REVIEW

Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system Maria Giulia Marini*,1, Luigi Reale1, Antonietta Cappuccio1, Marco Spizzichino2, Pierangelo Zini3, Francesco Amato4, Sergio Mameli4 & William Raffaeli5 Practice points ●●

In the last years, a number of important initiatives has been undertaken to improve pain management, and the most important development in Italy involved a dedicated law (Directive 2010 n. 3816).

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The VEDUTA project was designed to evaluate the role of clinicians involved in pain management, the work environment and their needs/problems.

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A ‘written interview’ was proposed between April and June 2012 to 350 Italian

pain clinicians working in hospitals, university pain units or hospices. The interview comprised a questionnaire on responders’ personal data, a description of the participants on themselves and their workplace using metaphors, and a story from a narrative outline supplied. A modified version of the Maslach Burnout Inventory (emotional exhaustion, depersonalization, personal achievement) was used to measure the level of ‘burnout’ of responders. ●●

In Italy the majority of healthcare professionals work within the public health system on a permanent contract but a high percentage of responders work under part-time contracts. Interestingly, 20% of therapists work alone or independently.

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Infrastructural issues such as lack of beds, shortage of personnel and suboptimal organization were frequently reported.

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Patients constitute a stimulus to do better for 98% of doctors. Clinicians show dedication to their patients over and above their official role.

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The most frequent metaphor used (39%) deals with pain relief intended as aid to the patient; recurring images indicate that the responder is seen as a ‘protective benefactor’.

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The presence of a psychologist was extremely modest (only 1%).

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Thirty-six of the 81 stories described an unexpected event perturbing a steadystate situation, such as a change in the working organization or the input of an authoritarian figure.

KEYWORDS 

• narrative • pain • working climate

ISTUD Foundation, Milan, Italy XI Ufficio Programmazione Sanitaria, Ministry of Health, Rome, Italy 3 Grunenthal, Milan, Italy 4 Federdolore SICD (Italian Society of Pain Clinicians) 5 Fondazione ISAL Italian Institute for Research on Pain, Rimini, Italy *Author for correspondence: [email protected] 1 2

10.2217/PMT.14.35 © 2014 Future Medicine Ltd

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Pain Manag. (2014) 4(5), 351–362

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Review  Marini, Reale, Cappuccio et al. SUMMARY Until 2010 pain management in Italy was only partially covered and no structural and qualitative mapping had ever been realized. The VEDUTA project was designed to provide a tool to unite pain therapists in national cooperation. Quantitative questionnaires and narrative plots were sent to 350 Italian specialists; 184 therapists completed the first section and 87 also wrote their stories. Narratives were analyzed through transactional analysis and emotional intelligence. Overall, results show that a patient-centered approach is common in daily practice, but that bureaucracy is endangering quality of care. This cultural analysis, through both the application of quantitative assessment and narrative plots, provides a useful tool to improve those aspects of the system detrimental to the appropriate management of pain in Italy. Pain, one of the most debilitating symptoms associated with a range of acute and chronic diseases, has a devastating impact on quality of life and frequently causes comorbidities such as depression, insomnia, asthenia and inability to work and conduct normal daily activities [1] . Untreated pain is detrimental to patients’ wellbeing and is reported by patients to be one of the important factors leading to the erosion of dignity at life’s end [2] . Despite the major advances in recent years, there are still many barriers that hinder pain and symptom management [2–6] ; some patients [7] are confused during chronic painful pathologies [8] , relationships between patients’ families and the staff in hospice structures may be complex [9,10] and healthcare system functionality, including the low priority given to pain management, may be an obstacle to the appropriate patient care [11–15] . Adequate pain management is a vital component of therapy and it must be carried out by competent clinicians [16] . In the last years, a number of important initiatives have been performed to improve pain treatment quality. Above all, the most important development in Italy involved a dedicated law (Directive 2010 n.38 [17]) which provides a series of measures, including the assessment of pain in the patients’ medical records and the development of a national network of palliative care and pain therapy centers. Since the application of this law, if pain is not adequately treated, physicians could eventually be liable. In such a flourishing environment in the fight against pain, no survey has ever been carried out to identify the mindset of people working in pain management structures and the met and unmet organizational needs of the pain therapists in Italy. Validated tools exist to assess the ‘climate analysis’ of the collaboration in a working organization, based on the practice of organizational behavior. The climate at the workplace can be understood as a set of shared perceptions

