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Conflicting Representations of Pain: A Qualitative Analysis of Health Care Professionals' Discourse


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Studies regarding health care professionals' representations of pain indicate that doctors and nurses tend to concentrate on the organic origin of pain, and to view pain as subordinate to diagnosis and treatment of the disease; they also tend to underestimate the psychological and psychosocial components of pain, which means that they generally view the patient's subjective experience as secondary. This leads to an underestimation of pain. The objective of this study was to analyze the representations of pain held by doctors, head nurses, and nurses in two Italian hospitals, focusing on how these representations are shaped according to the local culture in which they are constructed and negotiated. Our study is based on a socio-constructionist approach, drawing on semi-structured, in-depth interviews with 26 health care professionals. The results show similarities and differences in how health care professionals construct their representations of pain. Three main issues emerged. First, the contents of these representations are strictly related to participants' job position and professional training; second, the representation of pain is significantly influenced by the values and meanings associated with the different professions; and third, there are two conflicting representations of pain, focusing on the objectivity vs the subjectivity of pain, respectively. To promote significant change regarding pain management within hospital organizations, it is essential to construct shared representations of the problem and its implications, particularly as regards relations with the patient. This change should take place at the educational as well as the socio-organizational level, and it should take into account ideas and proposals from the subjects involved.
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Conflicting Representations of Pain:
A Qualitative Analysis of Health Care
Professionals’ Discoursepme_12521585..1593
Lorenzo Montali, PhD,* Colombo Monica, PhD,*
Paolo Riva, PhD,* and Roberto Cipriani, MS†§
*Psychology Department, University of Milan-Bicocca,
Azienda Ospedaliera San Gerardo, Monza, Italy
Reprint requests to: Dott. Lorenzo Montali, PhD,
Dipartimento di Psicologia, Università degli Studi di
Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126
Milan, Italy. Tel: +39-02-6448-3732; Fax:
+39-02-6448-3706; E-mail:
§This paper is dedicated to the memory of Roberto
Introduction. Studies regarding health care profes-
sionals’ representations of pain indicate that doctors
and nurses tend to concentrate on the organic origin
of pain, and to view pain as subordinate to diagnosis
and treatment of the disease; they also tend to under-
estimate the psychological and psychosocial com-
ponents of pain, which means that they generally
view the patient’s subjective experience as second-
ary. This leads to an underestimation of pain.
Objective. The objective of this study was to
analyze the representations of pain held by doctors,
head nurses, and nurses in two Italian hospitals,
focusing on how these representations are shaped
according to the local culture in which they are
constructed and negotiated.
Methods. Our study is based on a socio-
constructionist approach, drawing on semi-
structured, in-depth interviews with 26 health care
Results. The results show similarities and differ-
ences in how health care professionals construct
their representations of pain. Three main issues
emerged. First, the contents of these representa-
tions are strictly related to participants’ job position
and professional training; second, the representa-
tion of pain is significantly influenced by the values
and meanings associated with the different profes-
sions; and third, there are two conflicting represen-
tations of pain, focusing on the objectivity vs the
subjectivity of pain, respectively.
Conclusions. To promote significant change regard-
ing pain management within hospital organizations,
it is essential to construct shared representations
of the problem and its implications, particularly
as regards relations with the patient. This change
should take place at the educational as well as the
socio-organizational level, and it should take into
account ideas and proposals from the subjects
Key Words. Pain; Health Care Professionals; Italy;
Qualitative Research; Social Representation
Despite advances in research about pain, it is still difficult to
translate this knowledge into workable clinical practice,
and in this sense, the need to develop pain management
techniques has been widely documented [1–3]. Indeed,
research indicates that, even though pain can be kept in
check efficiently in approximately 90% of cases [4], the ratio
of hospitalized patients who admit to feeling pain varies
from 44% to 79% [5,6]. This data is particularly significant if
one considers its stability over time [7,8]. The fact that pain
continues to be undertreated seems to depend on a per-
sisting culture of pain—articulated in terms of knowledge
and representations of this problem as it relates to profes-
sional practice—which is not very sensitive to change.
Over the past three decades, a great number of studies
have been developed regarding knowledge and attitudes.
The main results indicate several areas of concern. First of
all, health care professionals generally seem to share low
goals where the relief of chronic pain is concerned [9,10].
Indeed, uncertainties have emerged both in the assess-
ment phase, when health care providers often seem
unsure of how often they should assess pain [11], and
during the treatment phase, where some misconceptions
regarding the pharmacological therapy of pain are evident.
Researchers found that such treatment misconceptions
were especially marked in the matter of opioid use, e.g.,
the belief that morphine has a dosage limit, or the pres-
ence of an exaggerated fear of overdosage when it comes
Pain Medicine 2011; 12: 1585–1593
Wiley Periodicals, Inc.
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to opioids in general [12–14]. Furthermore, in studies
aimed at investigating levels of knowledge about pain
management methods [15], decision-making processes,
or doctors’ knowledge regarding pain management [10],
there was evidence of a discrepancy between knowledge
effectively possessed (mediocre) and self-evaluation (posi-
tive) as expressed by doctors and nurses. However, as
much as the literature indicates the existence of a knowl-
edge deficit on the part of care professionals, the problem
of undertreating pain does not appear to be limited to
this aspect [15,16]. For instance, Hoffman [17] identified
several stereotypes shared by doctors and nurses; for
example, the idea that women are not accurate reporters
of their pain or that they are better able to tolerate pain.
