ACTA BIOMEDICA

Acta Biomed. - Vol. 86 - Suppl. 3 December 2015
Acta Biomed. - Vol. 86 - Suppl. 3 December 2015 | ISSN 0392 - 4203
ACTA BIOMEDICA
SUPPLEMENT
ATENEI PARMENSIS | FOUNDED 1887
Official Journal of the Society of Medicine and Natural Sciences of Parma
The Acta Biomedica is indexed by Index Medicus / Medline Excerpta Medica (EMBASE),
the Elsevier BioBASE
HEALTH PROFESSIONS (III-2015)
Free on-line www.actabiomedica.it
Pubblicazione trimestrale - Poste Italiane s.p.a. - Sped. in A.P. - D.L. 353/2003 (conv. in L. 27/02/2004 n. 46) art. 1, comma 1, DCB Parma - Finito di stampare December 2015
Mattioli 1885
Acta Bio Medica
Atenei parmensis
founded 1887
O F F I C I A L J O U R N A L O F T H E S O C I E T Y O F M E D I C I N E A N D N AT U R A L S C I E N C E S O F PA R M A
free on-line: www.actabiomedica.it
EDITOR IN CHIEF
Maurizio Vanelli - Parma, Italy
DEPUTY EDITORS
Loris Borghi - Parma, Italy
Marco Vitale - Parma, Italy
HONORARY EDITORS
Carlo Chezzi - Parma, Italy
Roberto Delsignore - Parma, Italy
Almerico Novarini - Parma, Italy
Giacomo Rizzolatti - Parma, Italy
EDITORIAL BOARD
Fernando Arevalo - Caracas, Venezuela Judy Aschner - Nashville, TN, USA
Michael Aschner - Nashville, TN, USA
Franco Aversa - Parma, Italy
Alberto Bacchi Modena - Parma, Italy
Salvatore Bacciu - Parma, Italy
Cesare Beghi - Varese, Italy
Stefano Bettati - Parma, Italy
Corrado Betterle - Padova, Italy
Saverio Bettuzzi - Parma, Italy
Mauro Bonanini - Parma, Italy
Antonio Bonati - Parma, Italy
Antonio Bonetti - Parma, Italy
Loris Borghi - Parma, Italy
David A. Bushinsky - Rochester, NY, USA
Ovidio Bussolati - Parma, Italy
Carlo Buzio - Parma, Italy
Ardeville Cabassi - Parma, Italy
Paolo Caffarra - Parma, Italy
Anthony Capone Jr. - Detroit, MI, USA Francesco Ceccarelli - Parma, Italy
Gian Paolo Ceda - Parma, Italy
Marco Colonna - St. Louis, MO, USA Paolo Coruzzi - Parma, Italy
Lucio Guido Maria Costa - Parma, Italy
Cosimo Costantino - Parma, Italy
LINGUISTIC ADVISOR
Rossana Di Marzio
Parma, Italy
Alessandro De Fanti - Reggio Emilia, Italy
Filippo De Luca - Messina, Italy
Giuseppe Fabrizi - Parma, Italy
Guido Fanelli - Parma, Italy
Vittorio Gallese - Parma, Italy
Livio Garattini - Milano, Italy
Mario J. Garcia - New York, NY, USA Geoffrey L. Greene - Chicago, IL, USA Donald J. Hagler - Rochester, MINN, USA
Rick Hippakka - Chicago, IL, USA
Andrew R. Hoffman - Stanford, CA, USA
Joachim Klosterkoetter - Colonia, Germany
Ingrid Kreissig - Heidelberg, Germany
Ronald M. Lechan - Boston, MA, USA
Annarosa Leri - Harvard, Boston, MA, USA
Nicola Longo - Salt Lake City, UT, USA
Wanyun Ma - Beijing, China
Marcello Giuseppe Maggio - Parma, Italy
Norman Maitland - York, United Kingdom
Gian Camillo Manzoni - Parma, Italy
Emilio Marangio - Parma, Italy
James A. McCubrey - Greenville, NC, USA
Tiziana Meschi - Parma, Italy
Mark Molitch - Chicago, IL, USA
Antonio Mutti - Parma, Italy
Giuseppe Nuzzi - Parma, Italy
Jose Luis Navia - Cleveland, OH, USA Donald Orlic - Bethesda, MD, USA Marc S. Penn - Cleveland, OH, USA Silvia Pizzi - Parma, Italy
Federico Quaini - Parma, Italy
Stephen M. Rao - Cleveland, OH, USA Luigi Roncoroni - Parma, Italy
Shaukat Sadikot - Mumbai, India
Simone Cherchi Sanna - New York, NY, USA
Leopoldo Sarli - Parma, Italy
Francesco Pogliacomi - Parma, Italy
Robert S. Schwartz - Denver, Colorado, USA
Anthony Seaton - Edinburgh,
United Kingdom
Mario Sianesi - Parma, Italy
Carlo Signorelli - Parma, Italy
Mario Strazzabosco - New Haven, CT, USA
Nicola Sverzellati - Parma, Italy
Maria Luisa Tanzi - Parma, Italy
Roberto Toni - Parma, Italy
Frederik H. Van Der Veen - Maastricht,
The Netherlands
Vincenzo Violi - Parma, Italy
Richard Wallensten - Solna, Sweden Ivana Zavaroni - Parma, Italy
Francesco Ziglioli - Reggio Emilia, Italy
EDITORIAL OFFICE MANAGER
Anna Scotti
Francesco Covino
Mattioli 1885 srl - Casa Editrice
Società di Medicina e ­­
Strada di Lodesana 649/sx, Loc. Vaio
Scienze Naturali
43036 Fidenza (PR), Italy
Office of the Faculty of Medicine
Tel. ++39 0524 530383
Via Gramsci, 14 - Parma, Italy
Fax ++39 0524 82537
Tel./Fax ++39 0521 033730
E-mail: [email protected] PUBLISHER
Mattioli 1885 srl Casa Editrice
Strada di Lodesana, 649/sx, Loc. Vaio
43036 Fidenza (PR), Italy
Tel. ++39 0524 530383
Fax ++39 0524 82537
E-mail: [email protected]
Health Professions
Acta Bio Medica
EDITOR EXECUTIVE
Leopoldo Sarli - Parma, Italy
DEPUTY EDITORS
Giovanna Artioli - Parma, Italy
(nursing topics)
Enrico Bergamaschi - Parma, Italy
(prevention topics)
Tiziana Mancini - Parma, Italy
(psychosocial topics)
Angelo Mastrillo - Bologna, Italy
(diagnostic and rehabilitative topics)
EDITORIAL BOARD
Rodolfo Brianti - Parma, Italy
Rachele La Sala - Parma, Italy
Enrico Pasanisi - Parma, Italy
Bui Vu Binh - Hanoi, Vietnam
Roberto Lusardi - Bergamo, Italy
Giovanni Pavesi - Parma, Italy
Adriana Calderaro - Parma, Italy
Claudio Macaluso - Parma, Italy
Vincenza Pellegrino - Parma, Italy
Luca Caricati - Parma, Italy
Tiziana Mancini - Parma, Italy
Diletta Priami - Bologna, Italy
Franco Carnevale - Montreal, Canada Sergio Manghi - Parma, Italy
Cristina Rossi - Parma, Italy
Matteo Castaldo - Parma, Italy
Gemma Mantovani - Parma, Italy
Annavittoria Sarli - Milano, Italy
Luigi Cavanna - Piacenza, Italy
Ardigò Martino - Bologna, Itly
Loredana Sasso - Genova, Italy
Francesco Chiampo - Parma, Italy
Giuliana Masera - Piacenza. Italy
Chiara Scivoletto - Parma, Italy
Cosimo Costantino - Parma, Italy
Maria Messerli Ernst - Berna,
Alberto Spisni - Parma, Italy
Renato Costi - Parma, Italy
Switzerland
Angelo Stefanini - Bologna, Italy
Pham Huy Dung - Hanoi, Vietnam
Nadia Monacelli - Parma, Italy
Laura Tibaldi - Piacenza, Italy
Guido Fanelli - Parma, Italy
Federico Monaco - Bergamo, Italy
Stefano Tomelleri - Bergamo, Italy
Paola Ferri - Modena, Italy
Maria Mongardi - Bologna, Italy
Annalisa Tonarelli - Parma, Italy
Laura Fieschi - Parma, Italy
Cecilia Morelli - Parma, Italy
Giancarlo Torre - Genova, Italy
Chiara Foà - Parma, Italy
Mamadou Ndiaye - Dakar, Senegal
Laura Fruggeri - Parma, Italy
Nicola Parenti - Imola, Italy
LINGUISTIC ADVISOR
Rossana Di Marzio
Parma, Italy
EDITORIAL OFFICE MANAGER
Anna Scotti
Francesco Covino
Mattioli 1885 srl - Casa Editrice
Società di Medicina e ­­
Strada di Lodesana 649/sx, Loc. Vaio
Scienze Naturali
43036 Fidenza (PR), Italy
Office of the Faculty of Medicine
Tel. ++39 0524 530383
Via Gramsci, 14 - Parma, Italy
Fax ++39 0524 82537
Tel./Fax ++39 0521 033730
E-mail: [email protected] PUBLISHER
Mattioli 1885 srl Casa Editrice
Strada di Lodesana, 649/sx, Loc. Vaio
43036 Fidenza (PR), Italy
Tel. ++39 0524 530383
Fax ++39 0524 82537
E-mail: [email protected]
Index
Volume 86 / Suppl. 3-2015
Mattioli 1885
srl­- Strada di Lodesana 649/sx
43036 Fidenza (Parma)
tel 0524/530383
fax 0524/82537
www.mattioli1885.com
Direttore Generale
Paolo Cioni
Direttore Scientifico
Federico Cioni
Direttore Commerciale
Marco Spina
Formazione/ECM
Simone Agnello
Project Manager
Natalie Cerioli
Massimo Radaelli
Editing Manager
Anna Scotti
Editing
Valeria Ceci
Foreign Rights
Nausicaa Cerioli
Distribuzione
Massimiliano Franzoni
Health Professions
Special Issue (III-2015)
Original article: Nursing
165 C. Foà, T. Mancini, R. Prandi, L. Ghirardi, F. De Vincenzi,
M.C. Cornelli, P. Copelli, G. Artioli
Meeting the needs of cancer patients: is there a need for an
organizational change?
174 R. La Sala, C. Foà, G. Paoli, M. Mattioli, E. Solinas, G. Artioli,
D. Ardissino
Multi-dimensional nursing form: a novel means of approaching
nurse-led secondary cardiology prevention
183 R. La Sala, K. Boninsegni, A. Tani, A. Rasi, B. Ricci, L. Sansovini,
G. Scarpelli, G. Artioli, L. Sarli
A cross selectional survey in a critical care: the job satisfaction and
functioning team of the health professionals
Original article: Midwifery
189 E. Tinelli, S. Vecchi, S. Illari
Analysis of obstetric care variables associated with caesarean section in
low-risk pregnancy patients
EXECUTIVE COMMITEE OF
THE SOCIETY OF MEDICINE
AND NATURAL SCIENCES
OF PARMA
Honorary President
Loris Borghi
President
Maurizio Vanelli
Past-President
Almerico Novarini
General Secretary
Maria Luisa Tanzi
Treasurer
Riccardo Volpi
Members
A. Mutti
O. Bussolati
P. Muzzetto
G. Ceda
P. Salcuni
G. Cervellin
L. Sarli
G. Ceresini
V. Vincenti
N. Florindo
V. Violi
G. Luppino
M. Vitale
A. Melpignano
December 2015
Original article: Professional education
194 V. Cremonini, P. Ferri, G. Artioli, L. Sarli, E. Piccioni, I. Rubbi
Nursing students’ experiences of and satisfaction with the clinical
learning environment: the role of educational models in the simulation
laboratory and in clinical practice
205 P. Lo Biondo, N. Avino, E. Podavini, M. Prandelli
Peer Tutoring and Clinical Stage: analysis of experience and potential
applications in the First Level Degree Course in Nursing, section of
Desenzano Del Garda
212 G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
Being an overseas student at the Faculty of Medicine and Surgery of
the University of Parma: the perceptions of students from Cameroon
Original article: Health care organization
223 T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
The dynamics of social capital and health
A U T H O R
G U I D E L I N E S
Acta BioMedica is the official Journal of the Society of Medicine and
Natural Sciences of Parma. The Journal publishes Original Articles,
Commentaries, Review Articles, Case Reports of experimental and
general medicine. The manuscript must be submitted using the journal
web site: http://www.actabiomedica.it
The Editorial Office will forward the text to the Editor-in-Chief, Prof.