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that are connected to each other in relation to the reality of the workplace [18] . It expresses how individuals perceive and interpret their work environment and its characteristics. The climate analysis allows for the quality of life of employees to be identified, people satisfaction to be improved and a model of shared values to be defined. It can be used in particular to investigate the risk to health care workers of developing burnout, which is a syndrome of emotional exhaustion, depersonalization and reduced personal skills that can occur in people whose profession is ‘dealing with people’ [19] . It is a reaction to chronic emotional tension created by the continuous contact with other human beings, particularly when they have problems or reasons to suffer. Psychologists Christina Maslach and Susan Jackson first identified the construct ‘burnout’ in the 1970s, and developed a measure that weighs the effects of emotional exhaustion and reduced sense of personal accomplishment [20] . This indicator has become the standard tool for measuring burnout in research on the condition. The Maslach Burnout Inventory (MBI) uses a three-dimensional description of: emotional exhaustion, measuring feelings of being emotionally overextended and exhausted by one’s work; depersonalization, measuring an unfeeling and impersonal response toward recipients of one’s service care treatment; and personal accomplishment, measuring feelings of competence and successful achievement in one’s work [21] . A second critical point that can be studied through the climate analysis is linked to organizational problems that affect the health sector. Pain therapists may have different academic degrees and different professional skills, and this affects the homogeneity of pain centers throughout the country. To explore burnout risk, organizational problems and the health professional approach to the management of pain therapy, we conducted a

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system  study using a standard questionnaire of climate analysis and a semi-structured plot, based on the narrative medicine approach. In fact, reflective writing is a powerful tool for physician self-assessment of one’s own mindset, and for allowing the inner world of the carer to come out [22] . The application of narrative is very wide and is not only to be applied for a better customization of patient care, but also to investigate the values, the mindset and the professional lives of a practice community, such as the physician ones. Since the dramatic change due to the Law 38/2010, the assessment of the level of the carers’ ‘wellbeing’ and its ‘consistency’ with empathic care was an issue to be investigated, and we decided to avoid oversimplified methods such as using standard questionnaires with boxes to tick [23] . Instead we decided to use an integrated approach between quantitative and qualitative research. Narrative medicine is a new emerging science which, by means of collection, patients’ and professional stories can ‘help doctors, nurses, social workers, and therapists to improve the effectiveness of care by developing the capacity for attention, reflection, representation, and affiliation with patients and colleagues’ [24] . Stories can be drafted from narrative plots which originate from tales. Vladimir Propp discovered a well-defined recurrence by analyzing thousands of tales from multiple countries: spatial and temporal vagueness; rupture of an equilibrium point (stable or unstable, happiness or unhappiness); a path, often a journey into nature; meetings (animals, people, villages); trials to be overcome which occur repeatedly; awarding end with the triumph of justice [25] . Often in these tales the drama triangle is manifested through its three key figures: the victim, the persecutor and the savior. The elements of analysis in the interpretation of the stories are based on the passive or proactive mode of the character (person), on the opportunities and repetitions of the three positions of the triangle drama, on emotions, and on the existential positions of the judgment of others. Narrative provides meaning, context and perspective in a given situation and it allows the possibility of understanding what cannot be captured by any other means [26] . Generally, narrative medicine is applied to the collection of patients’ stories, but Charon introduced the Parallel Chart [27] , in which physicians and other health care providers can write in a reflective way about how they feel towards their patients. This

