Recruiting and Retaining Care Workers in Italy: Building a Sustainable Workforce

A care organisation can recruit ten workers and still end the year with fewer experienced staff than it started with. A family can find a new badante but lose continuity when immigration status, working conditions or unsustainable hours make the arrangement unstable. A residential service can fill vacancies yet continue losing skilled workers because the workload has changed faster than staffing. Recruitment therefore solves only one part of Italy's long-term care workforce challenge.

The wider problem is examined across the Italy Ageing, Long-Term Care & Community Support Knowledge Hub: demand is rising as the population ages while the available workforce is fragmented across the Servizio Sanitario Nazionale, regional and local services, residential providers, home-care organisations, households and unpaid family networks.

Italy's labour model has important strengths. It has an established health workforce, a large domestic care sector, significant migrant participation and a strong tradition of family involvement. Yet recruitment conditions are becoming more difficult across several parts of the system. Nursing supply is constrained. Domestic worker numbers have been falling. The care workforce is ageing. Rural areas face additional recruitment barriers, while complex need is increasing the competence expected of staff.

The central strategic issue is therefore retention as much as recruitment. Italy needs not only to attract more people into care but to make the work sustainable enough for them to stay. That means examining employment quality, career progression, supervision, workload, migration pathways, skill mix and workforce planning together rather than treating vacancy filling as the whole problem.

Recruitment pressure is different across Italy's care sectors

There is no single Italian care-worker labour market.

A nurse employed within the SSN operates under different professional and employment arrangements from an OSS worker in an RSA. A home-care employee works within a different operating model from a privately employed domestic worker. A cooperative delivering social-health services may face different recruitment conditions again.

This matters because the causes of shortage differ.

In nursing, the issue includes training supply, remuneration, retirement, international mobility and competition between hospitals and territorial care. In residential long-term care, employers may compete with hospitals for clinical staff while simultaneously trying to retain OSS workers in physically and emotionally demanding environments.

Home care introduces travel, fragmented working time and lone-working pressures. Household employment introduces direct family-employer relationships, live-in arrangements and immigration issues that do not arise in the same way within institutional providers.

A credible recruitment strategy therefore starts by understanding the role and labour market being addressed.

This is why recruitment should be treated as a service-design issue rather than simply a human-resources function. The attractiveness of a job depends partly on what the service model asks the worker to do.

Italy cannot recruit its way out of poor retention

Vacancy rates attract attention because they are visible. Turnover is often more damaging over time.

A service can continually replace leavers and appear to maintain headcount while losing experience, relationships and organisational knowledge. New workers need induction and supervision. Remaining staff absorb gaps during recruitment. People using services repeatedly adapt to unfamiliar workers.

High turnover therefore creates additional demand inside the workforce system.

This is especially important in long-term care, where familiarity can directly affect quality. A worker who knows how a person communicates may recognise deterioration before it becomes obvious. A familiar care worker may reduce distress for somebody with dementia. A stable home-care team can identify subtle changes in mobility or nutrition.

Retention therefore has an outcome dimension as well as a financial one.

The factors influencing whether workers stay are usually cumulative:

• pay and financial security;
• workload and staffing levels;
• predictability of hours and shifts;
• quality of supervision and local management;
• opportunities to develop skills and progress;
• physical and psychological safety; and
• whether workers feel their contribution is respected.

Improving only one factor may help without resolving the wider problem.

A modest pay increase can be undermined by constantly changing shifts. Training can be welcomed but become frustrating if it never leads to greater responsibility or progression. Recruitment bonuses can attract people into a workplace they leave several months later because workload remains unsustainable.

Pay matters, but employment quality is broader than pay

Care work is labour intensive, and remuneration inevitably affects recruitment.

Workers compare long-term care roles with other employment requiring similar qualifications or offering more predictable working conditions. Nurses may compare residential or community roles with hospital employment. OSS workers may compare care work with occupations involving less physical and emotional pressure. Domestic workers may compare live-in care with other household employment or opportunities elsewhere in Europe.