Maurizio Vanelli (University of Parma).
For any information please refer to:
Acta BioMedica – Editorial Office
Dr. Anna Scotti
Mattioli 1885 srl
Strada di Lodesana 649/sx, Loc. Vaio - 43036 Fidenza (PR) - Italy
E-mail: [email protected] - Fax: 0039-(0)524-82537
The Journal does not hold itself responsible for statements made by contributors or for loss or damage of mailed manuscripts. They should be accompanied by an undertaking that they are submitted to this Journal only. Papers must be submitted in English. Papers are accepted on the understanding that they may be subject to editorial revision.
All Original Articles are subject to review and authors are urged to be
brief. Long papers with many tables and figures may require shortening
if they are to be accepted for publication. All manuscripts should include
a total text word count and an abstract word count on the cover page. Total text word count does not include title page, figure legends, references,
or tables. Only under exceptional circumstances will Original Articles
longer than 5500 words be considered, and under no circumstances will
abstracts greater than 250 words be published. Editorials and Reviews are
normally invited contributions but suitable papers may be submitted to
the Editor for consideration for this purpose. The presentation of Case
Reports should be as short as possible. Reports of co-existence of two diseases or conditions without proof of causal relationship are discouraged.
Letters to the Editor should not exceed 600 words of text, one figure or
table and up to six references. Because space limitation, publication of
submitted Letters will depend on priority rating.
TITLE PAGE must contain:
• a concise informative title
• author(s) names
• department or institution where work was done
• name and address of author to whom correspondence about the manuscript and request for reprints should be referred, as well as fax, E-mail
and telephone number
• a running title of no more than 40 characters.
Be certain to list the FAX number and E-mail of the corresponding author on the title page. All correspondence will be by E-mail and web site
only.
MANUSCRIPT should be typed in 12-point type and double spacing
should be used throughout. It should carry an abstract of not more than
250 words including 4 paragraphs labeled: Background and aim of the
work, Methods, Results, and Conclusions. Below the abstract provide 310 key words that will assist indexers in cross-indexing the article. Paragraphs to be set in a smaller type should be marked with an “s” (small) in
the left hand margin. Avoid footnotes; when essential they are numbered
consecutively and typed at the foot of the appropriate page.
ILLUSTRATIONS. It is the authors’ responsibility to obtain permission (from the author and copyright holder) to reproduce illustrations,
tables, etc. from other publications. Photographs and graphics should
be sent as high resolution files: not less than 300 d.p.i. and with a base
of the same size as a column of the Journal (8 cm). A letter of permission must accompany all photographs when there is a possibility of
identification. Authors will pay for colour illustrations. Present rate for
a full page colour illustration is about $ 600-1200. Final quotation will
be given by the publisher. Legends should be typed on a separate
“word”document.
TABLES should be numbered consecutively with Arabic numerals. Type
each table on a separate document, together with a brief caption. We do
not welcome large tables of unanalysed data.
REFERENCES should be numbered consecutively in the order in which
they appear in the text. References cited only in tables or in legends to figures should be numbered in accordance with the sequence established by
the first identification in the text. The list of references should be typed
in numerical order and indicate: authors’ names (all authors when six or
less; when seven or more list only the first three and add “et al.”); article
title, name of the Journal (abbreviated as in Index Medicus), publication
year, volume and first and last page numbers. Example:
Rizzato G, Marazzini L. Thoracoabdominal mechanics in elderly men. J
Appl Physiol 1970; 28: 457-60.
If the reference is concerning a book, give authors’ names, full title, name
and address of publisher and publication year. Personal communications
should not be included in the references, but may be cited in the text in
parentheses.
COPYRIGHT. Please include a signed release of copyright to ACTA BIO
MEDICA SOCIETY OF MEDICINE AND NATURAL SCIENCES OF PARMA
with your text. Include the title of the article being submitted, as well as
the date. Include the signature of coauthors.
The corresponding author must certify that the submitted manuscript is
an original article and that he is able to prove this originality if required
from the Referees. Without this declaration the manuscript will not be
considered.
GALLEY PROOF. Unless indicated otherwise, galley proofs are sent to
the first author and should be returned without delay. Alterations to galley proofs, other than those due to printer’s error, are charged to the author. Accepted and rejected manuscripts are retained for six months after
publication or rejection, then destroyed.
REPRINTS. Reprints are available at cost if they are ordered when the
proof is returned. Order form and a price list are sent with the galley
proofs; payment must be made with the order.
NOTICE TO SUBSCRIBERS
ACTA BIO MEDICA SOCIETY OF MEDICINE AND NATURAL SCIENCES OF
PARMA is published four-monthly. Individual annual subscription for
2015 is 35,00 Euro in Italy, 45,00 Euro outside Italy. Institutional subscription is 45,00 Euro in Italy, 45,00 Euro outside Italy. The publisher accepts no responsibility for replacing Journal issues unless notified of nonreceipt within 5 months of issue date. Payment should be made to the
publisher: Mattioli 1885 srl, Strada di Lodesana 649/sx, Loc. Vaio, 43036
Fidenza (PR), Italy, Tel. 0039-(0)524-530383, Fax 0039-(0)524-82537,
E-mail: [email protected]
COPYRIGHT
© 2015 ACTA BIO MEDICA SOCIETY OF MEDICINE AND NATURAL
SCIENCES OF PARMA. All rights reserved. Accepted papers become the
permanent property of ACTA BIO MEDICA SOCIETY OF MEDICINE AND
NATURAL SCIENCES OF PARMA and no part may be reproduced, stored in
a retrieval system or transmitted in any form or by any means without the
prior permission of both the author and the publisher.
Registrazione del Tribunale di Parma n° 253 del 21/7/1955
La banca dati viene conservata presso l’editore, che ne è titolare. La rivista viene spedita in abbonamento; l’indirizzo in nostro possesso verrà utilizzato per l’invio di questa o di altre pubblicazioni scientifiche.
Ai sensi dell’articolo 10, legge 675/96, è nel diritto del ricevente richiedere la cessazione dell’invio e/o l’aggiornamento dei dati in nostro possesso.
La testata fruisce dei Contributi Statali diretti di cui alla legge 7 agosto 1990, n. 250
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 165-173
© Mattioli 1885
Original article: nursing
Meeting the needs of cancer patients: is there a need for an
organizational change?
Chiara Foà1, Tiziana Mancini2, Rossella Prandi3, Lida Ghirardi1, Franca De Vincenzi4,
Maria Cristina Cornelli1, Patrizia Copelli5, Giovanna Artioli5
1
3
University Teaching Hospital, Parma, Italy; 2 Department of Literature, Arts, History and Society, Parma University, Italy;
Primary Care Trust, Modena, Italy; 4 Primary Care Trust, Parma, Italy; 5 Hospital of Santa Maria Nuova (Reggio Emilia), Italy
Abstract. As stated in the literature the most important needs of cancer patients are not adequately meet.
Improving information, communication and education provided have not led to incisive changes in the organizational model of the oncology departments. The study contributes to this direction, by planning an
“Integrated Operating Point” (I.O.P.) dedicated to cancer patients and their relatives in Italy. 42 Some professionals, patients and relatives were involved and 42 of them participated in focus group/or interviews. Results
of thematic content analysis allow us to sketch out some key elements that I.O.P. should have in order to
support cancer patients and their families. Integration of services, continuity of care, and cooperation between
professionals involved are key elements that might qualify such organizational development.
Key words: needs, cancer, patient, relative, professional, focus group, interview
Introduction
As stated in the literature the most important
needs of cancer patients are not adequately meet (1-6).
In particular, the continuity of care (7-10) and psychological support (11-14) are missing from clinical
agendas. Improving information, communication and
education provided to patients and their families, even
if it is necessary, have not led to incisive changes in
the organizational model of the oncology departments
(15-16). Indeed the integration of several services for
people with cancer needs to be enhanced, in order to
integrate resources and meet to patients and family
needs (1, 3).
The need of a strong integration of services at
all levels clearly emerged from some previous experiences of a Single Point of Access (S.P.A.) realized in
8 Italian Regions and dedicated to people with frailty,
chronic illness, addiction (17). S.P.A. has the following
functions: access reception, collection of recommen-
dations, guidance and management of demand, direct
activation of services in response to simple needs and
integration with local offices and hospital services network. The most important activities are: needs analysis,
recording of access, informative answers and guidance,
signalling complex cases with the transmission at a
Multidimensional Assessment Unit. The integration
“of all that is behind the single door access system” is
considered one of the biggest advantages of the experience conducted (17).
Moreover a randomized Italian clinical trial (18)
showed that the establishment of Points of Information and Support (P.I.S.) can reduce the psychological
distress of patients and increase their satisfaction. The
P.I.S. offers a library for patients, relatives and friends
with internet access. It is managed by a nurse specializing in oncology, specifically trained to respond to requests from patients or to address them, if necessary,
to the psychologist or oncologist. Even activity data of
the National Foundation G. Ghirotti (19) confirm val-
166
ue and importance assigned to the Points of Counselling for cancer patients. It helps the person and family
to get out of loneliness and disorientation. There are
many international internet sites providing information and services related to cancer cure and counselling. Among those some have institutional roles or
are public healthcare programs or projects as World
Health Organization (WHO, 20), and National Cancer Institute’s Cancer Information Service (NCI’s CIS,
21). Others are risen by initiative of patients and their
families, as People Living With Cancer supporting the
Cancer Call Centre (PLWC, 22).
More are funded and supported by multidisciplinary associations of professionals and organizations, as
American Psychosocial Oncology Society (APOS, 23)
or private funds, as PLWC (22).
Some of them are worldwide, such as the American Society of Clinical Oncology (ASCO, 24) a world
be known oncological society, and the WHO (20), that
provide full and detailed information about prevention
worldwide. Programs and initiatives about tobacco
risks, physical training, diet, expositions to infections
and radiations are included.
Others are European, such as Telematic Services
in Cancer (Telescan, 25) that is among the first European internet services about cancer research, treatment
and widespread of information completely online for
patients, families, professionals and researchers. Others important Services and society are national, such
as APOS (23), the Cancer Call Centre (22) and the
NCI’s CIS (21). For more than 35 years NCI’s CIS
has been providing scientific information to patients,
families, friends, and healthcare professionals about
risk factors, symptoms, diagnosis and other topics.