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type of writing enables the carers to get a deeper level of awareness regarding the act of care. The collected narratives can be analyzed using different acknowledged methodologies, beyond the mere frequency of the use of the single word: emotions, when clustered into the great realms of Joy, Rage, Sorrow and Fear, are markers of self-awareness. They can produce substantial positive changes in people’s relationships [28] . Daniel Goleman states that internal motivation which brings joy and optimism even in the face of failure [29] , could be the ingredient of success for organizational practice. Narrative is suitable to express the inner emotions, and therefore emotional intelligence analysis could be warranted to systematize the results obtained from the stories. Written narratives can gain benefit from the application of transactional analysis (TA), which is an integrative method with elements of psychoanalytic, humanist and cognitive approaches: as a theory of personality, TA describes how people are structured psychologically. It uses the model of the ego-state (Parent-Adult-Child) [30] . The same model helps explain how people function and express their personality in their behavior. It is a theory of communication that can be extended to the analysis of systems and organizations. Outside the therapeutic field, it has been used in education to help teachers remain in clear communication at an appropriate level, in counseling and consultancy, in management and communications training and with other bodies [31] . A worldwide application of TA principles has been and is still ongoing both in aids practice (as the healthcare field) and in managerial practice. One fundamental assumption of the theory and practice of transactional analysis is ‘I’m OK and you’re OK’ (OK-ness). It follows that every interpersonal relationship is aimed at achieving this goal. Every living being is basically ‘OK’. Nevertheless, the particular conditions of life undermine this reality, so as to favor the emergence of existential positions ‘Not OK’ [32] . In particular the OK-ness principle was applied to the tale analysis in order to identify the four existential positions that indicate an inclination and aptitude in the vision of ‘the other’: I’m OK, You’re OK (healthy physiological existential position, which leads to an assertive behavior, with self-esteem and esteem for the other); I’m OK, You’re Not OK (aggressive behavior, self-esteem, but lack of esteem for the

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Review  Marini, Reale, Cappuccio et al. other); I’m Not OK, You’re OK (passive behavior servant, depression, lack of esteem in itself, but sentiment of esteem, envy for the other); I’m Not OK, You’re Not OK (nihilism, cynicism, lack of esteem in oneself and in others). Aims The VEDUTA project, supported by the Italian Ministry of Health and other key pain scientific associations and active citizenship, was designed to evaluate the role of clinicians involved in pain management. It assessed the environment they work in and if there are diversity issues, particularly in regards to a gender effect due to different roles achieved and different ways of caring, and the needs/problems they encounter in everyday clinical practice using an integrated quantitative and narrative-based approach. The objective was to investigate the professional/personal identity of pain specialists in terms of their personal characteristics, history, education, feelings and needs at work. Materials & methods The survey was carried out between April and September 2012. A multidisciplinary board formed by clinicians, experts in statistics and in narrative medicine, developed a ‘written interview’ that was divided into three parts. The first part was a questionnaire on: the process and the professional culture of the healthcare organization; the impact of Law 38/2010; the organization as a participatory space; the group as a resource to manage the workload; the availability of personal resources; personal and organizational needs. In the second part, participants were asked to represent themselves by using a metaphor able to describe the inner self during their everyday activities. These metaphors were then clustered into groups to allow the analysis and the evaluation of their meaning. The second part uses a validated scientific tool to measure the level of ‘burnout’ of responders, which is a modified version of the MBI. The test is made up of 22 items and it measures three different dimensions of the burnout syndrome: emotional exhaustion, depersonalization and personal achievement. In the third part, the participants drafted a story from a narrative outline supplied which was organized according to the linear tales taken from the humanities sciences, by Vladimir Propp [25] . The chosen outline was: taking the path to reach the village of pain fighting, living

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in this village, overcoming hurdles and imagining the possible happy ending. This tool was used to probe for the true self of the person in the interaction with the others belonging to the community, ‘the village of people who help the others’, with a creative ending, which should have been able to activate the imagination of problem solving. The story of the town of care for people suffering: The proposed plot was: ‘Once upon a time a […] who through a long journey […] came to the town of care for people suffering […]. The town was near/in/on […]. In that town there were people suffering which had come from […]. And there were also people made of […]. However there were also their relatives and they were made of [...]. And then, in that town, there lived all the others who had stopped there to take care of those who needed it and were made of […]. When […] saw for the first time the faces of people engaged in taking care and he thought that those faces were […] and then looked at their hands and thought that those hands were […]. And then looked […] and listened to their words […]. Then he/she decided/thought that he/she would be staying in that town because he could have […]. But on a bad day it happened that […] but then it happened also that […]. Now that town is […]. That town will be happy on condition that […]’. The […] signs indicate the blank spaces left to the professionals to describe their experience. Quantitative questionnaires and a narrative plot to be completed were available on a website and on paper, and were proposed to 350 Italian pain therapists directly involved in pain management covering the entire Italian territory in all 21 Italian regions, according to the presence of pain centers. The health professionals contacted were identified in agreement with Federdolore as experienced professionals. The target redemption was 50% of the random sample. The written interviews were completely anonymous to allow participants to answer questions and write their story as freely as possible. The principles outlined in the Declaration of Helsinki have been followed and every therapist signed an online informant consent. ●●Data analysis