Low or compressed wages can make shortage worse, but the employment proposition also includes conditions surrounding the wage.

A home-care worker who is paid for direct visits but experiences long unpaid or poorly recognised travel periods may perceive the job differently from the headline hourly rate. A live-in domestic worker may receive accommodation as part of the employment arrangement but experience limited separation between work and private time.

Residential workers may value predictable hours but face repeated night and weekend shifts. Nurses may value professional autonomy while becoming frustrated by administrative work that reduces clinical time.

Retention policy therefore needs to examine the whole employment experience.

The wider principles of fair work and responsible employment are relevant because long-term care sustainability depends on making jobs viable over years rather than merely attractive at the point of recruitment.

Operational scenario: filling every vacancy does not stop workforce instability

An RSA in Piemonte has recruited successfully during the previous year. Every time an OSS worker leaves, another is appointed within several weeks. Management initially concludes that recruitment is functioning adequately.

Quality data begin to suggest a different picture.

Agency use and overtime are rising. Experienced workers are spending more time inducting new colleagues. Family complaints increasingly mention unfamiliar staff. Sickness absence is concentrated among several long-serving employees.

The organisation reviews turnover rather than vacancy alone.

Exit discussions reveal that employees are not primarily leaving because they dislike care work. Many report unpredictable rotas, frequent requests to cover vacant shifts and increasing resident dependency without corresponding changes in staffing deployment.

The provider changes its response. Recruitment continues, but retention becomes a formal workforce objective. Rota stability is monitored. Dependency is considered when planning deployment. Experienced employees receive stronger supervision and development opportunities. Repeated short-notice shift changes become a management indicator rather than being treated as normal flexibility.

Within the following period, recruitment numbers fall because fewer vacancies need filling.

The scenario illustrates why staff retention should be viewed as a form of capacity creation. Preventing avoidable turnover can increase effective workforce supply without recruiting an additional person.

Nursing recruitment is competing with wider health-system demand

Italy's nursing challenge cannot be solved within long-term care alone.

Nurses are required across hospitals, primary and territorial healthcare, home-care teams, residential facilities and other services. As Italy expands Case della Comunità and professional home healthcare, the same broad workforce becomes more valuable across more settings.

This creates competition.

A residential provider attempting to recruit nurses may be competing with an SSN employer offering different career structures and working conditions. A home-healthcare service may recruit successfully but draw professionals away from another local provider. National workforce growth can therefore be weaker than local recruitment figures imply if workers are mainly moving between employers.

The policy response needs to address supply as well as redistribution.

Training capacity matters. So does retention within the profession. International recruitment can help, but qualification recognition, language competence, employment conditions and ethical recruitment all affect whether internationally recruited nurses remain.

Professional roles also need to become more attractive outside hospitals. Territorial nursing requires autonomy, coordination skills and the ability to work across complex home environments. It should not be treated as a lesser form of nursing simply because the work occurs outside an acute institution.

Long-term care will recruit more effectively when career identity and progression are visible.

OSS recruitment depends on status, development and workload

Operatori Socio-Sanitari are central to many Italian health and social-health services, yet recruitment cannot rely indefinitely on the assumption that workers will accept demanding roles without visible progression.

OSS work can involve personal care, mobility support, dementia care, emotional support and observation of health changes. It is frequently physically demanding and requires considerable interpersonal skill.

The workforce therefore needs more than initial qualification.

Workers supporting increasingly complex populations benefit from continuing development in areas such as dementia, frailty, communication, mobility, infection prevention and recognition of deterioration.

But training needs to connect to role design.

A service that repeatedly asks workers to become more competent while keeping responsibilities, recognition and career prospects static may improve skill without improving retention.

This is where continuous professional development becomes a workforce tool as well as a quality tool. Development demonstrates that care work can become a career rather than remaining a job with little progression.

Organisations can use the Predictive Workforce Risk Module to examine comparable patterns in turnover, vacancy and continuity. It is not specific to Italian employment law or workforce regulation, but it can help leaders identify whether instability is concentrated in particular roles, teams or services.