The APOS (23) is the only multidisciplinary organization in the United States researching psychological, social and behavioral aspects of cancer. Il has
the goal of increasing the level of attention for health
professionals and for public engagement about cancer
patient’s care, for innovative methods for diagnosis and
treatment. The main aim is to create a network of patients and caregivers including psychiatrists, psychologists, nurses, social assistants and experts in managing
all problems related to cancer.
The study presented here attempts to make a contribution in this direction, planning the opportunity to
C. Foà, T. Mancini, R. Prandi, et al.
open an “Integrated Operating Point” (I.O.P.) dedicated to cancer patients and their relatives. Through
a qualitative research conducted in a region of North
of Italy this study has analyzed the representations of
patients, relatives, social and health professionals and
volunteers about an hypothetical Integrated Operating
Point (I.O.P).
Accordingly to action-research perspective (26),
the goal of the qualitative research was to improve the
participation of who directly involved, identifying the
problems and the possible solutions in collaboration
with the researchers (27).
Methods
Participants
The research has been conducted in a region of
the center of Italy. Heath Cancer Services’ professionals, members of Cancer Associations, cancer patients
and relatives took part in this study, for a total of 42
participants (76.2% women). All of them gave their
informed consent.
Four of the patients were women and among
them 3 had breast cancer and 1 had a sarcoma. The
relatives were 5 (3 women), the oncologists were 10 (6
women), the nurses were 7 (3 women), the volunteers
of Cancer Associations were 8 (7 women) and the social care assistants were 6 women. One psychologist
(woman), one social worker (woman) and one general
practitioner (man) took also part in the survey.
Instrument and data analysis
Patients, relatives, physicians, nurses, social
care assistants and volunteers participated in 6 focus
groups. To outgo the numerical inadequacy for focus
group criteria, three face to face in-depth interviews
were conducted with the psychologist, social worker
and general practitioner.
Focus group/ interview sessions were conducted
by researchers in order to explore:
a) the representation of the integrated operating
point (I.O.P) for information and orientation of the
people affected by cancer and their families. In par-
Integrated Operating Point to meet the cancer patient’s needs
ticular aims, functions and needs that the I.O.P. could
meet and its organization/location were identified;
b) the representation of patients/relatives who could
benefit from the I.O.P;
c) the representation of ideals operators of the
I.O.P;
d) the evaluation in term of advantages and disadvantages of I.O.P.
In order to boost the effective pooling of resources
from patients, families, social and health professionals and volunteers, it was examined whether and how
I.O.P. could be able to improve health and community
services skills to answer cancer patients and their family needs as to guarantee the continuity of care.
The average time span of focus groups/interviews
was 60 minutes. All focus group/interview sessions
were audio-recorded, transcribed verbatim and processed through an analysis of thematic content. The
analysis consisted in decomposing the text into sentences and in their classification in synthetic cores or
sub-categories (27). Five trained assistants independently coded the needs and the solutions to meet them
into different dimensions. The inter-rater agreement
was 96%. Quotations offered by participants are provided in order to illustrate the emerged theme that has
been then connected in order to synthesize participants’ representation of I.O.P.
Results
1. Identity of the Integrated Operational Point (I.O.P.)
for the reception and orientation of the people affected by
cancer and their families
1.1 Aims, functions and the needs that I.O.P. could meet
All participants imagine the I.O.P. as a well organized and coordinated context, in which both patients and their families can find answers to a variety
of problems that accompany cancer disease. Among
them, there are both supportive and informative functions. For example, the general practitioner underlined
the importance to give a waste range of information:
“patients often ask me who should go to get answers to some
problems that are often trivial for us, but an insurmountable obstacle for them [...]. Often they are not aware of
167
economic support, or waive the requirement to obtain it,
because the path is not properly explained” (General practitioner).
For other professionals and relatives the I.O.P. has
to be aimed to offer:
“Help, guidance and support to develop and maintain skills and contact with the family, providing palliative care at home and addressing the issue of death and of
mourning” (Health and social care assistant 6). “Surely
this must be a center point of listening for emergencies. If
the center does not have a doctor, for the medical emergency,
the connection with the hospital could offers […] a doctor
who can give information” (Relative 5).
According to family members, I.O.P. could satisfy
the need of psychological support (offering active listening and empathy). Furthermore, through a good information, professionalism and flexibility of the organization, it may act against the problem of complicated
bureaucracy. “A point of reference, a center where there is
someone in whom, at any time of need […].I dare to call,
just call, to ask also about bureaucratic practice”(Relative 1).
Volunteers agreed that the I.O.P. can offer “All
kinds of support. The I.O.P., which is an integrated approach, could support the person and his family for needs
never been talked about before [...] that’s why we need
more resources, because the support is heterogeneous: psychological, informational, therapeutic, in various fields”
(Volunteer 1).
General practitioner, nurses, social worker and
health and social care assistants, stressed the importance of strengthening a network of heterogeneous
services necessary to cancer patients’ support. The
opening of I.O.P. would have the advantage of concentrating the existing forces in a single meeting point,
saving resources: “It could put together all the energies,
avoiding the wastes, as at present, and it would optimize many things: cost, time, stress, everything! […] in
order not to leave the family alone in managing complex
problems”(Health and social care assistant 6). In particular volunteers emphasize the importance of the “continuity of care” (Volunteer 3, Volunteer 7)
1.2 Organization and location
For I.O.P. participants must be easy to access and
visible in the territory. Nurses and oncologists, for
convenience, recommended to set it in the hospital (in
168
contiguity with the Day Hospital), while health and
social care assistants, relatives and the social worker
suggested that I.O.P. should have a place outside of it
in the territory: “I think it is difficult to put it by the Day
Hospital, as it has happened” (Social worker).
Some interesting hypotheses regarding the structure of the I.O.P were found. For example, among
these views: “the service could be open 24 hours a day”
(Health and social care assistant 4), “through the callcenter “(Oncologist 8),”with telephone availability during the night “(Relative 5). I.O.P. is a place where “both
patients and family members can access to receive information before hospitalization” (Psychologist), but also, in
a second time, “where you can find moments of dialogue
and exchange and where you can also take part of patients’
groups” (Psychologist). An interesting perspective underline that I.O.P. has not to be “another structure to
which [the patient] goes to , but a structure that goes to the
patient: this is much more difficult!”(Volunteer 4). “It is
I.O.P. that has to go to those in need” (Relative 3).
Nurses, oncologists, volunteers and the social
worker agreed that I.O.P. should provide a suitable
space, with rooms to ensure confidential talks and not
simply a one-stop front-line: “Certainly a very private
space, small, but friendly” (Social worker).
2. Representation of patients/relatives who could benefit
from I.O.P.
All participants believe that I.O.P. could be useful
to all of cancer patients and their families (according
to oncologists), either those from the hospital or those
coming from their homes (according to nurses). Patients and family members may contact I.O.P. when
patients are discharged or when they are still in hospital: “No matter the target [...] whether call someone already discharged, or the relative of a person still hospitalized” (Nurse 6).
In particular, I.O.P could help people to manage the disease and its consequences along with cancer pathway. People need to be reached at the time of
diagnosis -”go to people as much as possible when people
find out they have cancer: a time of big bewilderment!”
(Volunteer 4)- or to be informed after their first visit
with the oncologist about the opportunity of making
use of I.O.P. support -After the visit [the doctor] could
C. Foà, T. Mancini, R. Prandi, et al.
say: <Look, now, if you need support, you can go to this
Centre> (Patient 2). I.O.P. activity could be extended
to family members as to entire groups of patients: “to
create groups could be an interesting thing [...] giving the
possibility of a space where patients and family members
can meet and discuss what would be useful” (Psychologist).
According to family members, all citizens should
still be informed of the existence of I.O.P: “A general
information to the citizenry, because someone fortunately
does not have that need, at this moment of life, but however they know the channels” (Relative 5).
3. Representation of ideals operators of the I.O.P.
Identifying ideal matching figures who can work
at I.O.P., participants gave particular importance either to operators’ personal characteristics or professionals roles and functions.
3.1 Personal characteristics
All participants stressed that I.O.P. operator must
possess certain fundamental trait of personality. He/
she has to be “helpful, balanced, tolerant, and friendly”
(Volunteer 5). The ideal figure should have good knowledge and training in medical and in social-psychological field as well, to create a trust relationship in order
to meet the needs, and to direct the person “tactfully”
(Relative 1).
Ideal professionals have to be prepared and competent and also know the person discharged from the
hospital. “They must be familiar with the physical and
family situations (Patient 4). They have to be “people
specialized in many things [...] able to be a point of reference” (Volunteer 1) “with both professional skills and
human qualities [...]” (Relative 3) fulfilling “the [I.O.P.]
needs to have a very well prepared and selected professionals” (Volunteer 4).
3.2 Professional roles
Professional roles suggested by participants as a
point of reference are various: psychologists, oncologists, nurses, social workers and volunteers, but also
a plastic surgeon, beautician, physiotherapist, speech
pathologist and radiation oncologist: “Many professionals […] and not only oncologists and nurses. I think
those figures are essential to understand certain emergen-
Integrated Operating Point to meet the cancer patient’s needs
169
cies and fundamental things”(Relative 5) as well as “a person who knows about work issues, laws, assistance such as
volunteers” (Health and social care assistant 6). The psychologist imagines nurses as a reference figure, even
for self-help groups. The general practitioner, instead,
reaffirms the need to have a psycho-oncologist: “Certainly I.O.P. requires competent people who have become a
point of reference for patients and their families. It could
be a psycho-oncologist, that mainly abroad is part of the
team, monitoring and guiding the patient in the course of
treatment “(General practitioner). “It looks good to have a
nurse, a physician and a psychologist in order to answer all
of the questions”(Nurse 7).
For all of the participants however I.O.P. should
be managed by a multidisciplinary team that has developed a strong capabilities to guide and support: “I
expect, especially with respect to such a program [...] that
nurses should be part of the operating unit, as supporting
figures [...] and psychologists as references. I wonder if, in
addition to these figures institutionally part of the operating unit, should be important to consider other figures [...]
such as members of associations [...] if you want to set up a
supporting activity to finalize, and optimize the relationship not only by a healthcare point of view, but by a more
global perspective, in a view of global care “(Oncologist 1).
Even patients said that within I.O.P. should be
“present operators of the hospital and the territory together,
to integrate the different aspects of care and strengthen
the network” (Patient 4), with a “psycho-social more than
medical training” (Patient 3).
In particular, nurses emphasized the center’s capacity to be a point of connection that could compensate the lack of a network, promoting the continuity of
care: “When the patient goes away from [the hospital] is
definitely useful!” (Nurse 1).
Even volunteers assess the possibility that I.O.P.
might serve as reference center by the ability to integrate resources: “I see this very positive, because of the
integrated resources, [...] the fact is that a lost person needs
points of reference, not only as people support, but also as
places where to go” (Volunteer 1).
All patients are favorable to the establishment of
I.O.P. considering it useful at the Cancer Center, because it is more convenient for patients, much visible
and accessible: “I think it’s really a nice project!” (Patient
2).
For some families, I.O.P. would be advantageous
to maintain a high quality of care services dedicated to
cancer patients: “In my opinion, yes, I.O.P. is very useful, because the city has many good qualities in the medical
field and this would be an additional excellence” (Relative
1). Even for the Health and social care assistant, the
opening of I.O.P. is viewed positively because it is a
place where those in need can find help and a psychosocial support: “I.O.P. is the only way to help people in
need! Just that! (Health and social care assistant 4) and it
allows the person to get out of the state of loneliness
caused by the disease: “I.O.P. opens communication and
allows to live less completely alone (Health and social care
assistant 1).