Socio-demographic data were analyzed by means of descriptive analysis. The source for comparison was the tables published by the Istituto Nazionale

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system  di Statistica (National Statistic Institute) (ISTAT). Data from the Fondazione ISTUD (Istituto Studi Direzionali) of women and men employed in healthcare and their leadership roles have been used. Due to the lack of responses from some of the participants, the sum of the percentages for a specific question was not always 100%. The MBI was analyzed following the given instructions. Methaphors and tales were analyszed, fragmented and classified into clusters by a group of researchers who read the stories in a blind fashion. All stories were elaborated by the NVivo software and the most frequent words were found for each section. Recurring words were analyzed in association with the previous results to depict a complete comprehension of the specialist. A final consensus group assigned interpretation and meaning to digits and stories. Stories were analyzed with the TA OK-ness approach, previously described. For the analysis of the tales, the use of Emotional Intelligence, developed by Goleman [27] , allows for the cluster of the four main emotions into: Joy, Sorrow, Rage and Fear. Results 184 out of 350 clinicians (54%) completed the first quantitative part of the questionnaire at least. Written interviews were mailed back in a balanced way by North, Central and South Italian centers. In addition, 87 responders (47.2%) completed metaphors and stories, but six of these were excluded because they were incomplete. The personal and working characteristics of responders are shown in Table 1 and are consistent with the Italian ISTAT demography. In Italy the majority of healthcare professionals work within the public health system on a permanent contract and this was confirmed in our sample. Italy still has a gender-based career structure with the majority of male physicians at top role (82%). Interestingly, both hospital and local National Health Service organizations were well represented with 47 and 34% of the responders, respectively. These data provide a positive starting point to develop a healthcare network to bridge the gap between hospitals where acute pain is usually treated and home where chronic pain is managed by a territorial unit. Of note, 40% of responders are employed part-time suggesting that their working time was spent in other roles and not only in the management of pain. This, with the addition of the fact that 20% of therapists work alone or independently (Table 2) , could prevent stable

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and long-term working group relationships in many cases. The presence of a psychologist was extremely rare (only 1%) and represented one of the main problems to be addressed considering that pain has both physical and emotional effects. On the other hand, if a structured team was in place, high levels of collaboration between team members were reported. However, data may be at least partially biased by the significant percentage of group leaders who believed that the executives have a positive impression on their own group and, also, by a partial sharing of the written interview to all components of the multidisciplinary team. A total of 26% of responders reported lack of time for training as the most important concern. In addition they had to face many difficulties on a daily basis that directly influence the management of work/life balance (Table 3) ; infrastructural issues such as lack of beds, or shortage of personnel and suboptimal organization were frequently reported, as were insufficient interactions with other healthcare professionals outside the discipline of pain treatment. The poor or absent (13 and 21%, respectively) interaction with the administrative staff reduced the possibility of solving organizational and structural problems, while the lack of answers on the relationship with the general practitioners in 30% of questionnaires indicates a major gap between two sides of the professional equation. Healthcare professionals’ expert opinion on Law 38/2010 were considered (Table 4) . Although it is generally thought that this policy is well designed and constitutes a solid frame to build new structures, its implementation is still fragile: this is indicated by the high percentage of physicians who feel that in most cases bureaucratic personnel do not yet understand the real focus of the law and prioritize economics rather than clinical issues. The healthcare professionals involved in the VEDUTA project expressed several wishes in order to improve pain therapy management. The four most-stated ambitions were increased personnel (19%), greater economic and structural support to pain therapy (17%), more time and better activity organization (15%), and competence increase (15%). Table 5 provides an overview of the clinician– patient relationship and shows evidence of the powerful interaction in many cases between patients and clinicians: patients constitute a stimulus to do better for 98% of doctors.

