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ORIGINAL RESEARCH ARTICLE
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,
Milano;
†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: lorenzo.montali@unimib.it.
§This paper is dedicated to the memory of Roberto
Cipriani.
Abstract
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
professionals.
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
involved.
Key Words. Pain; Health Care Professionals; Italy;
Qualitative Research; Social Representation
Introduction
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].
Method
Sample
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: http://www.tlab.it/en/presentation.
php) [47], which analyzes the structure of a text through
the same series of statistical tools used by the Alceste
(© Image, for more info: http://www.image-zafar.com/
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.
Results
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
(Doctor).
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
practice:
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
patients:
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
others:
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
itself:
Table 1 Themes, variables, weights, and lemmas of each cluster
CLUSTER N
CLUSTER 1 CLUSTER 2 CLUSTER 3 CLUSTER 4 CLUSTER 5
Weights (%) 27 17 39 10 8
Themes Pain
assessment
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
difficulties
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
Face
Attitude
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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
“imposition:”
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
(Nurse).
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
tasks.
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).
Discussion
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
experienced.
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
innovation.
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
pain.
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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
body.
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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