4. Evaluation of I.O.P. and potential prospects
4.2 Obstacles to the implementation of I.O.P.
Is in the opinion of health and social care assistants that fragmentation of the various services not
working on a network level and therefore not adopting
a systemic point of view constitute hard obstacles to the
foundation of an I.O.P. “There is still little work of network; currently there are services, but each one takes care of
their own piece and is hard to put all of the pieces together
“(Health and social care assistant 6). Furthermore quite
often patients themselves are those who do not want
to talk about the disease, because of “Fear and shame”
(Health and social care assistant 1); “They does not speak
about cancer and then they avoid coming to ask” (Health
and social care assistant 4). It follows that people who
could access I.O.P. services would not be the people
4.1 Advantages and strengths of I.O.P.
According to the almost unanimous opinion of
family members, nurses, general practitioners, oncologists, health and social care assistants, patients and
volunteers, the establishment of an I.O.P. is deemed
very important to inform and give acceptance: “It is
important that all those involved in cancer patients be
aware of the existence of I.O.P. and that they give the correct information for its use [...]. Well, maybe in the future,
this could become a useful tool for other types of patients
too” (General practitioner); “Definitely helpful!” (Nurse 7);
“An information point “(Oncologist 8).” “It could be a point
of reference!” (Health and social care assistant 4).
170
who have a real need. For these people the access to the
center is much more difficult: “The only doubt I have
is that I.O.P. may be accessed by people who know they
have this type of disease and are therefore well aware. The
problem is to facilitate access to people that don’t’ know or
who choose not to know for several reasons” (Health and
social care assistant 6). Although volunteers do not assume that, through I.O.P., it is possible to reach those
who actually need and in particular “the cancer patient
discharged and no longer hospitalized for chemotherapy or
continuous therapy. It is difficult for the patient himself to
take the initiative and go looking for someone who can
help him/her [...] it is not enough to wait for them to come
and ask, because they won’t do it (Volunteer 1).
Social worker’s evaluation of I.O.P. is quite positive: “Well, it could be very interesting” (Social worker),
while some concerns were expressed by the psychologist on the clarity of the tasks and functions: “The inclusion of IOP within the Oncology Day Hospital, could
be perceived as intrusive; so roles and tasks must be coordinated and designed at its best “(Psychologist). It is also
important to highlight the risk of confusion between
associations, Oncology Day Hospital and I.O.P.: “The
risk is that patients get confused “(Psychologist). Finally,
nurses, as well as families, glimpsed the actual implementation of I.O.P. complicated given the small financial resources: “How much money do we have?” (Nurse 5).
Discussion
The aim of this study was to evaluate, through an
action-research study, whether an Integrated Operative Point (I.O.P.) -meant for supporting and orienting
Figure 1. Integrated Operating Point
C. Foà, T. Mancini, R. Prandi, et al.
cancer patients and families- could provide answers to
cancer patients’ needs. Such needs often appear in this
study, as well as in literature, not yet satisfied.
Interpretation of thematic contents emerged from
the focus groups allows us to sketch out some key elements that I.O.P. should have in order to support
people affected by cancer disease and their families.
These were: integration of services, continuity of care, and
cooperation between professionals involved (figure 1).
I.O.P. will help to develop a useful and “virtuous”
integration between health and social services given the
output of participants of focus groups and interviews.
According to Gröne and Garcia-Barbero (28) the “[Integrated care] is a concept bringing together inputs, delivery, management and organization of services related
to diagnosis, treatment, care, rehabilitation and health
promotion […] to improve services in relation to access, quality, user satisfaction and efficiency”.
The design of an integrated operating point
(I.O.P.) offers an invaluable opportunity to rethink and
re-organize the provision of complex care needs, in response to different scenarios of disease (17). The answer
to health problems, through implementation of social
interventions, makes use of a defined national legal
reference (Legislative Decree n. 229/1999) which describes the social-health integration as a set of “activities to meet, through a complex process of care, health
needs of the person, requiring unitary health care and
social protection measures” (29). The integration has,
however, also a professional meaning to improve health
outcomes and to protect the more vulnerable social
groups, improving knowledge about the utilities’ location and the access to correct information. The integration of all operators is therefore essential to avoid the
Integrated Operating Point to meet the cancer patient’s needs
sense of abandonment and insecurity, experienced by
patients and their families (30). Although the regulations and guidelines of socio-health program highlight
the importance of an integrated approach to care, are
well known the difficulties of integration management
at the local level for what concerns: the collaboration
among institutions in implementing the network of
services; the definition of integrated care pathways useful to vicarious repetitions and/or overlapping of individual interventions and communication among professionals as a result of low use of specific tools integration (17). Only interdisciplinary and inter-professional
integration may provide a complex care, sharing tasks
and responsibilities and a rational use of resources, including the economic aspect.
In the opinion of those interviewed, especially
nurses and volunteers I.O.P. could represent an important organizational way to promote the continuity
of care. More precisely, the definition and adoption of
integrated care pathways are perceived as a prerequisite
for achieving the continuity of care, a goal set out forcefully to design services able to keep responses in step
with the times. The continuity of care is also one of the
most sensitive indicators of the functions of a health
service as it adds to the traditional concept of “cure”
the idea of “taking care” within different levels of care
network divided between hospital and community (30).
According to the findings the location and the
organization of I.O.P. would ensure the continuity of
contacts with patients and family and attending the
course of disease management. The Italian socio-sanitary contexts, however, highlight critical issues related
to both the widespread difficulties in ensuring continuity of care at the time of hospital discharge, and to
ensure the continuity of taking over at later stages. As
mentioned by some participants, the activation of I.O.P.
does not mean giving birth to another “health facility”,
but it means to fix an organizational model oriented
to the individuality of contacts between health services
and citizens and aimed to protect and take charge of
patients care needs (17).
The continuity of care must have procedures and
instruments for its ordinary realization (30). In this
sense, cooperation among departments, hospital and
territory associations, patients and their families is a
key strategy of the operating point of an integrated
171
structure that forms the active cooperation aimed at
overcoming the present fragmentation in a synergistic
way and to ensure the appropriateness of care pathways. To re-organize the provision of assistance in accordance with an I.O.P. means, in effect, to direct the
person within a complex system, simplifying the information and reducing the bureaucracy (17). Specifically,
it means to facilitate the comprehension, processing
histories of disease, offering an experience exchange
and shared resources, providing the interconnection
with the network of services (31). The public health is
moving from an organizational model focused on the
supply, to an integral model, based on a request: citizens are headed to care pathways by specific reference
structures which in turn direct those to the appropriate
services (30).
According to the representations of the participants of the present study, the I.O.P. has different
functions: orientation/information and facilitation of
access to services. I.O.P. constitutes one of the possible integrations between social and health professions,
a deputy to intercept the need to ensure continuity of
care. The participants had the mandate to discuss the
feasibility of opening an I.O.P. In this sense, the discussion has highlighted important issues which still
remain open, such as: need to manage problems during
the weekend; possible availability of telephone counselling during services’ closing times to handle problems
who do not require access to the hospital services; need
to have spaces dedicated to listening; an easy access and
traceability of I.O.P. in the territory or in a hospital
placement in contiguity with the Day Hospital.
The hypothesis of a concrete opening of a I.O.P.
is based on the possibility of relying on a precise set
of professional resources that, in a interdisciplinary and
synergistic way, breaks through the cultural barriers
that often demarcate individual professionals (17) In
particular, in several focus groups of this study there
were debates about roles of institutional reference,
pointing out that some barriers must be torn down
as soon as the function of listening on a single point
of reference was identified. The cultural reference is a
current culture that sees specialists -identified as ideal
figure- as the only professional problem-solver (e.g.:
the psycho -oncologists). It was noted also that would
be “extremely important to insist and urge the sensi-
172
tivity of general practitioners in relation to knowledge
of different settings [...] through tighter relationships
with institutions” (30). Several participants highlighted
the important role of reference for directing and coordinating actions, paths, strategies to be deployed to
meet the complex needs of cancer patients. The study
of Bellentani et al. (17) have led to differentiate the case
manager, as responsible clinician, that coincides with
the general practitioner, and the manager for the “care “
that, in close relation with the responsible clinician, has
the role of “director” and follows the implementation
of care project, interconnecting all of the resources. The
emerging continuity of care is provided by the “carepathway manager”. Often it is a nurse or a social worker, based on the prevalence of health, or family- relationship needs. This nurse, monitoring of the multiple
needs of the person, is also the “plotter” that links into
the network of community care through the activation
of voluntary or self-help groups. However, in oncology
and palliative care, the problems are so complex that
the whole team has put in a position of listening and
dialogue. This is why it is believed that the staff dedicated to I.O.P., as well as those working in oncology
and palliative care, should be specifically trained and
motivated and that the psychologist is not considered
as the only figure to delegate listening and decoding of
need The reference team does not imply a necessarily
stable staff. The I.O.P., from time to time depending
on the individual case, is able to integrate different aspects of care. The systemic perspective is designed to
overcome the fragmentation of services that still shows
discrepancy between social and health care, including
hospitals and local associations of patients, whereas it
would be important to promote really cooperative relationships, strengthening the services network (30).
In sum, the research project launched to the interlocutors of the focus groups the challenge to rethink the answer to the organizational change to meet
cancer patients’ needs, according to continuity and
integration. Starting from the formulation of organizational models able to respond to changing needs
of health care settings, social welfare and people who
work there (32), the I.O.P. is positioned as a system
of functional integration between services, professionals and users (17) characterized by health and social
integration, by interconnections between hospital and
C. Foà, T. Mancini, R. Prandi, et al.
territory, with a view to sharing of assumptions and
practices (33) where the intensification of integration
and professional collaboration required to start, first,
the construction of relations before the organization
networks (34).
Limitation
Focus groups are expected to capture experiences
and opinions from many people in a short amount of
time with facilitating effect because of the inclusion of
patients, relatives and professionals who have similar
experiences (35). Limitations of the present research
are the restricted number of each focus group participants and the convenience sampling here used. Moreover the focus group are not always balanced between
genders. In the coming future research it will be also
interesting to testify whether different results would be
gleaned from different patients and professionals and
to compare results obtained by mixed method analysis.
Acknowledgment
The research is supported by the University Hospital of
Parma and by Department of Psychology –University of Parma
within the course “The Psychosocial Research for Health Professions”.
References
1. Foà C, Copelli P, Cornelli MC, De Vincenzi F, Fanfoni R,
Ghirardi L, Artioli G, Mancini T. Meeting the needs of cancer patients: identifying patients’, relatives’ and professionals’ representations. Acta Bio Medica For Health Professions
2014; 85(3): 41-51.
2. Beesley V, Eakin E, Steginga S, Aitken J, Dunn J, Battistutta
D. Unmet needs of gynecological cancer survivors: implications for developing community support services. PsychoOncology 2008; 17(4):392-400.
3. Copelli P, Foà C, Devincenzi F, et al. I bisogni del paziente
con patologia oncologica e le risposte negli statuti di servizi
sanitari dedicati e associazioni [The needs of patients with
oncological disease and the responses offered by statutes of
dedicated health services and associations] AIR 2011; 30(1):
24-33.
4. Iconomou G, Viha A, Koutras A, Vagenakis AG, Kalofonos
HP. Information needs and awareness of diagnosis in pa-
173
Integrated Operating Point to meet the cancer patient’s needs
tients with cancer receiving chemotherapy: A report from
Greece. Palliative Medicine 2002; 16: 315-321.
5. Jefford M, Tattersall MHN. Informing and involving cancer patients in their own care. The Lancet Oncology 2002;
3(10): 629-637.