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Review  Marini, Reale, Cappuccio et al. Table 1. Description of responders’ status and working position. Participants’ Characteristics Mean age in years (range)

50.9 (28–66)

%

Sex     Family composition       Residency  

Male Female No answer Married Cohabiting Divorced Single Outside city City

Children        

Older than 20 years Aged 15–20 years Aged 6–10 years Younger than 6 years Any

63 34 3 70 6 10 11 86 14 (of those, 30% in large cities) 40 25 13 15 7

Yes No Public Private Permanent Others Full-time Part-time Hospital Private office Home assistance Hospice District office RSA Hospital Local NHS organization No-profit organization

56% 40% 87% 9% 85% 9% 55% 40% 44% 30% 12% 6% 3% 2% 47% 34% 2%

Working position Responsible role   Workplace   Type of employment contract   Time of contract   Kind of structure           Employer     RSA: Nursing home

Moreover, clinicians show dedication to their patients beyond their official role, as evidenced by the recurrent thoughts about their patients outside the workplace (78%) and the development of an emphatic relationship with them (73%). Clinicians are engaged with a strong accountability mission (72%): the high professional engagement and degree of empathy demonstrated by professionals in this survey explain the low level of burnout observed. By means of MBI analysis, burnout was assessed as low in 38% cases and at moderate risk in 51% of health professionals involved. High professional motivation and the good system of value contribute to keep burnout under

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control. Just 11% of responders showed signs of having a high risk of burnout, but these data should not be underestimated. On the other hand fast action should be taken in order to avoid its increase and to safeguard new pain therapists. The second part of the written interview helped responders to describe themselves openly on an emotional level outside of the rigorous and schematic clinical scientific world and leads to the creation of ‘ideal types’ (Table 6) . The most frequent metaphor (39%) deals with pain relief intended as aid to the patient: recurring images indicate that the responder considers him/herself to be a ‘protective benefactor’. That is consistent with the

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system  personality of the therapist and the only negative aspect could be the risk of excessive ‘self-giving’ without protection, but the fact that the physician remains close to their patients prevents the possibility of developing the ‘burn-out syndrome’. The second most frequently reported as ‘ideal type’ (30%) was that of the ‘tireless professional’ who tries to always give the best of himself. This group can be considered to be the most mature and aware of real working conditions they are experiencing, but are somehow deprived of vital energy and big dreams. The ideal type of the ‘hero’ accounted for 14% of responses and describes an idealistic soul, oriented to large objectives not

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always achievable. Loneliness was reflected by the 28% of pain therapists who work without a team for reference and comparison. The ideal type of the ‘prisoner’ (5%) can be associated with limitations classified as lack of discretion in the professional context and it has to be taken into account as an indicator for possible improvements. Out of 87 drafted stories, 61% of the female group completed the outline and provided a story, compared with 39% of the male group. This symbolic journey was used to interpret values (personal and professional) of pain therapists in their organization. The village represented life in a community with colleagues, patients and their

Table 2. Working groups: the table sums up the different compositions and relations between members. Working group     Team members       Team composition         How is your role inside the team considered?       Is there collaboration between team members?       Is there solidarity between team members?       Is there freedom of expression within the group?   Is your leader’s attitude to work well important?       How do you evaluate your leader’s work?        

Part of a team Alone - independent n.a 1–3 3–5 6–9 >10 Physician Nurse Volunteers Administrative staff Psychologist Very influential Influential Of low relevance Null High Sufficient Low No High Sufficient Low No Yes No Very much Much Not so much No Extremely valid Quite effective Quite negative Negative n.a

61% 20% 11% 33% 43% 15% 8% 51% 26% 9% 8% 1% 29% 58% 12% 1% 36% 42% 18% 4% 46% 43% 9% 2% 88% 12% 21% 53% 20% 6% 16% 39% 14% 7% 24%

n.a: Not answered.