Domestic care recruitment is becoming a strategic national issue

The household care workforce remains one of Italy's largest sources of long-term support.

INPS data for 2025 recorded 804,464 domestic workers with at least one contribution during the year, a further decline of 2.3% compared with 2024. The reduction continued a four-year downward trend, with approximately 173,000 fewer registered domestic workers than in 2021.

That matters because more than half of registered domestic workers are now classified as badanti, rather than general domestic workers.

Demand for family assistance is therefore rising while the registered workforce supporting it is shrinking.

The age profile compounds the problem. A substantial proportion of domestic workers are themselves approaching retirement age, while younger entrants form a much smaller share of the workforce.

This labour market cannot be separated from migration.

Foreign workers have played a major role in Italy's domestic care sector for decades, particularly women from Eastern Europe, South America and the Philippines. Without that labour supply, many household care arrangements would become difficult to sustain.

Recruitment policy consequently operates across both care and migration systems.

Migration policy has increasingly recognised care as a labour-market priority

The 2026–2028 immigration framework explicitly recognises family and social-health assistance as areas requiring labour.

For 2026, 13,600 quotas were allocated under the non-seasonal employment route specifically for family-assistance work, distributed territorially according to demand within the Decreto Flussi framework.

Separately, the system maintains a route for up to 10,000 workers annually outside the ordinary quota mechanism for family or social-health assistance to people with disabilities or people aged over 80.

These measures are significant because they acknowledge something Italy's long-term care system has demonstrated for years: migration policy affects care capacity directly.

However, a quota creates a legal route into the labour market. It does not guarantee stable retention.

Workers still need viable employment conditions, appropriate matching with households, accommodation arrangements where relevant, language support and protection from exploitation.

Families also need to understand their responsibilities as employers. The household model can blur boundaries because care happens in a private home and often involves close personal relationships.

A sustainable migration strategy therefore needs to support formalisation as well as entry.

Operational scenario: recruitment succeeds but retention fails at household level

A family in Lombardia recruits a care worker from outside the European Union to support an 88-year-old man with mobility impairment and early dementia.

The recruitment solves an immediate problem. His daughter can continue working, and the older man remains in his own home.

Over the following months, however, his dependency increases. Nighttime waking becomes frequent. The family begins assuming that because the worker lives in the property, she can respond whenever needed.

The worker has little protected rest and starts considering leaving.

From the family's perspective, this feels like a retention problem. From the worker's perspective, the job has changed fundamentally from the one she accepted.

A more sustainable arrangement requires the family to review the care model rather than merely trying to persuade the worker to stay. Working hours, rest, additional support and the increasing complexity of need are considered. Professional services become involved where appropriate, and the household recognises that one live-in worker cannot safely substitute for an entire multidisciplinary care system.

The example demonstrates why workforce resilience and continuity depend on employment design. Recruitment cannot create stable care if the role subsequently expands without corresponding support.

Formalising domestic work can support both quality and retention

Italy has long faced a significant undeclared domestic-work economy.

Informal employment may appear attractive where families want flexibility or seek to reduce costs, but it creates substantial risks for workers and households.

Workers without formal contracts have weaker employment protection and social-security coverage. Families can face legal and financial exposure. Continuity is more vulnerable because neither side operates within a clear employment framework.

Formal employment also supports professionalisation.

It makes the employment relationship visible, clarifies hours and responsibilities and creates a stronger basis for training and workforce planning. National policies such as the experimental Prestazione Universale have also moved towards linking additional care support with formally employed domestic assistance or qualifying services.

This illustrates an important policy direction: public support can be used not only to increase household purchasing power but also to encourage a more formal care market.

Formalisation should not be confused with turning every domestic worker into a regulated health professional. The purpose is to create safer employment and clearer boundaries.

That can improve retention because workers are more likely to remain in roles where expectations are explicit and employment rights are recognised.

Geography changes what recruitment incentives need to achieve

Recruitment difficulty varies markedly by location.

A major urban area can draw on a larger labour pool but may face high housing costs and competition between employers. Rural and mountain areas may offer lower living costs but have fewer workers available locally and greater travel requirements.