6. Rutten LJF, Arora NK, Bakos AD, Aziz N, Rowland J. Review: Information needs and sources of information among
cancer patients: a systematic review of research (1980-2003).
Patient Education and Counseling 2005; 57(3): 250-261.
7. Arantzamendi M, Kearney N. The psychological needs of
patients receiving chemotherapy: an exploration of nurse
perceptions. Eur J Cancer Care 2004; 13(1): 23-31.
8. V ivar CG, Canga N, Canga AD, Arantzamendi M. The
psychosocial impact of recurrence on cancer survivors and
family members: a narrative review. J Adv Nurs 2009; 65
(4): 724-736.
9. Walton LM, Reeve J, Brown PM, Farquhar CM. Gynaecologic cancer patients’ needs and experiences of supportive
health services in New Zealand. Psycho-Oncology 2010;
19(2): 201-8.
10. Marlow B, Cartmill T, Cieplucha H, Lowrie S. An interactive process model of psychosocial support needs for women
living with a diagnosis of breast cancer. Psycho-Oncology
2003; 12: 319-330.
11. Alfieri SM, Carver CS, Artoni MF, et al. An exploratory
study of social support, distress, and life disruption among
low-oncome Hispanic women under treatment for early
stage breast cancer. Health Psychology 2001; 20(1): 41-46.
12. Helgeson VS, Cohen S. Social support and adjustment to
cancer: reconciling descriptive, correlational, and intervention research. Health Psychology 1996; 15: 135-148.
13. Nelles WB, McCaffrey RJ, Blanchard CG, Ruckdeschel JC.
Social support and breast cancer: a review. J Psychosoc Oncol 1991; 9: 21-34.
14. Talley A, Molix L, Schlegel RJ, Bettencourt A. The influence of breast cancer survivors’ perceived partner social support and need satisfaction on depressive symptoms: a longitudinal analysis. Psychol Health 2010; 25(4): 433-49.
15. Baile WF, Aaron J. Patient-physician communication in
oncology: past, present, and future. Curr Opin Oncol 2005;
17: 331-335.
16. Fallowfield L, Jenkins V. Current concepts of communication skills training in oncology. Recent Results Cancer Res
2006; 168: 105-12.
17. Bellentani MD, Inglese SA, Banchero A. Punto unico di accesso, presa in carico, continuità assistenziale. Monitor. Elementi di analisi e osservazione del sistema salute. Trimestrale dell’Agenzia nazionale per i servizi sanitari regionali
2008; Anno VII, 21( 2): 7-22.
18. Passalacqua R, Caminiti C, Campione F et al. Prospective,
multicentrer, randomized trial of a new organizational modality for providing information and support to cancer patients. J Clin Oncol 2009; 27(11): 1794-1799.
19. Teresi N. I dieci anni del centro di ascolto. Gigi Ghirotti Noti-
zie/Notiziario 2009 - Retrived from: http://www.fondazione
ghirotti.it/index.phppption=com_content&view=article
&id=158:i-dieci-anni-del-centro-di-ascolto&catid=68:noti
ziario&Itemid=185.
20. World Health Organization (WHO), Cancer Prevention.
http://www.who.int/cancer/prevention/en/
21. National Cancer Institute’s Cancer Information Service (NCI’s
CIS), Retrived in from http://www.cancer.gov/aboutnci.
22. Cancer Call Centre-0861-ask-now in People Living With
Cancer (PLWC), Retrived from http://plwc.org.za/blog/
2009/11/25 /cancer-call-centre.
23. American Psychosocial Oncology Society (APOS), Retrived from http://www.apos-society.org/
24. American Society of Clinical Oncology (ASCO), Retrived
from http://www.asco.org/ Homepage
25. Telematic Services in Cancer (Telescan), Retrived from
http://telescan.nki.nl/ Homepage
26. Lewin, K. Action research and Minority problems, Journal
of Social Issues 1946; (2): 34-46.
27. Meyer J. Using qualitative method in health related action
research. BMJ 2000; 320: 178.1.
28. Gröne O, Garcia-Barbero M; WHO European Office for
Integrated Health Care Services. Integrated care: a position
paper of the WHO European Office for Integrated Health
Care Services. Int J Integr Care 2001; 1: e21.
29. Decreto legislativo 229/1999. Retrived from: www.parlamento.it/parlam/leggi/deleghe/99229dl.htm.
30. ACP (Associazione Cure Palliative) – Onlus. Retrieved
from: http://curepalliative.valeostudio.it.
31. Di Nicola P. (Ed,) Rete: metafora dell’appartenenza. [Network:
metaphor of belonging]. Franco Angeli Editore, Milano, 1998.
32. Di Nicola P. Reti in movimento, politica della prossimità e
società civile. [Moving networks; policy of proximity and
civil society] Sociologia e politiche sociali 2004; 7(1): 5-175.
33. The Quality of Health Care Received by Older Adults,
Santa Monica, Calif.: RAND Corporation, RB-9051, 200a.
As of January 2008; Retrived from www.rand/org/pubs/research_briefs/RB9051
34. Folgheraiter F.Nel welfare delle relazioni (oltre I Piani di
zona). [In welfare relationships (over the Area Plans)] Centro Studi Erikson, Trento. 2006.
35. F lynn KE, Jeffery DD, Keefe FJ, Porter LS, Shelby RA,
Fawzy MR, Gosselin TK, Reeve BB, and Weinfurt KP.
Sexual Functioning Along the Cancer Continuum: Focus Group Results from the Patient-Reported Outcomes
Measurement Information System (PROMIS™). PsychoOncology 2011; 20(4): 378-386.
Accepted: 18 november 2015
Correspondence:
Chiara Foà
University Teaching Hospital, Parma, Italy
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 174-182
© Mattioli 1885
Original article: nursing
Multi-dimensional nursing form: a novel means of
approaching nurse-led secondary cardiology prevention
Rachele La Sala1, Chiara Foà1, Giorgia Paoli1, Maria Mattioli1, Emilia Solinas1,
Giovanna Artioli2, Diego Ardissino1
1
University Teaching Hospital, Parma, Italy; 2 Santa Maria Nuova Hospital, Reggio Emilia, Italy
Abstract. Background and Aim: Secondary prevention after an acute coronary syndrome (ACS) has proved to be
effective in patients with coronary heart disease, and is strongly recommended by the international guidelines.
However, there is a lack of widespread secondary preventive programmes in real-world clinical practice, even
though it has been shown that these can be successfully conducted by nurses. Method and Results: We have designed a multicentre randomised trial involving patients with ACS in which nurses will fully coordinate secondary
prevention in the intervention arm using a multidimensional nursing form after attending ad hoc teaching sessions.
Key words: multidimensional nursing form, narrative, acute coronary syndrome, secondary prevention
1. Introduction
1.1. Cardiovascular disease: risk factors and therapeutic
compliance
Acute coronary syndrome (ACS)
Coronary heart disease (CHD) is a chronic degenerative condition, and patients who have recovered
from an acute coronary syndrome (ACS) are at high
risk of developing recurrent events (1). Secondary prevention has proved to be efficacious in patients with
CHD and is strongly recommended by all international cardiovascular societies, but the Euroaspire I, II,
III and IV surveys have revealed a gap between the
guidelines and real-world clinical practice, and a lack
of widespread preventive programmes (2).
It has been demonstrated that nurses can be successfully involved in cardiovascular disease (CVD)
prevention programmes aimed at reducing risk factors, modifying lifestyles, and monitoring adherence
to pharmacological therapy, which are more likely to
be effective in reducing CV risks over time (3-7).
Cardiovascular risk factors
Secondary prevention programmes can only have
a limited effect on unmodifiable cardiovascular risk
factors such as genetics, and so we concentrate on the
classic, additive and psychococial factors that can be
modified. There is considerable scientific evidence that
classic risk factors such as diabetes (8-11), arterial hypertension (12-15), cigarette smoking (16-23), dyslipidemia (24, 28) and obesity (29-35) play a pathogenetic
role in the development of CVDs, and that controlling
or even reducing them has a beneficial effect on major
clinical outcomes. Additive risk factors include physical activity (36-41), diet (42) and alcohol consumption
(43, 44) for which there is a well-documented physiopathological rationale that may be involved in the
reoccurrence of CVDs, but less concrete scientific evidence that they influence major clinical outcomes than
Supporting agencies: This study was funded by Regione Emilia-Romagna
Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention
in the case of classic risks. Finally, there is increasing
evidence (45) that psychosocial factors such as anxiety
(46-50), depression (45, 51-59), anger and hostility
(60-64), type A (65) and type D personality patterns
(66, 67), self-efficacy (68-70), and isolation and a lack
of social support (71-75) correlate with the onset and
course of ischemic heart disease.
Adherence to pharmacological therapy and lifestyle changes
Therapeutic compliance requires the active collaboration of patients, who should be involved in the
consensual planning and implementation of treatment
(76). Various studies have highlighted the importance
of not only modifying the risk factors described above,
but also taking the prescribed drugs because it has been
shown that this has a positive impact on the prognosis
and reoccurrence of CVDs.
However, it is well known that there is a considerable lack of compliance to both (77). According to the
WHO (78), this is due to a multiplicity of socio-economic (e.g. indigence, little health knowledge); socio-demographic and clinical (age, gender, stress), psycho-social
(the perception of disease, beliefs concerning health
and/or medicine), and treatment-related factors (the
number and doses of drugs, and their side effects (7981). Others (77) suggest that it can be attributed to intentional and non-intentional factors, the former, which
often lead to treatment discontinuation, are characterised by a patient’s conscious decision (a subjective conviction that the drugs are inefficacious or toxic; rational
non-adherence), problems related to the presumed cost
of treatment, insufficient exchange of information between physician/nurse and patient (defaulting), or an
emotional response to the disease and is treatment; the
latter by a patient simply “forgetting” to follow a prescription he or she explicitly wishes to respect.
1.2 Nurses’ programmes for implementing therapeutic
compliance
The involvement of nurses is a key element in the
primary and secondary prevention of CVDs (82-84).
Nurse-led health education programmes increase patients’ awareness and understanding of a disease and its
treatment, and improve their expectations concerning
175
their health (85), thus favouring treatment compliance
(5-7, 86, 87). Even relatively brief, individualised interventions (88, 89) based on multiple methods (e.g. direct
contact, printed booklets and the use of audiovisual aids)
can lead to self-care behaviours (90), and may improve
outcomes (91,92) even in the long term (93).
One major challenge when trying to improve
health results in ACS patients is to implement multidimensional, structured nursing care pathways oriented towards therapeutic continuity (94, 95) because the
limitations of many programmes include the partial
nature of their goals (e.g. concentrating on only one or
just a few classic risk factors) and the lack of structured
healthcare instruments that demonstrate their efficacy
in terms of outcomes. For example, the Global Secondary Prevention Strategies to Limit Event Recurrence
After Myocardial Infarction study (6) does not propose a nursing care model for managing patients during follow-up or describe the changes in nursing care
activities generated by the training. The RESPONSE
study (7) did not specify whether or not the healthcare professionals had participated in a special training programme, and therefore does not describe what
the content of such a programme might have been or
what method was used. Finally, the paper describing in
the principal results of the EUROACTION study (5)
does not mention the training of nurses, the nursing
model and instruments used, or collaboration with or
other professionals such as a psychologist or dietician.