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Review  Marini, Reale, Cappuccio et al. Table 3. Interaction with the other players involved in the care system. How to improve services for patients?       Relationship with administrative direction     Relationship with hospital pharmacy       Interactions with general practitioner     Most frequent problems at work       Reconciling work and private life      

family members: thus it was meaningful for a community of praxis. The analysis allowed four different macroclusters to be identified: 1) The event flow is disrupted; 2) Patients’ care; 3) The story of a journey; 4) The suffering of workers. Thirty-six stories described an unexpected event concerning a steady-state situation, caused by external causes, and alien to everyday life, such as a change in the working organization or the input of an authoritarian figure. “But on a bad day it happened that the king dwelt in the land. But then it happened also that he established his court there. Today, that country is destroyed. That country will be happy on condition that the king will be eliminated’. These images symbolize the manager who does not understand the role of the clinician or who does not allow correct patient management

Structure Organization Doctor-specific role Education Good Scarce Absent Direct By phone/mail By forms Absent Direct By phone/mail Any Frenetic rate Lack of personnel staff No time to update Other Very feasible Feasible Difficult Very difficult

41% 33% 16% 10% 23% 21% 13% 39% 50% 2% 9% 5.3% 47% 12.7% 53.3% 51.6% 26% 13.6% 14% 14% 36% 31%

in a context that was previously effective, and show notes of controversy towards the handling of leadership roles. Of these stories, only 20% have a positive ending, while others maintain an underlying uncertainty, which reveals a changing situation. The second group (21 stories) reported the great sorrow due to patients’ deaths: doctors remember every dead patient, indicating that they consider the personal interaction a very important part of their role. Indeed, all but one of these stories talk about a specific patient indicating the paramount importance of the patients for the clinicians. These stories, related to the care of an individual patient, are all successful, probably because the narrators wanted to express through them the ‘reason why’ of their work. These stories give an important message of hope: ‘as pain therapists we are able

Table 4. Opinions on the effects produced by the Italian directive 38/2010 on the working environment. Does the Law 38/2010 modify the Yes perception of others MD? Little or no Does the Law 38/2010 modify Yes the perception of administrative No personnel?  Does the law improve the quality Yes of your work?  No

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52% 38% 24% 68% 45% 45%

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system 

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Table 5. Clinician–patient relations. Are patients or their families a source of stress?   Are patients or their families a stimulus to work better?   Do you think to patients outside the workplace?   How do you manage difficult patients?     Have you effective relations with patients?   Do alternative therapies exist to treat pain?        

to solve complex situations, regardless of the organization’. The third group (17 stories) dealt with their professional career. In the majority of cases, the idea of true job satisfaction was present despite the problems encountered in daily work. Only three stories describe an exhausted and negative vision of the situation. All these data were in line with the questionnaires. In addition, the stories indicate a very peculiar aspect: the physician must have received an injury, in order to develop the ability to empathize with the patient. ‘Once upon a time a healing magician [...]. But on a bad day he fell ill like many others. But then [...] the magician found a plant and realized that the pain diminished when chewing its leaves and he felt better. So he decided to prepare an infusion that he gave to all suffering ones’. The remaining four stories described the difficulties physicians encounter due to a professional crisis for whatever reason including loneliness, depression and anguish. ‘Once upon a time a beautiful and good princess went for a long journey through fearful, rough and grim worlds, populated by evil creatures. She arrived at the country of care to the people who suffered for love, illness, or for any worthy cause [...]’. These

Yes No Yes No Yes No I become detached I ask to be substituted I try to do my best Sometimes/often Almost never /never Acupuncture Psychotherapy Physiotherapy Other A combination of these

31% 69% 98% 2% 87% 14% 4% 20% 72% 73% 28% 22% 27% 26% 14% 5%

difficulties could have developed in the most sensitive subjects, or in those not completely aware of the painful situation they would find themselves in once they decided to enter into this field of therapy. Crises were triggered by the constant exposure to the patients’ suffering. These stories insisted on the necessary ‘injury of the therapist’, on the benefit of the moment of crisis, and on the resulting exit from the darkness of anguish. The analysis of metaphors and of the free text of the plots through TA depicted a positive and encouraging picture of the reality. In total, 52% of responders were in a balanced state towards themselves and others. This is an assertive behavior necessary to work, both independently and in the context of a multidisciplinary group. When metaphors were assessed by the TA tool, 36% fell in the position ‘I’m OK – You’re Not OK’, the one in which the subject considers oneself to be above others and which may lead to aggressive behavior. As in other parts of the survey, the aggressive feeling is usually directed towards the administrative figures because they seem not to be aware of the real needs of the care environment. There is a minority (9%) of passive behavior or depressed clinicians who are undergoing burnout slightly, emphasizing the need to set up working groups