Home-care recruitment is particularly sensitive to geography.

A worker in a dense city can support several people within a relatively small area. A worker serving scattered municipalities may spend a large proportion of the day travelling.

That changes the economics of employment.

If travel is not sufficiently recognised in schedules and costs, employers can struggle to make rural jobs attractive. Workers may prefer residential or urban employment where shifts are more predictable and travel is minimal.

Recruitment incentives therefore need to reflect the actual barrier.

Additional advertising will not solve a role whose fundamental structure is unattractive. Rural strategies may need stable local zones, transport support, stronger coordination, remote professional input and different staffing ratios.

The broader principles of safe staffing and deployment become especially relevant when geography converts nominal workforce numbers into very different usable capacity.

Housing and local infrastructure can affect whether workers stay

Recruitment is often analysed through wages and qualifications, but place matters too.

Professionals considering work in rural or high-cost areas may assess housing, transport, schools, employment opportunities for partners and access to professional networks.

This is particularly relevant when Regions seek to redistribute workers towards underserved areas.

A financial supplement may help, but retention can remain poor if workers experience professional isolation or cannot establish a viable life locally.

Workforce policy therefore overlaps with regional development.

Smaller communities can also offer advantages: closer professional relationships, continuity with local populations and lower housing costs in some areas. Effective recruitment should identify those strengths rather than presenting hard-to-recruit territories only through deficits.

The policy challenge is to understand why workers leave a location and design responses accordingly.

Supervision is a retention tool as well as a quality control

Care work frequently involves difficult judgement without continuous managerial presence.

A home-care worker may encounter deterioration or family conflict alone. An OSS worker may support a distressed resident during a night shift. A newly recruited nurse may manage complex home situations far from immediate colleagues.

Workers who feel unsupported in these situations are less likely to remain.

Supervision provides a mechanism for discussing practice, workload and emotional impact. It can also identify early signs that somebody is struggling before the problem appears through sickness absence or resignation.

This connects with staff supervision and monitoring, but the strongest approach should not make supervision feel purely disciplinary.

A workforce that experiences supervision only after mistakes will not necessarily regard it as support.

Managers need enough capability and time to coach staff, recognise good practice, discuss development and respond when workload becomes unsafe.

This is particularly important for newly recruited workers. The first months of employment often determine whether somebody develops confidence and belonging or decides that the role is not sustainable.

Operational scenario: a home-care provider redesigns the first six months

A home-care organisation in Toscana is recruiting adequately but losing a significant proportion of new employees within six months.

Exit feedback indicates that workers feel prepared for individual tasks but poorly prepared for the reality of working alone, travelling between homes and dealing with family expectations.

The provider redesigns induction.

New recruits spend more time shadowing experienced workers. Caseload complexity increases gradually rather than immediately. Each new employee has a named supervisor and scheduled early reviews. Travel planning is explained clearly, and workers receive practical guidance on escalation when a person's condition changes.

The organisation also monitors whether new staff are being repeatedly placed into shifts that experienced workers avoid.

The changes do not reduce recruitment standards. They improve transition into the job.

Retention improves because recruits understand both the work and the support available when it becomes difficult.

The example illustrates why recruitment success should be measured beyond the signed contract. A worker who leaves after eight weeks represents recruitment activity without sustainable workforce capacity.

Organisations can use the Governance Maturity Assessment to consider whether workforce responsibility, escalation and oversight are sufficiently clear. It is not an Italian employment-compliance tool, but it can help leaders examine whether retention problems are visible at the level where operational decisions are made.

Career pathways can make long-term care more competitive

Retention becomes harder when workers cannot see where a role leads.

Long-term care often requires substantial practical expertise that develops through experience. Yet career structures do not always recognise that expertise clearly.

An experienced OSS worker may become highly skilled in dementia or complex mobility support without seeing a corresponding progression route. A nurse may develop strong expertise in home-based chronic disease management but perceive hospital roles as offering greater professional status.

Career pathways can help change this.