2. The ALLiance for sEcondary PREvention after an
episode of acute coronary syndrome (ALLEPRE) trial
1.1 Study design
The ALLEPRE trial is an Italian multicentre,
randomised and controlled study designed to compare
the benefit offered by a structured, intensive and fully
nurse-led intensive secondary prevention intervention
programme (ISPP) with that offered by standard care
in a high-risk population of ACS patients admitted
to cardiological centres in the Region of Emilia-Romagna. The patients are randomised 1:1 by means of
a centralised interactive voice response system under
the responsibility of the Study Coordinator and the
Principal Investigator of each centre. The two primary
176
endpoints are the difference in the degree of adherence
to goals concerning risk factors, lifestyle modifications
and pharmacological therapy between the start of the
study and month 24, and the occurrence of major adverse events (all-cause mortality, non-fatal re-infarction or non-fatal stroke) after five years of follow-up.
In order to create an ISPP that is consistent in all
participating centres, the nurses underwent a preliminary centralised training programme provided by a multidisciplinary team of medical, nursing and psychological experts coordinated by the Training and Continuous
Education Centre of Parma University Hospital with the
support of ad hoc paper-based teaching material. The programme, which was repeated four times In order to allow
the creation of small groups and promote better interactions, consisted of three 8-hour sessions held on consecutive days during which the professional nurses proposed by the participating centres (6-10 per centre, 50%
from a hospital setting, 50% from a community setting)
were trained in secondary CVD prevention, and how to
take multi-dimensional and structured responsibility for
it using appropriate communication strategies aimed at
reducing risk factors, modifying lifestyles and improving
adherence to prescribed pharmacological therapy.
1.2 Multi-dimensional nursing form (MNF)
During the training sessions, the nurses were
trained how to use an innovative multi-dimensional
nursing form MNF, an interactive guide to patient assessment and education aimed at promoting all three
of the above objectives. Based on the latest scientific
evidence and the Cardiovascular Secondary Prevention Guidelines (10), it was prepared by a multi-disciplinary team of nurses, cardiologists and psychologists
from the University Teaching Hospital of Parma.
The MNF is the working instrument that will be
used for all of the nine interviews planned for the patients in the study’s experimental arm: a pre-discharge
interview will be followed by others after one, three,
six, 12, 18, 24, 36 and 48 months. It is based on a “cure”
and “care” nursing paradigm that affectively integrates
the bio-clinical and psycho-socio-relational dimensions of nursing also by means of the use of NANDA
language (97) and a cardiovascular narrative approach
(98). The model considers CVD in the three senses of
R. La Sala, C. Foà, G. Paoli, et al.
“illness”, “disease” and “sickness”, and uses quantitative
and qualitative data collected by means of narrativebased interviews in order to make a multi-dimensional
assessment of each patient with the aim of arriving
at a more profound understanding of their and their
caregivers’ (the phase of nursing ascertainment). The
model of care is based on a nurse/patient/caregiver coconstruction of the therapeutic plan and personalised
education in order to favour behaviours oriented towards reaching the ALLEPRE study endponts.
In addition to a socio-demographic part that includes the patient’s personal details and CV medical
history (the number of CV events at the time of admission), the MNF is divided into five areas, each of
which is covered during all of the nine interviews:
− A) the assessment of classic risk factors (diabetes,
smoking, hypertension, dyslipidemia, and obesity);
− B) the assessment of additive risk factors (physical activity, diet, and alcohol consumption);
− C) the assessment of psycho-social risk factors
(anxiety, depression, anger/hostility, type A and
D personality patterns, self-efficacy, and social
support);
− D) the assessment of adherence to CV drugs
(aspirin, anti-aggregant, ACE inibitor/sartan,
statin, beta-blocker) and other drugs (e.g. antidepressant and anxiolytic), as well as the intentional (insufficient information, incredulity and
irrationality) and non-intentional (forgetting)
of therapeutic non-compliance;
− E) the nursing ascertainment by means of a narrative interview.
Areas A-D has fields for the ascertainment of CV
risk factors, the definition of selected nursing diagnoses
and related objectives, and the definition of the educational interventions required. Area E consists of a grid
with the stimulus questions that guide the narrative interview, which is essential for completing the assessment
of aspects relating to disease perception, strategies for
coping with the critical event and the difficulties perceived by the patient in relation to the prescribed treatment (e.g. What are the difficulties you may encounter
once you return home? What strategies will help you to
confront the disease and its treatment?).
Figures 1-6 shows some sample extracts of the
MNF.
Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention
Figure 1. Socio-anagraphic area (example)
Figure 2. A Area: Typical risk factors (example)
Figure 3. B Area: Additional risk factors (example)
Figure 4. B Area: Pshyco-social risk factors (example)
177
178
R. La Sala, C. Foà, G. Paoli, et al.
Figure 5. D Area: Pharmacological compliance (example)
Figure 6. E Area: Assessment through Narrative Nursing (example)
3. Conclusions and clinical implications
The ALLEPRE trial is the first to test a structured,
fully nurse-led, intensive secondary prevention programme based on a broad multidisciplinary network of
primary care and hospital nurses in a large population
of high-risk ACS patients in Emilia-Romagna (sufficiently representative of Italy as a whole) by evaluating
its clinical efficacy on major endpoints and its feasibility and impact on the regional healthcare system.
The MNF is an innovative instrument aimed at
maximising the great potential contribution that nurses can make to CV secondary prevention. Based on
a multi-disciplinary, it allows a multi-dimensional assessment that takes into account both bio-clinical and
psycho-socio-relational factors, thus responding to
four major healthcare needs by:
1. orienting the assessment of risk factors and
treatment compliance in ACS patients by means of
standardised parameters based on scientific evidence;
2. using narrative interviews to identify diseaserelated problems and factors predicting non-compliance, thus allowing the personalisation of subsequent
interventions;
3. maintaining continuity of care between hospital
and home with the aim of improving health outcomes
by increasing treatment compliance and reducing the
incidence of re-infarctions and re-hospitalisations as a
result of multiple follow-up visits;
4. overcoming the known limitations of concentrating exclusively on bio-clinical aspects and ignoring
psycho-socio-relational factors, by evaluating the efficacy of the instrument itself in terms of its effects on
nursing practice in various operational contexts.
Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention
Last but by no means least, the inclusion of the
MNF in a 5-year clinical trial will make it possible
to assess whether the patients treated using the form’s
underlying model of integrated care will lead to better
health outcomes than those achieved using traditional
standards of care.
References
1. Fox KA, Carruthers KF, Dunbar DR, Graham C, Manning
JR, De Raedt H, Buysschaert I, Lambrechts D, Van de Werf
F. Underestimated and under-recognized: the late consequences of acute coronary syndrome (GRACE UK-Belgian
Study). Eur Heart J 2010; 31: 2755-2764.
2. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyörälä
K, Keil U; EUROASPIRE Study Group. Cardiovascular
prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009; 373(9667): 929-40.
3. The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of
Cardiology (ESC). ESC Guidelines for the management of
acute myocardial infarction in patients presenting with STsegment elevation. Eur Heart J 2012; 33: 2551-2567.
4. Clark AM, Hartling L, Vandermeer B, et al. Meta-analysis:
secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143: 659-72.
5. Wood DA, Kotseva K, Connolly S, et al for EUROACTION Study Group. Nurse-coordinated multidisciplinary,
family-based cardiovascular disease prevention programme
(EUROACTION) for patients with coronary heart disease
and asymptomatic individuals at high risk of cardiovascular
disease: a paired, cluster-randomised controlled trial. Lancet
2008; 371(9629): 1999-2012.
6. Giannuzzi P, Temporelli PL, Marchioli R, Maggioni AP,
Balestroni G, Ceci V, Chieffo C, Gattone M, Griffo R, Schweiger C, Tavazzi L, Urbinati S, Valagussa F, Vanuzzo D;
GOSPEL Investigators. Global secondary prevention strategies to limit event recurrence after myocardial infarction: results of the GOSPEL study, a multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network.
Arch Intern Med 2008; 168(20): 2194-204.
7. Jorstad HT, von Birgelen C, Alings AM, Liem A, van
Dantzig JM, Jaarsma W, Lok DJ, Kragten HJ, de Vries K,
de Milliano PA, Withagen AJ, Scholte Op Reimer WJ, Tijssen JG, Peters RJ. Effect of a nurse-coordinated prevention
programme on cardiovascular risk after an acute coronary
syndrome: main results of the RESPONSE randomised trial.
Heart 2013; 99(19): 1421-30.
8. Norhammar A, Malmberg K, Ryden L, et al. Under utilisation of evidence-based treatment partially explains for the
unfavourable . Eur Heart J 2004; 25: 1880-90.
9. Schnell O, Schäfer O, Kleybrink S, Doering W, Standl E,
179
tter W. Intensification of therapeutic approaches reduces
O
mortality in diabetic patients with acute myocardial infarction: the Munich registry.; Munich registry. Diabetes Care
2004; 27(2): 455-60.
10. ACCF/AHA Practice Guideline. Circulation 2013; 128: e
240-e 327.
11. Gaede P1, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. See comment in PubMed Commons below. N Engl J Med 2003; 348(5): 383-93.
12. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R.
Age-specific relevance of usual blood pressure to vascular
mortality: a meta-analysis of individual data for one million
adults in 61 prospective studies. Prospective Studies Collaboration. Lancet 2003; 361(9362): 1060.
13. INternational VErapamil SR Trandolapril STudy. Retrived
from https://clinicaltrials.gov/ct2/show/NCT00133692.
14. Liu L, Zhang Y, Liu G, Li W, Zhang X, Zanchetti A. The
Felodipine Event Reduction (FEVER) Study: a randomized
long-term placebo-controlled trial in Chinese hypertensive
patients. FEVER Study Group. J Hypertens 2005; 23(12):
2157-72.
15. Vasan RS. Leip MG, Evans JC, O’Donnell CJ, Kannel WB,
Levy D. Impact of high-normal blood pressure on the risk
of cardiovascular disease. New Engl J Med 2001; 345: 12911297.
16. MERIT-HF Study Group. Effect of metoprolol CR/XL
in chronic heart failure: Metoprolol CR/XL Randomised
Intervention Trial in-Congestive Heart Failure (MERITHF). Lancet 1999; 353(9169): 2001-2007.
17. Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery
disease: Randomised, double-blind, placebo-controlled,
multicentre trial (the European study). Lancet 2003; 362:
782-788.
18. Godtfredersen I, Prescott E. Smoking reduction, smoking
cessation, and incidence of fatal and non-fatal myocardial
infarction in Denmark 1976-1998: A pooled cohort study. J
Epidemiol Commun H 2003; 57: 412-416.
19. Meyers DG, Neuberger JS, He J. Cardiovascular Effect of
Bans on Smoking in Public Places: A Systematic Review
and Meta-Analysis. J Am Coll Cardiol 2009; 54(14): 12491255.
20. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart
disease: A systematic review. JAMA 2003; 290: 86-97.
21. Yusuf S. Two decades of progress in preventing vascular disease. Lancet 2002; 360: 2-3.
22. Gerber Y, Rosen LJ, Goldbourt U, Benyamini Y, Drory Y.
Smoking status and long-term survival after first acute myocardial infarction a population-based cohort study. J Am
Coll Cardiol 2009; 54: 2382-2387.
23. Hamm CW et al. Esc guidelines for the management of
acute coronary syndromes in patients presenting without persistent st-segment elevation: The task force for the
management of acute coronary syndromes (acs) in patients
180
presenting without persistent st-segment elevation of the
european society of cardiology (esc). Eur Heart J 2011; 32:
2999-3054.
24. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of
dietary fatty acids and carbohydrates on the ratio of serum
total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin
Nutr 2003; 77(5): 1146-55.