Table 6. Profiles arising from the analysis of the provided metaphors. Type

% of responders

Metaphor example

Benefactor Tireless professional Hero Lonely man Prisoner

39 30 14 11 5

Harbor in the tempest Barber of Seville Don Quixote Lonely eagle Bird in a cage

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Review  Marini, Reale, Cappuccio et al. based on dialogue and the shared objectives. Only 3% reflect the existential position ‘I’m Not OK– You’re Not OK’, so it is again confirmed that most therapists are free from nihilism and cynicism and do their job with enthusiasm and passion. Stories were also analyzed by the ‘emotional competencies’ model developed by Goleman to extrapolate the main feelings of the responders. The four standard categories (Joy, Anger, Fear and Sorrow) were used to sum up the various feelings. No differences were observed between genders; the analysis confirms the opinion that daily activity exerted, in very close proximity with suffering patients, impacts on the perception of pain and boosts sensitivity. However this kind of feeling does not induce an increased risk of burnout and demotivation. Joy (23%) can be interpreted as a consequence of the highly professional motivation which is accompanied by the satisfaction obtained by helping others. Anger (22%) is a multifaceted emotion: possible meanings are the need for more appropriate resources, poor communication with management or others who do not support the work of pain therapists, or the feeling that their professional efforts are not understood. Sorrow (39%) clearly reflects the symptoms and the feelings of patients. This is due to the situations that clinicians face daily, and the hopelessness felt from being unable to prevent the adverse fate of patients. Fear (15%) is the least represented feeling and goes hand in hand with anxiety. The professional world around clinicians is undergoing many transformations, not always supported by a clear plan of organization, thus some situations may be related to insecurity. Results from the emotional competencies were in agreement with those of TA. Emotions extrapolated from clinicians’ stories correlate well with the life-orientation and the attitude towards themselves and the people around them. No relationship was found between having full time/part time contracts and the sense of commitment in patients’ care. Discussion The VEDUTA project was performed in Italy to get a holistic picture of the role, the work environment and the needs and feelings in daily practice of the healthcare providers actively involved in pain management. This study provided a very useful tool for the Italian scientific societies of pain therapists to investigate the identity of members.

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Results from both questionnaires and written interviews show that a patient- (and family-) centered approach is very common among pain professionals in Italy. The system of values supporting responders is not so common in the medical field and it is very far from the defensive medicine behaviors that are disrespectful to patients’ bodies and soul habits [33] . The ethics are robust and protect therapists from burnout, as the Maslach test results showed. Surprisingly, even evidence-based anesthetists stated in their stories that effective care can be achieved only if the physician had gone through a ‘personal wound’, accordingly to the Jung perspective of the ‘wounded healer’ [34] , which is normally applied to the psychological art. The stories showed that the majority of doctors started to work in the pain therapy field after previously working in different specialist settings (mainly anesthesia and resuscitation), since, up to the legal act of 2010, no specific academic education on palliative care and pain therapy was learned in the Faculty of Medicine, but these disciplines were studied at anesthesia and intensive care specialties. The encounter with this job has been described as a bumpy, almost hidden, often bended path. However at work they found themselves having to deal with pain with a sharp mind, competence, and empathy. Although pain management has been only recently considered to be a specific discipline, pain specialists are continuing their campaign to improve the consideration of their role and their ability to impact on the patients’ well-being. From the language of the stories, they are aware of the need to confer to patients more than just a specific medical treatment, but also relieve their psychological, environmental and physical pain. The passion for their role generates a positive emotional state, influencing the patients’ outcomes and compliance to treatment. Accountability for their work can be seen in their dedication to the role. The complete openness towards patients and their needs arises from the analysis of metaphors where the ‘ideal type’ of the benefactor is the most frequent. Alongside these providers with positive attitude, however, a small proportion of therapists at high risk of burnout were identified: in a perspective of expansion and reorganization of pain therapy, the experiences of those in distress should be listened to with particular regard. Loneliness is permeating their stories, together with the need to share critical moments with colleagues. The organization of joint care teams is of paramount

