Low Pay, High Risk: The Nursing Pay Gap in Italy as a Systemic Health Policy Vulnerability

Background The nursing workforce is a key determinant of health system resilience, quality, and sustainability. In Italy, nurses receive significantly lower salaries compared to the OECD average, and the country has one of the lowest nurse-to-population ratios in Europe. This study examines the Italian nursing pay gap as a systemic vulnerability in health policy, with implications for the National Health Service's (NHS) capacity to deliver safe and continuous care. Methods This study follows a descriptive policy analysis approach integrated with comparative data analysis. Salary and workforce data were obtained from Organisation for Economic Co-operation and Development (OECD) datasets (2015–2024) and complemented with national and international institutional sources. The analysis was guided by Walt and Gilson's Policy Triangle and the Nursing Theory of Complex Adaptive Systems (NTCAS). Results Italy reports an average nursing salary of approximately USD 48,000 (PPP), about 21% lower than the OECD average, and a density of 6.2 nurses per 1,000 inhabitants compared with 9.4 internationally. In the selected country comparison, higher salary levels co-occurred with higher nurse density, while the policy analysis identified persistent constraints in remuneration, career development, workforce planning, and retention. Theoretical interpretation frames the pay gap as a systemic variable with potential consequences for quality, safety, and equity. Discussion The Italian pay gap reflects structural weaknesses in workforce governance rather than an isolated issue. Limited career pathways, migration, and workforce shortages further increase system vulnerability. Conclusion Addressing the nursing pay gap is a strategic priority to strengthen retention, reduce inequalities, and ensure the long-term sustainability of the NHS.