Based on these findings, McCaffery [18] showed the influ-
ence of patients’ lifestyle features in determining analgesic
dosage. In this sense, studies have shown a general ten-
dency on the part of health care professionals to judge
pain on the basis of several indicators—different from
patients’ accounts—such as medical evidence [19], facial
expression [20,21], and socio-demographic features
[10,22]. This seems to be in line with a persisting convic-
tion that patients exaggerate their pain [23], and, corre-
lated to this, an underestimation of the patient’s role in
reporting pain. This latter aspect seems to be particularly
relevant. Indeed, theories regarding pain indicate that the
perception of pain is a multidimensional phenomenon
influenced by cognitive and psychological variables, which
are in turn linked to cultural factors depending on context
and past experience [19,24]. This implies that patient nar-
ratives should be considered as relevant indicators of the
level of pain experienced and of the efficacy of any treat-
ments aimed at relieving this symptom [25]. What
emerges instead is the fact that patients’ accounts are
either little understood or totally ignored by doctors,
mostly because doctors appear skeptical about the truth-
fulness of these accounts [26,27].
For this reason, a number of qualitative research studies
have focused on doctors’ and nurses’ representations
of pain. Such qualitative research seems to constitute
a more efficient tool when it comes to collecting data
compared with the use of standardized questionnaires.
The latter allows for a more in-depth analysis of the rep-
resentational field because participants have a chance to
express themselves more freely and can therefore situate
their narrative within the context of their own concrete
experience [28].
The literature regarding this issue is still limited, but it
provides us with useful indications. First, it appears that
the representation of pain regards it as a potential diag-
nostic tool and therefore attributes a lesser role to
the patient’s subjective experience [29,30]. What is
reported about pain is therefore dominated by medical
and scientific language [31], concentrating mostly on the
organic origin of pain, underestimating its psychological
and psychosocial components [32], and viewing pain as
subordinate to diagnosis and treatment of the disease
[33]. This leads to an underestimation of pain, and to
differences between the pain perceived by patients
and that reported by doctors and nurses [34]. Several
researchers have concluded that, in order to ensure a
better management of patients in pain, adequate training
and information is required. To date, there is a large
amount of knowledge about the impact of educational
programs. These experiences often report the positive
impact of courses on health care providers’ knowledge
and attitudes [35,36]. However, improvement of know-
ledge appears not be enough so long as we are unable to
grasp the complex systems of theories and practices that
are involved in pain management [15,37,38].
Context and Objectives of This Research Study
The framework for the present study is that of a project
called “Towards a Pain-Free Hospital,” which was
started in 1992 at St-Luc Hospital in Canada and is
now being applied in other countries such as the United
States, France, Belgium, Switzerland, Spain, and Italy. The
general aim of the project was to promote change in
doctors’ and nurses’ attitudes and work practices [39],
starting from the evidence that current treatment of pain is
largely inadequate. Such attitudes are associated to a
representation of the patient as a passive beneficiary of
medicine, which explains the difficulty in involving the
patient in the care and treatment process.
Among the project’s specific objectives is that of iden-
tifying both the incidence and treatment of pain, and the
knowledge and attitudes of health care professionals, so
that training programs promoting a new culture of pain
may be devised.
The problems involved in pursuing these objectives, par-
ticularly the difficulty to introduce practices that are appro-
priate to pain management, can perhaps be better
understood by adopting a socio-constructionist approach
based on the notion that pain cannot be properly under-
stood without taking into account the fact that it lies in the
interface between biology and culture [32]. This means
that, on the one hand, the representation of pain is based
on shared cultural models [40], and on the other hand that
medical practices are a result of the interaction and nego-
tiation between doctor and patient [41].
In line with this premise, our main objective was to analyze
the content and structure of pain representations held by
health care professionals in two Northern Italian hospitals,
within the framework of the theory of social representa-
tions (TSR) [42–44]. Such a choice is motivated by four
main reasons. The first has to do with the fact that TSR
recognizes the link between the beginning of a change
process—such as the “Towards a Pain-Free Hospital”
project—and the need to redefine the representations of
an object, in this case the representation of pain. Our
analysis therefore aims to underline both continuity and
change within the participants’ representations of pain.
Second, because TSR goes beyond any approach cen-
tered on the individual, it conceptualizes those represen-
tations as the result of a communication/negotiation
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processes through which various social groups construct
reality. In this sense, our research sets out to underline
similarities and differences in how health care profession-
als construct their concept of pain. Indeed, the idea is that
pain might be better understood if one could study it as
part of the local culture in which it is constructed and
negotiated [45]. Third, within this theoretical framework,
social representations are regarded as related to specific
social practices. The aim of our study was therefore to
investigate how doctors and nurses position themselves
with respect to the overall institutionalized and informal
procedures used to assess and treat pain. Finally, the TSR
theoretical framework was chosen because of the rel-
evance given to the participants’ narrative. The role of
language has indeed been pointed out in many research
studies aimed at investigating the concept and experience
of pain [46].
The study was conducted on a sample of 26 health care
professionals (12 physicians, 9 nurses, and 5 head
nurses), working in two different wards (internal medicine
and surgery) of two Northern Italian hospitals.
Data Collection
Data were collected by means of semi-structured inter-
views whose aim was to explore the pain representations
and practices of health care professionals. The interview
grid focuses on three main areas: pain assessment, treat-
ment activities, and rapport and communication with
patients. Interviews were audio-taped and transcribed.
Data Analysis
A computer-aided content analysis was conducted by
means of the software T-Lab (version 5.1, © Franco
Lancia, for more info:
php) [47], which analyzes the structure of a text through
the same series of statistical tools used by the Alceste
(© Image, for more info:
english/index_alceste.htm) software [48,49]. Our aim was
to come up with a global view of the data, so as to identify
the main topics featured in participants’ discourse and
common/distinctive elements for each profession. To this
purpose, we performed cluster analysis. Each cluster
includes a set of lemmas selected by the software and the
sentences in which they occur. Moreover, the program
indicates the variables (in our case: nurse, head nurse,
and doctor) associated with each cluster.
As such, this method is akin to content-analysis proce-
dures. However, unlike the latter, it does not derive the
internal structure of a corpus from ad hoc categories
established by researchers, but rather from the distribution
of the words in the corpus.
Five clusters were identified. For each cluster, the software
indicates (Table 1) the relative “weight” compared with the
explanatory power of the variability affecting the whole
corpus and the variables that contribute more extensively
to the cluster. The themes were labeled according to
typical vocabulary and sentences featured in each cluster
presented in the next sections.