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system  importance: this option allows doctors, nurses, psychologists and other health professionals to strengthen their identity as pain therapists. A wise and mature leadership should focus on potential strategic diversity as a core strategic management issue, given the used metaphors: the positive energies of the ‘hero’ to rescue the workload of the ‘tireless’ providers. The Italian health care system is undergoing a period of major re-organization due to the tough spending review linear cuts, but the clear message left by clinicians is to guarantee a good standard of care to patients affected by chronic pain and their dedicated and constant attitude, must be associated with a strong and accurate application of the Law 38/2010. Despite the mainstream of shrinking the resources in healthcare and welfare, it is necessary to increase dedicated staff, the know-how of the various players involved and to implement the network with all the medical providers. Notably, responders show an optimistic positive behavior about a future with more women at top roles, since the feminization of the medical profession in Italy. They have confidence in themselves and trust in the closest people with whom and for whom they are working. Importantly, a straight interaction is growing between other players which makes a patient’s full journey feasible, in particular with the general practitioners. The opportunity to dialogue with administrative personnel is a challenging gap: the law has not yet been powerful enough to raise awareness among staff in hospitals and in the local health authorities, although it was able to improve awareness on healthcare personnel who work outside the pain-treatment field. In conclusion we believe that the cultural analysis of the professionals involved in pain therapy and the environment they work in provides a useful tool for healthcare management: the integrated quantitative and narrative approach is by far a rich and sophisticated tool to analyze a praxis community’s virtues, goals, lives and organizations. Conclusion Cultural analysis of the professionals involved in pain therapy and the environment they work in provides a useful tool for healthcare managament: the integrated quantitative and narrative approach is by far a rich and sophisticated tool to analyze a praxis community’s virtues, goals, lives and organizations.

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Review

Future perspective Pain therapy in Italy has undoubtedly benefited from the legal act of 2010: education is the driving force which allows the full realization of implementation of pain therapy. After the law, pain therapy and palliative care received academic acknowledgment as an individual discipline, structured in Masters as a new education subject for students after the degree in medicine. However, a full specialization after medical degree is still missing, and pain therapy and palliative care are learned on short course programs and Masters: even if these actions are spread all over Italy, a long specialization course has not been embraced by the Italian university system. The current local actions can definitely foster the education of pain therapist, but a systemic framework of complete educational careers, with certified curriculum vitae, should be warranted, according also to European Union standards. Despite money constraints and the cuts of welfare state, in the future, narrative medicine should be applied more appropriately in daily clinics on patients for a better and deeper understanding. From their stories, and the narratives of their families, it will be possible to understand the full living of the patient suffering by a certain condition, and only narrative medicine will bring the social impulse to move from the direction of curing just symptoms and signs, to take care of the person in the entire wholeness. Narrative medicine is a tool to develop empathy, which is now already present in Italian pain therapists. This cognitive skill should be fostered and circulated across Europe, through teaching and practice at the European Federation of Pain Therapists, who are still very much focusing on the disease concept and too little on the illness side. Financial & competing interests disclosure The authors would like to thank the Italian Society of Pain Clinicians and the Fondazione iSAL for their support and Grunenthal for the unconditional grant. P Zini works in Grünenthal Italia s.r.l. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Writing assistance was utilized in the production of this manuscript. Editorial assistance for the preparation of this manuscript was provided by Laura Brogelli of Content Ed Net, and was supported by internal funds.

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Review  Marini, Reale, Cappuccio et al. 12 Varrassi G, Raffaeli W, Marinangeli F et al.

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Narrative medicine to highlight values of Italian pain therapists in a changing healthcare system.

Until 2010 pain management in Italy was only partially covered and no structural and qualitative mapping had ever been realized. The VEDUTA project wa...
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