cp\u003eFuture studies should explore the perspectives of healthcare workers, group involvement, and the impact of organizational climate on communication to develop more tailored and effective solutions.\u003c/p\u003e \u003cp\u003eIn conclusion, an integrated communication approach that balances traditional and informal methods, manages information overload, and dedicates time to communication is vital for improving efficiency and quality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCWs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Data Protection Regulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGen X\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneration X\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGen Y\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneration Y\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRAFSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRanking of Alternatives through Functional mapping of criterion sub-intervals into a Single Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAccording to the institutional policies of the University of Verona, studies focusing on organizational processes and professional perspectives and not involving patients, clinical interventions, or experimental treatments do not require formal approval by an ethics committee. The study was therefore exempt from review by the Ethics Committee of the University of Verona. All participants received written information about the study and provided written informed consent prior to participation. Participation was voluntary, and anonymity and confidentiality were ensured throughout the research process.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval and consent to participate\u003c/b\u003e \u003c/strong\u003e \u003cp\u003eBefore conducting the study, all participants received clear and detailed information about the nature and objectives of the research, which focused exclusively on internal communication practices within the hospital organization. The study did not involve patients, clinical interventions, or experimental treatments. Still, it was instead designed as an organizational quality-oriented initiative aimed at analysing the experiences of Heads of Nursing and Allied Health Professionals and generating evidence to inform a structured improvement project on internal communication. Written informed consent was obtained from each participant, who was fully informed about how the data would be collected, stored, and used. Specific consent was also sought for audio recording of the interviews, which were later transcribed verbatim for analysis. To protect anonymity and confidentiality, identifiers were removed from the transcripts and replaced with participant codes (e.g., Participant 1, 2, etc.), ensuring no individual could be traced from the data. Participants were explicitly informed that they could withdraw from the study at any time, either verbally during the interview or afterwards by email, without justifying and without any negative consequences for their professional role. In accordance with the institutional policies of the University of Verona, projects of this nature\u0026mdash;centred on organizational processes and professional perspectives and not involving patients or clinical experimentation\u0026mdash;are exempt from the requirement of formal ethics committee approval. Nonetheless, the research team adhered rigorously to the principles of integrity, voluntariness, and respect for participants, ensuring that the study was conducted in line with internationally recognized ethical standards for qualitative research in healthcare.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was conducted independently by the authors in their own time, outside of their formal employment duties. No funder or employer had any role in the design of the study, data collection and analysis, interpretation of results, writing of the manuscript, or the decision to submit it for publication.\u003c/p\u003e\u003ch2\u003eAuthors contributions\u003c/h2\u003e \u003cp\u003eFV: Conceptualization, data collection, data analysis, writing \u0026ndash; original draft.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors thank Dr. Jessica Longhini for contributing to preliminary data collection and early pilot activities during the initial phase of the project.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to confidentiality agreements with the participants but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCastro-Mart\u0026iacute;nez A, Diaz-Morilla P, Torres-Mart\u0026iacute;n JL (2022) Internal communication, wellbeing and happiness at work in Spanish hospital institutions during the COVID-19 crisis. 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Carocci editore, Rome, pp 1\u0026ndash;271\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Internal communication, Nursing management, Healthcare leadership, Healthcare workers, Heads of Nursing and Allied Health Professionals, Nursing leadership, Information transmission, Qualitative research.","lastPublishedDoi":"10.21203/rs.3.rs-8671538/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8671538/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInternal communication is crucial in today's corporate world, ensuring alignment with organizational goals and enhancing performance. However, organizational complexity and lack of standardization may hinder this effectiveness. The transmission of information top-down is a critical element in ensuring effective and timely communication between the various hierarchical levels. The aim of this study was to analyse the process of top-down communication from Heads of Nursing and Allied Health Professionals to Healthcare Workers in hospital care units, with the specific purpose of identifying challenges and strategies that may result in the design of a structured quality improvement project on internal communication.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive study was conducted between June and July 2024 in a large university hospital in Northern Italy. Nineteen Heads of Nursing and Allied Health Professionals with at least two years of experience were recruited using purposive sampling. Semi-structured interviews were audio-recorded after written consent from the participants, transcribed verbatim, and analysed through content analysis by two independent researchers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis highlighted five main categories: (1) use of software applications for the transmission of information, (2) time management for the transmission of information, (3) use of feedback as a verification strategy, (4) contextualization of information in the care unit, and (5) the uncertainty on the effectiveness of official communication channels. The primary channels of communication are formal tools such as email and meetings, while instant messaging apps are employed for the dissemination of urgent alerts. The effective management of time in the transmission of information is regarded as a crucial aspect. Feedback is employed as a strategy for verifying the effective reception and understanding of information. Nevertheless, a sense of uncertainty persists regarding the effectiveness of official channels.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTo enhance internal communication, it is vital to strike a balance between technological efficiency and the well-being of Heads of Nursing and Allied Health Professionals, while guaranteeing the quality of care, adopting structured feedback practices, and contextualising information. An integrated approach that combines informal technologies and traditional methods is essential to address operational challenges and improve information management in the healthcare sector.\u003c/p\u003e","manuscriptTitle":"Challenges and Strategies in Internal Communication: Insights from Head of Nursing and Allied Health Professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 00:31:03","doi":"10.21203/rs.3.rs-8671538/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c147b575-9fd5-49fd-a7af-0e77019c0df1","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61878125,"name":"Nursing"}],"tags":[],"updatedAt":"2026-01-29T00:31:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 00:31:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8671538","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8671538","identity":"rs-8671538","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}