Cluster N° 1: “Pain Assessment”
This cluster includes words (Table 1) referring to the
assessment of pain. The first aspect (“note,” “assess,”
“measure”) refers to a complex set of practices linked
mainly to pain-assessment procedures (“objective,”
“correct,” “perceive”), which represent a crucial element
in pain management work practices. This issue is
also discussed in terms of transformation and evolution
(“evolution,” “improve,” “arise”) as it is perceived by the
participants and is part of a more general change that is
still in progress regarding medical science and how it
relates to patients.
From the analysis of the excerpts, it is clear that doctors
perceive a new culture regarding illness, which goes
together with an increased attention to pain-treatment and
the pain-assessment process:
Doctors’ and nurses’ attention to this problem has
gotten better, compared to many years ago, but we
can still improve in the sense that we could use it as
one of the basic post-operative parameters; we
should include pain as well, that way it would force
us, the doctors and the nurses, to ask the patients
if they are in pain (Doctor).
Nevertheless, discourse shows a certain ambivalence
because everyone agrees in principle that pain is important
and should be noted, but some of the practices mentioned
tend to go against this principle. For example, in the
following excerpt, there is a statement regarding the impor-
tance of pain, as well as reference to behaviors such as
occasional assessment, which would appear to contradict
this, and the absence of any pain-assessment scale:
We sometimes check whether there is pain when
we do rounds, it’s one of the most important
parameters because if you don’t check the level of
pain you miss key information but no, we don’t
have a pain measuring scale, we ask generic ques-
tions but there’s no objective measurement
More generally, as seen in the previous excerpt as well,
there seems to be a certain level of uncertainty regarding
expected pain-assessment procedures, to the point that
mandatory pain assessment is sometimes indicated as
an optimal solution, when it should already be standard
Nurses should have pain as one of the parameters
they should check, but often they don’t take it into
much consideration, that is, pain should also be
mandatory as a parameter to check (Doctor).
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The issue of using a pain scale is once again presented
as a need to go beyond the patient’s sentences regarding
his/her pain. On the one hand, this leads health care
professionals to give greater credit to “objective examina-
tions” than to what the patient communicates, and on the
other hand it leads them to “seek alternatives” to the
patient’s words, which is why the notion of a double scale
is proposed, showing that participants have serious
doubts regarding the point of view expressed by the
We don’t have a chart that enables us to measure
the patient’s perception of pain, and on the other
hand for what we perceive we don’t have this type
of instrument, at least in my ward we don’t have
such a precise tool that might enable us to measure
if the patient’s subjective sensation is four whereas
my impression of that pain could be zero (Doctor).
Cluster N° 2: “Filling out the Patient’s Chart”
This cluster regards the new recently introduced patient’s
chart, which includes a pain-assessment scale and the
presence of a cluster for this topic indicates its relevance
in the participants’ discourse. The words are grouped into
two main topics: words referring to filling out the chart
(“medical chart,” “nurses chart,” “fill out,” “register,”
“progress notes”) and words referring to the problems
derived from the introduction of these charts (“problem-
atic,” “expectation”).
The analysis of the sentences shows that there is resis-
tance to the use of the new charts, expressed in three
different ways: how little it is used, how little it is known,
and a sort of “nostalgia” for past methods.
Many of the participants admitted the underuse of the
chart, referring both to their own behavior and that of
Our patient charts includes a pain-assessment scale
but we don’t always fill it out, sometimes we ask
verbally, we note on the chart that the patient doesn’t
have good pain control, but we often neglect to fill
out the section regarding pain (Doctor).
For others the introduction of the new chart appears to
have been more readily accepted, but its use does not
always seem to be in line with the objectives of the chart
Table 1 Themes, variables, weights, and lemmas of each cluster
Weights (%) 27 17 39 10 8
Themes Pain
Filling out
the new
patient’s chart
Pain treatment and
the subjectivity
of pain
Daily patient care and
how this has evolved
over the years
Participants’ professional
training, motivations and
Variables Doctors Common Common Nurses and head nurses Nurses and head nurses
Lemmas Note Medical chart Morphine Move Ward
Parameter Nurses’ chart Increase Walk Surgery
Assess Fill out Terminal Sit Medicine
Measure Register Care Get up Specialty
Instrument Progress notes Die Position Profession
Objective Instructing Metastasis Posture Worse
Correct Gather Analgesic Get down Bureaucratic
Perceive Problematic Pain killer Bed Frenetic
Precise Expectation Vein Wash Quality
Adequate Needs Home care Evening Demanding
Verify Charge Palliative Send School
Correct Question Sufficient Watch University
Disagreement Judgment Painful Hygiene
Evolution Request Suffer Morning
Improve Person Self-sufficient
Arise Feel Good
Problem Experience Calm
Culture Threshold Excessive
Practice Placebo Intolerable
Education Subjective
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I must say though that now we have to fill out
the various sheets when we update the medical
chart and then we go and check and maybe we’ve
accumulated up to seven or eight sheets and then
we check them one after the other (Doctor).
What emerges is, more likely, the picture of a change that
has not yet been fully understood and that is viewed as an
Now I don’t know if they fill it out after the dressing
down they got from management, because man-
agement has seen incomplete medical charts, while
the whole chart must be properly filled out, signed
and checked, so it must be complete (Head nurse).
This is also clearly shown by the fact that talking about the
chart led some of the participants to remember assess-
ment and documentation tools that were used in the past,
and what emerges is regret, without full awareness of the
possible advantages of the new tool:
We’re not used to the new medical chart, there are
a million more things to fill out and we’re not used to
it, we’re used to writing up good notes with every-
thing spelled out, we were used to filling out the
chart when the patient is admitted and then we
would write up the progress notes every day but
now there are so many things on the chart that
need to be updated all the time (Doctor).