Not every worker wants management responsibility. Progression can also include specialist practice, mentoring, advanced competence, education or coordination roles.

Creating visible pathways has several benefits.

It rewards expertise, supports succession and creates reasons for experienced employees to remain. It also improves recruitment because entrants can see care work as a developing profession rather than a static role.

Career progression needs to remain tied to competence rather than simply tenure. Training, assessment and supervision should provide evidence that increased responsibility is appropriate.

This creates a direct relationship between retention and quality.

Worker wellbeing needs operational measures, not only wellbeing initiatives

Long-term care organisations increasingly recognise staff wellbeing, but wellbeing can become superficial if operational pressures remain unchanged.

Stress produced by chronic understaffing cannot be solved with resilience training alone. Fatigue created by repeated additional shifts requires rota action. Emotional strain after difficult incidents needs supervision and team support, not simply generic wellbeing information.

Italy has also strengthened attention to violence and aggression affecting health and social-health workers. National monitoring for 2025 recorded close to 18,000 reported episodes, underlining that staff safety is part of workforce sustainability.

Long-term care settings have their own risk patterns. Dementia-related distress, family conflict, lone working and emotionally demanding end-of-life care can all affect workers.

The strongest staff engagement and wellbeing strategies therefore connect employee feedback with operational action.

If workers repeatedly report that one shift is unsafe, leaders should examine deployment. If sickness rises in one service, workload and management should be reviewed. If experienced workers leave one supervisor's team disproportionately, that pattern needs governance visibility.

Wellbeing data become most useful when they influence decisions.

Technology can improve retention when it removes frustration

Technology is frequently presented as a response to labour shortage. Its more immediate workforce value may be reducing avoidable work.

Digital scheduling can reduce inefficient travel. Shared records can prevent repeated data entry. Mobile systems can give home-care staff access to information without returning to an office. Remote specialist support can reduce professional isolation.

These improvements can make jobs more attractive.

Poorly implemented technology can have the opposite effect.

Staff may have to enter the same information into several systems. Applications may be slow or unreliable. Digital alerts can generate additional workload without clear priorities. Workers may feel technology is used primarily to monitor them rather than support care.

This is why digital skills and workforce adoption matter to retention.

Workers need involvement in implementation because they understand where administrative friction occurs.

The Digital Transformation Readiness Assessment can help organisations examine whether technology, workforce capability and operational processes are aligned. Its relevance is practical: digital transformation should reduce unnecessary burden rather than create another reason for experienced workers to leave.

Recruitment data should identify whether the problem is attraction, conversion or retention

A single vacancy figure provides limited management intelligence.

Different workforce problems require different responses.

If few people apply, the role may be unattractive or poorly advertised. If many apply but few meet requirements, training supply or recruitment criteria may be the issue. If suitable candidates are offered jobs but decline them, pay or conditions may be uncompetitive. If people join and leave quickly, induction or employment experience is more likely to be responsible.

Workforce governance should therefore follow the recruitment funnel and subsequent employment journey.

Useful measures include applicant volume, qualified applicants, offer acceptance, time to recruit, early turnover, one-year retention, sickness, internal progression and exit reasons.

These measures should be segmented by role and location.

An organisation-wide average can hide a service where half of new recruits leave rapidly.

The Quality Dashboard Builder can help organisations considering comparable oversight structures connect workforce indicators with service quality. The Italian metrics would need to reflect local employment models, but the principle remains useful: workforce data should answer a management question rather than exist as a reporting exercise.

Operational scenario: recruitment data reveals that pay is not the main problem

A provider operating residential services in Emilia-Romagna assumes that pay is responsible for high nurse vacancies.

It increases recruitment advertising and considers a general salary supplement.

Before implementing the change, leaders review recruitment data more closely.

Application rates are reasonable. Most shortlisted candidates attend interview, and salary is not the most common reason for rejecting offers. The largest loss occurs during the first year after appointment.