25. Cholesterol Treatment Trialists’ (CTT) Collaboration,
Baigent C, Blackwell L, Emberson J, Holland LE, Reith C,
Bhala N, Peto R, Barnes EH, Keech A, Simes J,Collins R.
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants
in 26 randomised trials. Lancet 2010; 376(9753): 1670-81.
26. Cholesterol Treatment Trialists’ (CTT) Collaboration,
Fulcher J, O’Connell R, Voysey M, Emberson J, Blackwell
L, Mihaylova B, Simes J, Collins R, Kirby A, Colhoun H,
Braunwald E, La Rosa J, Pedersen TR, Tonkin A, Davis B,
Sleight P, Franzosi MG, Baigent C, Keech A. Lancet 2015;
385(9976): 1397-405.
27. American Diabetes Association. Dyslipidemia Management in Adults With Diabetes. Diabetes Care 2004; 27(1):
s68-s71.
28. American Diabetes Association. Standards of Medical Care
in Diabetes-2015: Summary of Revisions. Diabetes Care
2015; 38: 1 S4.
29. Jensen mK, Chiuve SE, Rimm eB, De-thlefsen C, Tjonneland A, Joensen AM, Overvad K. Obesity, behavioral lifestyle factors, and risk of acute coronary events. Circulation
2008; 117: 3062-3069.
30. Mehta L, Devlin W, mccullough Pa, O’Neill WW, Skelding KA, Stone GW, Boura Ja, Grines CL. Impact of body
mass index on outcomes after percutane-ous coronary intervention in patients with acute myocardial infarction. The
American journal of cardiology 2007; 99: 906-910.
31. Martin JL, Jia G, Martin SS, Shapiro TA, Herrmann Hc,
Dibattiste PM, Topol EJ, Moliterno DJ. The relationship
of obesity to ischemic outcomes following coronary stent
placement in contemporary prac-tice. catheterization and
cardiovascular interventions. Official journal of the Soci-ety
for Cardiac Angiography & Interven-tions 2006; 67: 563570.
32. Buettner HJ, Mueller C, Gick M, Fer-enc M, Allgeier J,
Comberg T, Werner Kd, Schindler C, Neumann FJ. the
impact of obesity on mortality in ua/non-st-segment elevation myocardial infarction. European heart journal 2007; 28:
1694-1701.
33. Nigam A, Wright RS, Allison TG, Wil-liams BA, Kopecky
SL, Reeder GS, Mur-phy JG, Jaffe AS. Excess weight at
time of presentation of myocardial infarction is associated
with lower initial mortal-ity risks but higher long-term risks
includ-ing recurrent re-infarction and cardiac death. International journal of cardiology 2006; 110: 153-159.
34. Kadakia MB, Fox CS, Scirica BM, Mur-phy SA, Bonaca
MP, Morrow DA. Central obesity and cardiovascular outcomes in patients with acute coronary syndrome: observa-
R. La Sala, C. Foà, G. Paoli, et al.
tions from the merlin-timi 36 trial. Heart 2011; 97: 17821787.
35. Das SR, Alexander KP, Chen AY, Pow-ell-Wiley TM, Diercks DB, Peterson ED, Roe MT, De Lemos Ja. Impact
of body weight and extreme obesity on the pres-entation,
treatment, and in-hospital out-comes of 50,149 patients
with st-segment elevation myocardial infarction results from
the ncdr (national cardiovascular data reg-istry). Journal of
the American College of Cardiology 2011; 58: 2642-2650.
36. Giada F, Carlon R, Biffi A, Agostoni P, Anedda A, Belardinelli R, Bettini R, Caru B, D’andrea L, Delise P, De
Francesco A, Fattirolli F, Guglielmi R, Guiducci U, Notaristefano A, Pelliccia A, Penco M, Perticone F, Thiene
G, Vona M, Zeppilli P. Consensus statement of multisocietary task force--prescription of physical exer-cise in the
cardiological environment (first part). Monaldi archives for
chest disease = archivio monaldi per le malattie del tora-ce
/ Fondazione clinica del lavoro, irccs (and) istituto di clinica
tisiologica e malat-tie apparato respiratorio, Universita di
Napoli, secondo ateneo 2007; 68: 13-30.
37. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss
P, Foody JM, Franklin B, Sanderson B, Southard D. Core
com-ponents of cardiac rehabilitation/second-ary prevention programs: 2007 update: a scientific statement from the
american heart association exercise, cardiac reha-bilitation,
and prevention committee, the council on clinical cardiology; the councils on cardiovascular nursing, epidemiology
and prevention, and nutrition, physical activity, and metabolism; and the ameri-can association of cardiovascular
and pulmonary rehabilitation. Circulation 2007; 115: 26752682.
38. Smith SC, Jr., Allen J, Blair SN, Bonow RO, Brass LM,
Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz
Hm, Mo-sca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert Ka. Aha/acc guidelines for secondary prevention for
patients with coronary and other atherosclerotic vas-cular
disease: 2006 update: endorsed by the national heart, lung,
and blood insti-tute. Circulation 2006; 113: 2363-2372.
39. Suaya JA, stason WB, Ades PA, Normand SL, Shepard DS.
Cardiac re-habilitation and survival in older coronary patients. Journal of the American College of Cardiology 2009;
54: 25-33.
40. Arthur Hm, smith Km, Kodis J, mcK-elvie r. a controlled
trial of hospital versus home-based exercise in cardiac patients. Medicine and science in sports and exer-cise 2002;
34: 1544-1550.
41. Dimmeler S, Zeiher AM. Exercise and cardiovascular
health: Get active to “ak-tivate” your endothelial nitric oxide
syn-thase. Circulation 2003; 107: 3118-3120.
42. Barzi F, Woodward M, Marfisi RM, Tavazzi L, Valagussa F,
Marchioli R. Medi-ter myocardial infarction: results from
the gissi-prevenzione trial. European journal of clinical nutrition 200; 57: 604-611.
43. Mukamal KJ, Conigrave KM, Mittleman MA, Camargo
CA Jr, Stampfer MJ, Willett WC, Rimm EB. Roles of
drinking pattern and type of alcohol consumed in coronary
Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention
heart disease in men. N Engl J Med. 2003; 348(2): 109-18.
44. Costanzo S, Di Castelnuovo A, Donati MB, Iacoviello L,
De Gaetano G. Alcohol consumption and mortality in patients with cardiovascular disease: a meta-analysis. J Am
Coll Cardiol. 2010; 55(13): 1339-47.
45. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, &
Kubzansky LD. The Epidemiology, pathophysiology, andmanagement of psychosocial risk factorsin cardiac practice.
The emergingfield of behavioral cardiology. Journal of the
American College of Cardiology 2005; 45(5): 637-651.
46. Sirois BC, Burg MM . Negative emotions and coronary
heart disease. A review. Behav Modif 2003; 27: 83-102.
47. Lesperance F, Frasure-Smith N. Negative emotions and
coronary heart disease: getting to the heart of the matter.
Lancet 1996; 347: 414-415.
48. Moser DK, Dracup K. Is anxiety early after myocardial infarction associated with subsequent ischemic and arryhytmic events? Psychosomatic Medicine 1996; 58: 395-401.
49. Sullivan MD , LaCroix AZ, Spertus JA, Hecht J. Five-year
prospective study of the effects of anxiety and depression in
patients with coronary artery disease. American Journal of
Cardiology 2000; 86: 1135- 1111-1139.
50. MacMahon KM, Lip GYH. Psychological factors in heart
failure: a review of the literature. Arch Intern Med 2002;
162: 509-516.
51. Carney RM , Blumenthal JA, Catellier D, Freedland BerkmanLF, Watkins LL, Czajkowski SM , Haynan AS. Depression as a risk factor for mortality after myocardial infarction. Am J Cardiol 2003; 92: 1277-81.
52. Frasure-Smith N, Lesperance F. Reflections on depression
as a cardiac risk factor. Psychosomatic Medicine. 2005; 67
Supplement 1: S19-S25.
53. Frasure-Smith N, Lesperance F, Ginette G, Masson A, Juneau M, Talajic M, Bourassa MG. Social support, depression, and mortality during the first year after myocardialinfarction. Circulation 2000; 101: 1919-24.
54. Barth J, Schumacher M, Herrmann-Lingen C. Depression
as a risk factor for mortality in patients with coronary heart
disease: A meta-analysis. Psychosomatic Medicine 2004;
66(6): 802-813.
55. Van Melle JP, de Jonge P, Spijkerman TA , Tijssen JGP,
Ormel J, van Veldhuisen DJ, van den Brink JH, van den
Berg MP. Prognostic association of depression following
myocardial infarction with mortality and cardiovascular
events: A metaanalysis. Psychosomatic Medicine 2004;
66(6): 814-822.
56. Hippisley-Cox J, Fielding K, Pringle M. Depression as a
risk factor for ischemic heart disease in men: population
based case-control study. Brit Med J 1998; 316: 1714-1719.
57. Maier K, Chatkoff D, Burg MM . Cardiopatia coronarica
e depressione: prevalenza, prognosi, fisiopatologia e trattamento. In E. Molinari, A. Compare & G. Parati (Eds.),
Mente e cuore. Clinica psicologica della malattia cardiaca
Milano: Springer-Verlag, 2007: 93-107.
58. DiMatteo MR, Lepper HS, Croghan TW. Depression is
a risk factor for noncompliance with medical treatment:
181
Meta-analysis of the effects of anxiety and depression on
patient adherence. Archives of Internal Medicine 2000;
160(14): 2101-2107.
59. Ziegelstein RC , Fauerbach JA, Stevens SS et al. Patients
with depression are less likely to follow recommendations
to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med 2000; 160: 1818-1823.
60. Rozanski A, Blumenthal JA, Kaplan J.Impact of psychological factors on the pathogenesis of cardiovascular disease
and implications for therapy. Circulation 1999; 99(16):
2192-2217.
61. Williams JE, Paton CC , Siegler IC et al. Anger proneness predicts coronary heart disease risk: prospective analysis from the Atherosclerosis Risk In Communities (ARIC )
study. Circulation 2000; 101: 2034-2039.
62. Krantz DS , McCeney MK. Effects of psychological and
social factors on organic disease: A critical assessment of
research on coronary heart disease. Annual Review of Psychology 2002; 53: 341-369.
63. Hardy JD, Smith TW. Cynical hostility and vulnerability to
disease: social support, life stress, and physiological response
to conflict. Health Psychology 1988; 7: 447-459.
64. Kawachi I, Sparrow D, Vokonas PS, Weiss ST . Symptoms
of anxiety and risk of coronary heart disease. The Normative
Aging Study. Circulation 1994; 90: 2225-2229.
65. Compare A, Manzoni M, Molinari E, Moller A. Personalita
di Tipo A e di Tipo D, rabbia e rischio di recidiva cardiaca.
In E. Molinari, A. Compare & G.Parati (Eds.), Mente &
Cuore. Clinica psicologica della malattia cardiaca Milano
Springer 2007: 135-161.
66. Denollet J. Type D personality: a potential risk factor refined. Journal of Psychosomatic Research 2000; 49: 255266.
67. Denollet J, Schiffer AA , Spek V. A general propensity to
psychological distress affects Cardiovascular Outcomes. Evidence from research on the Type D (Distressed) Personality
Profile. Circulation: Cardiovascular Quality and Outcomes
2010; 3: 546-557.
68. Bandura A. Self-efficacy and health. In N . Smelser & P .
Baltes (Eds.), International encyclopedia of the social and
behavioral sciences. Oxford: Elsevier Science, 2001: 1381513820.