Cluster N°3: “Pain Treatment and the Subjectivity
of Pain”
The vocabulary of Cluster N°3 shows that pain treatment
and the subjectivity of pain are two interconnected themes
in doctors and nurses/head nurses’ discourse. The first
theme is expressed by lemmas such as “morphine,” “pain
killer,” and “analgesic.” When speaking about treatment,
the patient’s clinical condition is a significant element
(“metastasis,” “terminal,” “palliative” “treatment,” “die”),
because it appears that for health care professionals,
there is a prototypical type of pain that is seen as a
reference model for any other type of pain, namely the
pain associated with neoplasia. Regarding this aspect of
the interviews, an ambivalent position emerges. The
analysis shows a prevailing opinion that morphine is an
efficient drug, which could be used more often regardless
of diagnosis or type of illness:
It often happens that they are given morphine for
4–5 days and then the patients slowly improve, and
then the drug is interrupted and afterwards the
patients thrive again, so at least in those days they
were able to stay calm, without pain and then you
see the difference (Nurse).
However, there is awareness of the fact that many care
professionals still view morphine as a drug to be given only
to terminal patients. For the participants that we inter-
viewed, there is evidence of a change regarding this issue,
that this change affecting attitudes and professional prac-
tices is still in progress, and that it inevitably implies a
number of contradicting thoughts and opinions:
This aspect still hasn’t taken hold because there are
still people who believe that morphine should only
be given to patients who are dying, while morphine
can easily be given to people who are simply in pain
(Head nurse).
On the other hand, when the clinical condition is not that
critical and therefore the patient is not seen as “objec-
tively” suffering, the subjectivity of pain takes on a central
role in determining treatment. In this sense, the terms
“suffer,” “feel,” and “experience” seem to refer to the
patient’s perception, whereas the words “threshold” and
“subjective” indicate an attitude consisting in seeing pain
as something that varies from patient to patient.
The problem is the same as with any other subjec-
tive issue, and pain is subjective: some people are
capable of tolerating more pain regardless and
therefore complain a lot less, whereas other people
have very low tolerance for pain (Doctor).
The stakes ultimately depend on seeing patients as
capable of recognizing their own pain and seeing their
point of view as an integral part of the symptom-
assessment process. What emerges is a tendency to
perceive the patient’s behavior in polarized terms, as
either exaggerating the symptoms or as hiding them. Pain
is indeed associated to a specific image, that of a suffering
patient’s “face,” as one of the clues indicating “real” pain,
over and above what the patient expresses verbally. This
would seem to indicate that the patient’s account is seen
as something that shouldn’t be trusted:
People who have a hard time tolerating their pain will
exaggerate their symptom, this often happens and
when patients tend to exaggerate their pain, then
you underestimate them and maybe you don’t pay
them enough attention, it is indeed difficult to under-
stand exactly when there is real pain (Head nurse).
Cluster N°4: “Daily Patient Care and How this has
Evolved over the Years”
Terms typical of this cluster refer mostly to the “physical”
care of patients, either in terms of movement (“move,”
“walk,” “get up”), or everyday activities that are not strictly
related to diagnosis or treatment (e.g., “wash,” “hygiene”)
but are indicative of what nursing professionals view as
their priority. The references to temporal aspects
(“evening,” “morning”) underline the importance of time for
nurses and head nurses, who appear to be acutely aware
of how time sets the pace of all the activities performed in
the course of their working day. Time is also a preoccu-
pation when discussing the lack of sufficient hospital
resources: time is “never enough” and lack of time makes
it difficult to effectively monitor patients’ pain or their
response to pain treatment.
The sentences within this cluster describe, mostly on the
part of nurses and head nurses, everyday activities and
interactions with the patient, including remarks on how
these involve a greater workload than in the past because
hospitalized patients are now usually less autonomous:
It used to be that many people were hospitalized
just to do tests, they washed themselves, they were
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able to walk on their own; now the percentage of
bedridden patients to care for has increased
because the number of available beds has been
reduced, so patients who can walk get discharged
as soon as possible (Head nurse).
The description of these everyday activities brings out
certain stereotypical theories, through which the patient’s
behavior may be viewed and interpreted, for example, the
representation is that men are more “active” than women
because the latter require more extensive care and atten-
tion. These are important elements inasmuch as they
affect the structure of the relationship between the care
professional and the patient:
Men normally try to get around more so as to be
more autonomous, maybe it bothers them more to
be washed by a woman, women don’t really care if
they are washed by a man because they’ve
decided they can’t be budged from their bed
More generally, there is a clear separation of tasks
between nurses and doctors: whereas the former deal
with communication, the latter deal with treatment:
Pain is taken under consideration more by doctors
than by nurses in the sense that you tell the doctor,
this patient was in pain during the night, for
example, and wasn’t able to sleep because he was
in pain (Nurse).
Cluster N°5: “Participants’ Professional Training,
Motivations and Difficulties”
This category features words referring to hospital organi-
zation (“ward,” “surgery,” “specialty”), participants’ opinion
about hospital resources (“worse,” “bureaucratic,” “fre-
netic”) and references to their professional education
(“school,” “university”). Each participant tells about his/her
personal “story,” explaining personal choices, motivations,
and expectations. However, this description of their work
is linked to a negative assessment of the resources pro-
vided by the hospital. What emerges is a discrepancy
between the “means” perceived as available, and the
“end” stated by the hospitals. Although this topic is
present in all three professions considered here, it must be
noted that it was brought up most often by head nurses.
This is probably due to the fact that this profession differs
from the others in terms of its greater focus on adminis-
trative tasks:
As for resources we often have to make do with
what we’ve got and this keeps us from doing
certain things. For example in this period demand is
higher than our resources, we’ve got a lot of com-
plicated patients and a lot of work to do, 32
patients, all with difficult problems to deal with
(Head nurse).