Interviews with recent leavers reveal another pattern. Newly recruited nurses frequently feel they are carrying clinical responsibility without enough experienced support during evenings and weekends. Some expected a long-term care role but discovered that residents' acuity was substantially greater than described during recruitment.

The provider changes its response.

Job information becomes more realistic. Senior clinical coverage is strengthened. New nurses receive structured mentoring. Staffing reviews reflect acuity rather than occupancy alone.

Pay remains part of the employment proposition, but the organisation avoids spending its entire retention budget on a problem that salary alone would not have solved.

The scenario demonstrates why workforce strategy requires evidence. Assumptions about why people leave can become expensive if they are not tested.

National and regional policy need to reinforce employer action

Individual employers control many aspects of retention, but they cannot solve structural workforce shortages alone.

National and regional policy shapes training places, immigration routes, professional regulation, health funding and broader labour-market conditions.

Regions also influence how territorial services develop and where workforce demand increases.

This creates a need for joined-up planning.

Expanding Community Houses, home healthcare and residential capacity without considering workforce supply can intensify competition between services. Creating more training places without improving retention can increase throughput into a workforce that continues leaking experienced staff.

Migration routes can increase supply but need to connect with integration, language support and formal employment.

Workforce policy therefore needs to consider stocks and flows together: how many people enter, how many leave, where they work and how long they stay.

This is particularly important as Italy's working-age population declines. Long-term care will be competing for labour with other sectors in an economy where the number of potential workers is itself under demographic pressure.

Retention should be treated as part of long-term care capacity planning

Traditional capacity planning often focuses on beds, service places and funded hours.

Those measures are incomplete if the workforce required to deliver them is unstable.

A residential facility with available beds but insufficient staff does not represent usable capacity. A home-care contract with funded hours but high vacancy may create waiting. A Community House without enough nurses cannot deliver its intended service model.

Workforce retention therefore needs to sit inside demand and capacity planning rather than being treated as a separate organisational concern.

This perspective changes investment decisions.

Before expanding a service, leaders should consider whether sufficient labour is available, what recruitment assumptions underpin the model, expected turnover and what level of supervision and development will be required.

Where the assumptions are unrealistic, service redesign may be safer than continual vacancy management.

What Italy's recruitment challenge offers international learning

Italy's particular mix of regional healthcare, household employment, migration and family care makes its workforce model distinctive. Other countries cannot simply reproduce the Italian badante system or its professional structures.

Several principles are widely relevant.

Recruitment and retention should be analysed together. A service that recruits effectively but loses staff rapidly has not solved its workforce problem.

Employment quality matters alongside pay. Predictability, workload, supervision, professional identity and development all influence whether people stay.

Migration can provide essential labour but needs stable legal routes and decent employment to become sustainable capacity.

Career pathways matter in care roles that have historically offered limited progression. Increasing complexity makes experience more valuable, not less.

Finally, workforce planning should follow the whole labour market. Formal providers, privately employed workers and family carers can substitute for one another in ways that conventional staffing data may miss.

The transferable lesson is that sustainable recruitment depends on creating work people can realistically continue doing.

Conclusion

Italy's challenge is no longer simply to find enough people willing to enter long-term care. It is to create a labour market in which enough of those people can build sustainable careers and remain long enough to provide continuity, expertise and trusted relationships.

The pressures are substantial. Nursing supply is constrained, domestic worker numbers have been declining, many care workers are themselves ageing and demand continues to grow. Migration remains essential to household care, while Regions and providers compete for scarce skills as territorial services expand.

The strongest response therefore combines recruitment with retention. Employers can improve rota stability, induction, supervision, career development and workload management. National and regional policy can strengthen training supply, migration routes, formal employment and geographic distribution. Better workforce data can distinguish shortages caused by poor attraction from those created by early turnover or unsustainable service design.

Italy's long-term care ambitions ultimately depend on whether work in care becomes sufficiently attractive, supported and sustainable. Buildings, benefits and service reforms create the architecture of support, but continuity is delivered by people. A workforce strategy that values retention as strongly as recruitment is therefore not simply an employment policy. It is a central condition for the quality and sustainability of Italian long-term care.