Regarding training activities, almost all participants
stressed the importance of getting more training regarding
the issue of pain. In spite of this, they also point out the
limitations of current training programs, which they feel are
mostly centered on providing information rather than
responding to care professionals’ needs and daily
I wouldn’t focus on getting a course on any specific
topic because then you end up talking about drugs
or technical subjects. If on the other hand they
could organize courses where you talk more about
the rapport that we healthcare professionals have
or should have with patients, maybe in different
ways with external or with post-op patients, with
teenagers or elderly patients...(Nurse).
Two main elements emerge from our analysis, and both
involve all the topics discussed by the participants.
The first element has to do with perceiving that an impor-
tant process of change is in progress, regarding on the
one hand the way that patients see their illness, and on the
other hand the relation between patients and health care
professionals, in the context of a new organization within
the hospital. As part of this general change process, par-
ticipants contextualize and give meaning to the various
innovations when it comes to assessing and treating pain,
i.e., a more extensive use of opioids, the new medical
chart, and the use of pain-assessment scales.
The second aspect has to do with participants’ ambiva-
lence with respect to these changes. Indeed, while they
recognize the value of the innovations, they express per-
plexity regarding the actual usefulness of the new tools
and they also refer to the persistence of previous prac-
tices, which seem to indicate opposition to these
changes. Of particular interest is the oscillation that may
be observed regarding the emotional and psychological
aspects of the patient’s experience of pain, which appear
to be both recognized and “distanced” by the participants.
The interviews feature explicit references to psychological
and emotional components involved in defining pain that
should be recognized as an essential element in caring for
the patient. Affective states attributed to the patient (for
example fear, agitation, anxiety), and the subjectivity which
in participants’ view characterizes the patients’ perception
of their own pain, appear to be factors that interfere with
performing an “accurate assessment” of the actual pain.
Furthermore, as indicated by the data, the patients’ words
are not seen to be a credible indicator of the actual pain
Such ambivalence may be interpreted in the light of dif-
ferent theoretical and conceptual perspectives. It may be
seen as a form of organizational resistance, as a knowl-
edge deficit or as an individual attitude that could be
modified. Although legitimate, all these interpretations
share the same limitations in that, to some degree, they all
put the blame on the health care professionals themselves
for not being able to fully take on the challenge of
In our perspective the focus shifts from the individual to
the social level and this ambivalence can be interpreted as
a tension between two conflicting, socially shared repre-
sentations of pain: the objectivity vs the subjectivity of
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In the first representation, pain is first and foremost a
symptom, which is secondary to diagnosis, and its treat-
ment may be viewed by doctors as much less important
compared with the level of attention given to the illness
itself and to other care activities performed by nurses.
Moreover, the treatment of pain depends on the severity of
the illness, which means the focus is on the pain felt by
cancer or other terminal patients, because this pain serves
as the basic gauge to measure all other types of pain.
Such a view underlines the need to determine pain in
objective terms, i.e., independently from the patient’s nar-
rative, focusing on the need for doctors and nurses to use
tools specifically designed to assess and “measure” pain
through standardized procedures. In the absence of such
tools, identification of pain is based on individual capacity,
learned and refined through professional experience, to
recognize “true” pain by observing the patient’s face and
The second representation, which emerges from the inter-
views through indications that the change in progress is
seen as positive and especially through repeated state-
ments regarding the need for a much less superficial rela-
tionship with the patient, paves the way for the possibility
to view pain assessment and treatment as a process
involving both the care provider and the patient.
In this sense, the two representations of pain refer to two
epistemological models of medicine [41]. The first is bio-
medical, objectivistic, and disease centered, and it is the
main reference framework in health care professionals’
education. As such, it considers medicine as one of the
natural sciences, seeing the illness as a natural phenom-
enon to observe and on which to intervene. The second is
a subjectivist, patient-centered model, which values
patient involvement as well as negotiation between health
care provider and patient as tools to tackle illness.
Both models are part of current medical culture, but there
is no credible integration of both views, which means that
even when organizations try to promote positive innova-
tions, they end up giving doctors and nurses the task of
mediating between diverging premises and demands in
the context of their professional practice.
In our opinion, this integration can be effected not only
through training and educational programs aiming to
increase health care professionals’ knowledge regarding
pain treatment modalities, but first and foremost through
forming groups of hospital professionals who can reflect
upon their own professional practices and cultural models,
with the aim of constructing and sharing new representa-
tions of the problem.
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Representations of Pain: A Qualitative Analysis
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... However, such overgeneralization could be particularly relevant in the clinical pain context. Indeed, the pain management literature indicates that pain reported by patients is often met with doubt and skepticism on the part of observers (Blomqvist & Edberg, 2002;Clarke & Iphofen, 2005;Montali et al., 2011), which might lead to an underestimation of the patient's pain (Riva, Rusconi, et al., 2011;Rusconi et al., 2010), especially when displayed by the elderly and women (Blomqvist & Edberg, 2002;Riva, Sacchi, et al., 2011), or ethnic minorities like black individuals (Banaji et al., 2021;Hoffman et al., 2016). In this context, different trust construal features will likely be at stake, ranging from a generalised trust to a more specific trust developed within the patient-carer relationship. ...
... Such a mechanism may have important implications for clinical pain practice, as previous research suggests that perceived trustworthiness does not reflect the actual trustworthiness of our interaction partners (Rule et al., 2013). Indeed, past research indicated that patients' pain reports are often met with doubt and skepticism by observers (Blomqvist & Edberg, 2002;Clarke & Iphofen, 2005;Montali et al., 2011) and that this can lead to an underestimation of pain (Riva, Rusconi, et al., 2011;Rusconi et al., 2010). ...
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Past research indicates that patients' reports of pain are often met with skepticism and that observers tend to underestimate patients' pain. The mechanisms behind these biases are not yet fully understood. One relevant domain of inquiry is the interaction between the emotional valence of a stranger's expression and the onlooker's trustworthiness judgment. The emotion overgeneralization hypothesis posits that when facial cues of valence are clear, individuals displaying negative expressions (e.g., disgust) are perceived as less trustworthy than those showing positive facial expressions (e.g., happiness). Accordingly, we hypothesized that facial expressions of pain (like disgust) would be judged more untrustworthy than facial expressions of happiness. In two separate studies, we measured trustworthiness judgments of four different facial expressions (i.e., neutral, happiness, pain, and disgust), displayed by both computer-generated and real faces, via both explicit self-reported ratings (Study 1) and implicit motor trajectories in a trustworthiness categorization task (Study 2). Ratings and categorization findings partly support our hypotheses. Our results reveal for the first time that when judging strangers' facial expressions, both negative expressions were perceived as more untrustworthy than happy expressions. They also indicate that facial expressions of pain are perceived as untrustworthy as disgust expressions, at least for computer-generated faces. These findings are relevant to the clinical setting because they highlight how overgeneralization of emotional facial expressions may subtend an early perceptual bias exerted by the patient's emotional facial cues onto the clinician's cognitive appraisal process.
... In the treatment of patients with chronic pain, a group that generally struggles with being believed, as this has been identified as the most important factor for successful pain management [40]. Interestingly, there are some similarities between the ability to recognise a patient's pain and the ability to recognise dental anxiety, with both being generally underestimated in comparison with the patients' own ratings [9,41,42]. Both are more easily recognised when a patient exhibits physical signs of distress, and both are met with disbelief when no physical signs exist [43]. ...
... The theoretical construct of "social representations" has been regarded as both a product and a process (Kalampalikis & Apostolidis, 2021). First, representations have an actual content consisting of an organised system of values, ideas, and practices related to a peculiar and relevant social object (Montali et al., 2011;Sammut et al., 2015). Second, representations consist in the dynamic activity of representing, which occurs within the plurality of encounters and worldviews offered by contemporary society (Duveen, 2007). ...
The vegetative state is a condition in which a person is wakeful without being aware. To understand a patient who can be considered neither alive nor dead, caregivers and professionals re-define traditional identities, roles, and practices. By drawing on wider research, in the current chapter, we aimed to show how caregivers and practitioners positioned the patient and themselves within the institutional context of five nursing homes in Lombardy. We conducted 65 semi-structured interviews with 35 caregivers (children, partners, parents) and 30 professionals (health, mental health professionals, and social workers). Our discourse analysis identified three different interpretative repertoires to position the patient: an organic, an interactional, and a possibilistic one. Their encounter both led to disagreement and convergence. For instance, by taking each other’s perspective, professionals and caregivers converged toward the common ground of balanced hope, where the possibility for patients’ awareness was neither fostered nor denied. In this space of possibilities, caregivers found a justification for their monitoring and patient stimulation activity and took on the role of spokesperson for the patient. This common ground allowed caregivers and professionals to communicate, justify their reciprocal action and acknowledge their roles and expertise in taking care of the patient.
... In particular, we analyzed the transcripts using the "Thematic analysis of elementary context" from T-Lab software (Lancia, 2017). In the thematic analysis, the software examined the text of all the newspaper articles considered as a single set of data, and performed cluster and correspondence and factorial analysis (Caputo, 2013;Montali et al., 2011;Potì et al., 2018). ...
Over the past few years, there has been a great deal of concern regarding the potential links between childhood vaccinations and the development of ASD, possibly leading to vaccine hesitancy. This study aims to explore the representational field related to the vaccine-autism link in a mainstream Italian newspaper. We analyzed newspaper articles published on La Repubblica, from January 2009 untill January 2017 (N = 168 newspaper articles), via T-Lab software. The analysis produced four clusters: a) Trust and sense of belonging; b) Judgment dimension; c) Catastrophic narratives; d) Organization of the public healthcare system. The need to monitor media coverage on key healthcare topics was considered of paramount importance.
... To explore how representations are shaped across different social milieus we conducted an Analysis of Lexical Correspondences (ALC) on the corpus of 900 articles by using T-Lab software. T-Lab is a worddriven software based on word frequency distribution (Montali et al., 2011). The outcome of this word-driven, statistical analysis is an automatically generated output that requires interpretation. ...
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Our research explored the social representations of the “vegetative state” across different cultural (India, Italy, and the UK) and social milieus (left-leaning, right-leaning, and religious/tabloid newspapers). The aim was to discover how public discourse engages liminality between life and death. Qualitative and quantitative text analyses were conducted on news headlines and full-texts from British (n = 300), Indian (n = 300), and Italian (n = 300) newspapers published between January 1990 and June 2019. Our study shows three results: (a) the vegetative state is a potentially global issue that remains discussed with local timing and characteristics; (b) it is commonly represented in eight frames of different resonance across cultural milieus; (c) the news flows are organised on different dimensions (quality, political, and ideological). Results shed light on how liminality is discursively managed by the interplay of cultural resources and social positionings. In particular, this suggests a hitherto unrecognised function of the objectification process: personification as position-taking. This article is protected by copyright. All rights reserved
... To our knowledge, no previous study has evaluated the ability of clinicians to rate dental anxiety. There is, however, a similar pattern of underestimation in health care, in which there is a tendency to underestimate a patient's pain (34,35). ...
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The aim of this study was to evaluate the ability of dental clinicians to rate dental anxiety. A total of 104 clinicians from 24 public dental clinics in the Region of Östergötland, Sweden, examined 1,128 adult patients undergoing their regular dental examination. The patients rated their dental anxiety using the Modified Dental Anxiety Scale and a Visual Analogue Scale. After the examination, the clinicians rated the patients’ levels of dental anxiety on a Visual Analogue Scale. The correlation (rs) between the clinicians’ and patients’ ratings of dental anxiety was 0.45. Among highly dentally anxious patients, there was no correlation between clinicians’ and patients’ ratings. Dental clinicians rated dental anxiety lower than their patients did, especially if the patients were highly anxious. The ability of clinicians to rate dental anxiety was better when the clinician was older and the patient was older. There was an inverse association between clinicians’ confidence and their ability to rate a patient's dental anxiety. In conclusion, clinicians are unsuccessful in identifying a dentally anxious patient without the concurrent use of patient self‐assessment tools. A Visual Analogue Scale is a suitable screening tool in general practice for detection of dental anxiety.
... 26 The software allows for data synthesis and a deeper understanding of the meanings expressed by participants, allowing inferences about the emotional and cognitive representations that are not easy to identify at an explicit semantic level. 27,28 We analysed the accounts produced by different HCPs working with hemophiliac patients of different ages. The data were collected within a broader international and multidisciplinary research program, the Haemophilia Experience, Results and Opportunities (HERO) Initiative, aimed at understanding the psychosocial aspects of hemophilia from the perspective of patients, their caregivers and their HCPs. ...
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Background: Assessing the viewpoints of health care professionals concerning their work with chronic patients is a relatively new research topic, widely overlooked in the literature. However, understanding their subjective work experience is highly relevant for identifying problems and perceived resources, enhancing health service organisation, improving relationships or communication with patients, and maintaining well-being. Purpose and method: Qualitative data from the“Haemophilia Experience, Results andOpportunities” Initiative–a research program aimed at investigating the psychosocial aspects of hemophilia–were used to evaluate the experiences of 62 professionals from seven countries around the world. Semi-structured interviews were submitted to thematic analysis of elementary contexts with the aid of T-Lab software. Results: Five dominant themes emerged, identifying the main challenges that professionals have to deal with in their everyday work practice: caring for impaired adult patients; handling policies and stakeholders; providing counselling on diagnosis and reproductive choices; considering the role of family dynamics; coping with adolescent patients.Conclusion: The outcomes of the study provide an opportunity to develop the area of the non-technical skills in the core curriculum of those who work with chronic illnesses by focusing on cross-professional competences and by improving a comprehensive care model for hemophilia patients.
... Health professionals' core representation of migraine as a disease also interferes on the medical history of the patients. As Montali, Monica, Riva, and Cipriani (2011) pointed out, when treating chronic pain sufferers, health professionals tend to focus on the organic nature of the pain and leave the patients' subjective experience in the background. ...
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Migraine is a disease with serious impacts on quality of life. We conducted a phenomenological qualitative inquiry in order to understand how 10 female patients with migraine dealt with their disease and its treatment, at a headache unit of a reference hospital. Through a phenomenological analysis, we highlighted seven themes that connected participants’ experiences to those reported in the previous literature. We noticed that participants recurrently described their migraine experiences through metaphors. The communicative metaphors indicated an overarching theme of constant vigilance for the unpredictable. Participants felt lack of empathy from others during headache episodes, and showed ambivalence about several aspects of treatment. Our interpretation is that addressing to how patients communicate about their illness might help health professionals to establish stronger therapeutic alliances based on empathy and respect. Professionals’ communication skills are the primordial resource to facilitate adherence to treatment and its success.
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Introdução: Políticas de saúde e qualidade de vida no trabalho devem ser desenvolvidas a partir de cada realidade. Objetivo: Caracterizar o perfil sociodemográfico, ocupacional e de saúde de profissionais com sintomas osteomusculares da unidade ambulatorial de um Hospital Universitário. Material e Métodos: Estudo transversal, descritivo, quantitativo, com profissionais de um hospital universitário com sintomas osteomusculares. Utilizou-se questionários de caracterização sociodemográfica e ocupacional, questionário internacional de atividade física, Nórdico, escala numérica, tempo de duração dos sintomas, questionário de avaliação de incapacidade causada pela dor, tratamento para a dor relatada e escala de estresse percebido. Resultados: População constituída, majoritariamente, por mulheres (66,4%), na metade da vida economicamente ativa (média de 39,02 anos±11,00), com formação superior (60,8%), apenas um emprego (84%), celetistas no local (68%), jornada de trabalho conforme estipulado pela legislação trabalhista (média de 42,30 horas±9,36), atuantes em setores assistenciais (59,2%) e que praticavam atividades físicas (58,4%). A maioria relatou tempo de duração da dor de até 6 semanas (50,4%), mas parcela considerável referiu dor persistente por mais de 12 semanas (40%), sendo a parte inferior das costas a região de maior ocorrência (38,4%). A maioria não consultou profissionais de saúde (62,4%) e não realizou tratamento (72,8%). Dentre as pessoas que realizaram, a maior parte informou utilizar medicação prescrita (7,2%), pilates (5,6%) e automedicação (4,8%). A intensidade da dor foi semelhante à de outros estudos (média de 6,05±2,77). A maioria informou não ter impedimentos para realizar atividades (76%) e a incapacidade causada pela dor caracterizou-se como moderada (média de 29,46±18,87). A média de estresse percebido condiz com resultados de estudos nacionais (19,06±4,73). Conclusão: O conhecimento dessa realidade pode subsidiar o planejamento de políticas e implementação de estratégias que contribuam com a promoção da saúde dos trabalhadores e qualidade de vida no trabalho.
Social representation theory provides a framework for studying how scientific knowledge affects common sense and communication through inquiries into everyday discourse. This qualitative study examined social representations of chronic pain from 4 sources: North American newspapers; "Chronic Illness Cat" memes from the social media web site, Pinterest; video blogs on YouTube; and from a 2014 film, Cake, and interviews and comments concerning it. Using thematic analysis, we first identified social representations found in our 4 sources and others found in 1 or 2 of them. Second, we analyzed the sources for their rhetorical intentions. Vlogs directly and memes indirectly were first-person accounts, self-authorizing statements of the truth of chronic pain, whereas newspaper articles and the film were third-person accounts of pain, the differences between these perspectives affecting what was said. We conclude that the medium shapes the message.
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The analysis of discourses involves problems and choices related to the integration of quantitative and qualitative methodologies, the formalisation of qualitative analysis, the software used and the identification of the units of analysis. These are issues that can be solved considering the typology of discourses analysed and the topic under examination.We present results of research that examined the integration of two different methods of analysing data using the two computer programmes Alceste and NUD*IST. The corpus examined is made up of articles published in two leading news magazines about ‘the Di Bella affair’, which exploded in Italy at the end of the 1990s. The affair concerned an anti-tumour therapy introduced as an alternative to chemotherapy by Doctor Di Bella, but rejected by the Ministry of Health.This issue flared up in the mass media and public opinion seemed mainly to side with the Di Bella treatment. Our general hypothesis is that this affair gave rise to a conflict between ‘the reified universe’ – scientific and governmental institutions – and ‘the consensual universe’ – laymen, patients and their relatives. An important role was played by the mass media that inflamed the conflict at the same time as representing it. We suggest that this case is understandable only if viewed within the context of the Italian political, cultural and ideological situation.The description of the results stresses the usefulness of integrating the two methods of analysis since what emerges from one method serves to corroborate and clarify that which emerges from the other.
Structured interviews of 37 medical inpatients being treated with narcotic analgesics for pain showed that 32% of the patients were continuing to experience severe distress, despite the analgesic regimen, and another 41% were in moderate distress. Chart review suggested significant undertreatment with narcotics: meperidine in doses of 50 mg every 3 to 4 hours or less (if needed) was prescribed for 63% of the 37 patients; a dose of more than 75 mg was prescribed for only 1 patient. The average amount actually received per day by the patients was 90 mg. A questionnaire survey of 102 house staff physicians in two New York teaching hospitals showed considerable misinformation about meperidine. Many physicians underestimated the effective dose range, overestimated the duration of action, and exaggerated the dangers of addiction for medical inpatients receiving meperidine in a therapeutic dosage range. Physicians who exaggerated the dangers of addiction were more likely to prescribe lower doses of drugs, even for patients with terminal malignancy. The authors suggest that such misconceptions probably lead to undertreatment with narcotic analgesics, causing much needless suffering in medical inpatients.
Background. The variability in physician attitudes and goals for chronic pain relief and satisfaction with chronic pain management is unknown.Objectives. To provide quantitative data regarding the status of chronic pain management by Michigan physicians. To relate physician's goals for pain management to physician confidence, preferences, and satisfaction with their chronic pain care.Research Design. A prospective cohort study utilizing a survey with four chronic pain vignettes.Subjects. Three hundred and sixty-eight Michigan physicians who provide clinical care.Measures. Evaluate differences in chronic pain decision making based upon physician demographic characteristics, knowledge, and attitudes.Results. The respondents reported a high frequency of treating patients with chronic pain. However, many expressed generally low satisfaction and confidence in their treatment of chronic pain, as well as low goals for the relief of chronic pain. A large number of respondents selected the worst or a poor treatment option for the chronic pain vignettes. In particular, prescriptions of opioid analgesics were infrequent. Younger physicians and those with pain education were more likely to choose the best responses to the vignettes.Conclusion. Low pain relief goals and satisfaction with the management of chronic pain suggests the potential for its undertreatment. Our data highlight the variability in pain decision making and provide insight into the educational needs of physicians regarding chronic pain management.
Serge Moscovici first introduced the concept of social representations into contemporary social psychology nearly forty years ago. Since then the theory has become one of the predominant approaches in social psychology, not only in continental Europe, but increasingly in the Anglo-Saxon world as well. While Moscovici's work has spread broadly across the discipline, notably through his contributions to the study of minority influences and of the psychology of crowds, the study of social representations has continued to provide the central focus for one of the most distinctive and original voices in social psychology today. This volume brings together some of Moscovici's classic statements of the theory of social representations, as well as elaborations of the distinctive features of this perspective in social psychology. In addition the book includes some recent essays in which he re-examines the intellectual history of social representations, exploring the diverse ways in which this theory has responded to a tradition of thought in the social sciences which encompasses not only the contributions of Durkheim and Piaget, but also those of Lévy-Bruhl and Vygotsky. The final chapter of the book consists of a long interview with Ivana Marková, in which Moscovici not only reviews his own intellectual itinerary but also gives his views on some of the key questions facing social psychology today. The publication of this volume provides an essential source for the study of social representations and for an assessment of the work of a social psychologist who has consistently sought to re-establish the discipline as a vital element of the social sciences.
To date, social representations research in the field of health and illness has focused mainly on lay representations of health. In the context of the “New Public Health”, the more general concept of health (instead of the more reduced concept of curing illness) has become a major target for professional work. From this trend, the following research questions can be drawn: do health professionals hold a concept of health? If so, what is the major focus of such a concept? And does it include topics from the New Public Health discourse? Following a short review of the research into social representations of health, some preliminary results of a qualitative research study are presented. This study focused on representations of health held by two groups of professionals - general practitioners and nurses - both working in home care with elderly people in two German cities. The first results of this study found that, in both groups, different types of health concepts can be identified. In both groups, a strong reference was made to the World Health Organization definition. Among other concepts, a relative concept of health was held. The concepts are expressed with reference to the specific clientele of home-care work. The results are discussed with reference to the differences and overlaps with the other research on health concepts.
This article proposes a theoretical contribution to critical health psychology. Charles Sanders Peirce’s semiotics provide health psychology and related fields with an analytic that centers interest at the intersection where the co-constitution of reified categories occurs. I begin with the terms symptom and sign as used in medical contexts. Symptoms and signs can be reinterpreted, drawing on the Heideggerian notion of ‘attunement’, and upon Peirce’s semiotics. Next, I present Peirce’s concept of sign, with its triadic structure of object-representamen-interpretant. An understanding of pain as a sign in this sense is developed on this basis. The value of Peircian semiotics for a critical health psychology is illustrated with some examples drawn from a qualitative study. Pain is not only something of concern and the bearer of meanings, but a way of interpreting one’s situation. This semiotics of pain furthers the project, common to phenomenological and discursive approaches in health psychology and related fields, of studying the upsurge of meaning in speech and in other acts that co-constitute it.