69. Zimmerman B J & Schunk D H. Educational psychology:
A century of contributions. Mahwah, NJ: Erlbum, 2003.
70. Jerant AF, Friedrichs-Fitzwater MM , Moore M. Patients’
perceived barriers to active self-management of chronic
conditions. Patient Education and Counseling 2005; 57(1):
300-307.
71. Woloshin S, Schwartz LM, Tosteson AN, Chang CH,
Wright B, Plohman J et al. Perceived adequacy of tangible
social support and health outcomes in patients with coronary artery disease. J Gen Intern Med 1997; 12: 613-618.
72. Uchino BN. Social support and health: A review of physiological processes potentially underlying links to disease
outcomes. Journal of Behavioral Medicine 2006; 29(4):
377-387.
182
73. Berkman LF, Blumenthal JA, Burg M, Carney RM , Catellier D, Cowan MJ, et al. Enhancing Recovery in Coronary
Heart Disease Patients Investigators (ENRIC HD). Effects
of treating depression and low perceived social support on
clinical events after myocardial infarction: the Enhancing
Recovery in Coronary Heart Disease Patients (ENRIC
HD). JAMA 2005; 289: 3106-3116.
74. Wang HX, Mittleman MA and Orth-Gomer K. Influence
of social support on progression of coronary artery disease in
women. Social Science and Medicine 2005; 60(3): 599-607.
75. Sayers SL, Riegel B, Pawlowski S, Coyne JC and Samaha F.
Social Support and Self Care of Patients with Heart Failure.
Annals of Behavioral Medicine 2008; 35(1): 70-9.
76. Osterberg L & Blaschke. Adherence to medication. Engl J
Med. 2005; 353(5): 487.
77. Colivicchi F, Abrignani MG , Santini M. Aderenza terapeutica: il fattore di rischio occulto. Ital Cardiol 2010; 11 (5
Suppl 3): 124S-127S.
78. World Health Organization (WHO) 2003.
79. Rozanski A, Blumenthal JA, David-son KW, Saab PG &
Kubzansky LD. The epidemiology, pathophysiology, and
management of psychosocial risk factors in cardiac practice.
the emerging field of behavioral cardiology. Journal of the
American College of Cardiology 2005; 45(5): 637-651.
80. Bisiacchi P, Cardaioli C. Cappellari G, Savadori L & Tarantino V. The patient adherence to treatment: initial results of
a longitudinal study. Proceedings of the conference decision
and reasoning in medical field Council of the Autonomous
Province of Trento, 2002.
81. Sonali P. Kulkarni MD, Alexander KP, Lytle B, Heiss G,
& Peterson ED. Long-term adherence with cardiovascular
drug regimens. American Heart Journal 2006; 151: 185191.
82. Scardi S, Gori P, Umari P. Nurse involvement in primary care: it is the key to improve the outcomes in primary
and secondary prevention? Monaldi Arch Chest Dis 2010;
74(2): 82-5.
83. Delaney EK1, Murchie P, Lee AJ, Ritchie LD, Campbell
NC. Secondary prevention clinics for coronary heart disease: a 10-year follow-up of a randomised controlled trial in
primary care. Heart 2008; 94(11): 1419-23.
84. Chummun H, Gopaul K, Lutchman A.Current guidance
on the management of acute coronary syndrome. Br J Nurs
2009; 18(21): 1292-8.
85. Briggs J. Nurse-led interventions to reduce cardiac risk factors in adults. Nurs Health Sci 2010; 12(3): 288-91.
86. Holst M, Willenheimer R, Martensson J, Lindholm M, et
al. Telephone follow-up of self-care behaviour after a single
session education of patients with heart failure in primary
health care. Eur J Cardiovasc Nurs 2007; 6(2): 153-9.
87. AmodeoR, De Ponti A, Sorbara L, Avanzini F, Di Giulio P,
De Martini M. How to increase patient knowledge of their
coronary heart disease: impact of an educational meeting led
by nurses. G Ital Cardiol 2009; 10(4): 249-55.
88. Buckley T, McKinley S, Gallagher R, DracupcK, Moserd
R. La Sala, C. Foà, G. Paoli, et al.
DK, Aitkene LM. The effect of education and counselling
on knowledge, attitudes and beliefs about responses to acute
myocardial infarction symptoms. Eur J Cardiovasc Nurs
2007; 6: 105-111.
89. Kirchberger I, Meisinger C, Seidl H, Wende R, Kuch B,
Holle R. Nurse-based case management for aged patients
with myocardial infarction: study protocol of a randomized
controlled trial. BMC Geriatr 2010; 27: 10-29.
90. Tokunaga-Nakawatase Y, Taru C, Miyawaki I. (Development of an evaluation scale for self-management behavior
related to physical activity of patients with coronary heart
disease. Eur J Cardiovasc Nurs 2012; 11(2): 168-74.
91. Fredericks S, Beanlands H, Spalding K, Da Silva M. Effects
of the characteristics of teaching on the outcomes of heart
failure patient education interventions: A systematic review.
Eur J Cardiovasc Nurs 2010; 9(1): 30-37.
92. McKinley S, Dracup K, Moser DK, Riegel B, Doering
LV,Meischke H, Aitken LM, Buckley T, Marshall A, Pelter
M. The effect of a short one-on-one nursing intervention on
knowledge, attitudes and beliefs related to response to acute
coronary syndrome in people with coronary heart disease:
a randomized controlled trial. Int J Nurs Stud 2009; 46(8):
1037-46.
93. Sreedharan J, Muttappallymyalil J, Venkatramana M. Nurses’ attitude and practice in providing tobacco cessation care
to patients. J Prev Med Hyg 2010; 51(2): 57-61.
94. Longo F, Salvatore D, Tasselli S. Are Public Health Authorities Able to “Steer” rather than “Row”? An Empirical Analysis in the Italian NHS. International Journal of
Health Planning and Management, 2011; 26: 319-333.
95. Leventhal H, Marcia JE, Carlsonc B, De Geest S. Negotiating compliance in heart failure: Remaining issues and questions. Eur J Cardiovasc Nurs 2005; 4(4): 298-307.
96. Carpenito-Moyet LJ (Ed). Diagnosi infermieristiche. Applicazione alla pratica clinica. 6ª edizione[Nursing diagnoses. Application to clinical practice. 6th edition]. Milano:
Casa Editrice Ambrosiana, 2014.
97. La Sala R. Modello assistenziale tradizionale e integrato a
confronto: outcomes bio-clinici e psico-socio-relazionali del
paziente con sindrome coronarica acuta [Traditional and integrated models of care compared: bio-clinical and psychosocio-relational outcomes in patients with acute coronary
syndromes]. University of Parma, Italy. Unpublished PhD
Thesis, 2013.
Accepted: 10 september 2015
Correspondence:
Rachele La Sala
University Teaching Hospital,
Via Gramsci 14,
43126 Parma, Italy
Tel. +39-0521 703232
Fax +39-0521/702569
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 183-188
© Mattioli 1885
Original article: nursing
A cross selectional survey in a critical care: the job
satisfaction and functioning team of the health professionals
Rachele La Sala1, Katiuscia Boninsegni2, Alice Tani2, Alice Rasi2, Barbara Ricci2,
Linda Sansovini2, Giulia Scarpelli3, Giovanna Artioli4, Leopoldo Sarli5
University Teaching Hospital, Parma, Italy; 2 Nurse Case/care Manager; 3 RN, Nursing Home Fidenza (Parma), Italy; 4 Hospital of Santa Maria Nuova (Reggio Emilia), Italy; 5 Departmemt of Surgical Sciences, Parma University, Italy
1
Abstract. Background and aim of the work: Health care workers, especially those who are part of the OS core,
are essential in the delivery of services, as they represent the institution at the time of the contact with the user
and they represent also the image of the organization. Health administrations, therefore, are called to improve
the performance through a better motivation and satisfaction of the staff, in view of two strategic aspects:
job satisfaction of professionals and team collaboration. Method: Between January and September 2014, a
survey at the OU (UUOO) intensive care and sub intensive has been made inside three hospitals in Emilia
Romagna. It’ s been a multicentre cross-sectional quantitative study by administering a self-report questionnaire designed to investigate the different constructs. On 742 questionnaires were spread 454 professionals
gave it back (response rate = 73%). Of those, 273 (60.1%) were nurses, 119 (26.2%) were physicians and 62
(13.7%) were healthcare operators. 62 (13.7%) Job Satisfaction was measured with the McCloskey Mueller
Satisfaction Scale. Team Functioning was measured with the Index of Interprofessional Team Collaboration.
Results: Results from MANOVA indicated that physicians were less satisfied of scheduling than both nurses
and healthcare operators. For professional opportunities, instead, healthcare operators showed the lower level
of satisfaction. The participants seem to perceive a high level of team effectiveness and therefore the professionals involved in the care of critically ill patients than the two dimensions analysed, (reflection between the
processes and interdependent roles), also state a greater tendency to respect the roles interdisciplinary , maintaining their professional autonomy and a lower tendency to use critical thinking to act professionally in order
to improve the effectiveness of care provided. Conclusion: The study results oriented healthcare administrators,
to take paths that feed the job satisfaction and the collaboration of professionals by developing the aspects
investigated. Considering the shared perception among the professions studied, compared to the constructs
under investigation, it seems to be clear how the routes should be designed in a systematic order to involve,
in an integrated way the best professionals (nurses, doctors and OSS) involved in taking managing critical
patients. No statistically significant difference have been found between these three professions considered,
on most dimensions of job satisfaction investigated (relations between colleagues, ‘social interactions, workfamily balance, time work organization and working professional opportunity). There is a difference between
two specific factors: the work time planning organization and wich is seen less by the nurses, while the job
opportunities that are perceived less from the OOS.
Key words: job satisfaction, team functioning, health professional, intensive care unit
184
Introduction
Health care workers, especially those who are part
of the OS core, are essential in the delivery of services,
as they represent the institution at the time of the contact with the user and they represent also the image
of the organization.. The staff, added to a health care
organization, you configure it as an integrated system
of strategic apex and the operating core, for a common
project of identification of needs, both quantity and
quality of human resources, with the use of tools and
recruitment consistent selection to the identified needs
and to design systems of inclusion-oriented mission to
a culture of origin (1). Health administrations, therefore, are called to improve performance through greater
motivation and satisfaction of the staff, taking into account two strategic aspects: job satisfaction of professionals, it will be recognized, understood and cured
continuously and organizational well-being which refers the relationship that binds people to their work environment, taking into account the many variables that
characterize the operation of the team: interpersonal
relationships, the meaning that people give to their
work, the sense of belonging to their organization (1).
Job satisfaction
Job satisfaction is defined as an emotional response to a worker in respect of its work, which is derived from the comparison between positive outcomes
and benefits actually produced by labor and those who
were wanted, desired, anticipated, believed to be correct and fair. It’s the way people feel their work and the
different aspects that qualify. It refers to a pleasant or
positive emotional state resulting from the assessment
made by an operator towards his work and his work
experience (2). Job satisfaction is, therefore, be a complex and multidimensional construct because there are
different variables that influence it: individual professional (eg. Age, sex, level of education); cultural (eg.
beliefs and values); social (eg. the group dynamics, the
formal and informal relationships; organizational (eg.
personnel policies, the structure of the organization,
technology, management systems); environmental (2,
3). Some research has shown that job satisfaction of
health professionals is decreasing worldwide (4, 5).
R. La Sala, K. Boninsegni, A. Tani, et al.
This element is not negligible since the reduction of
job satisfaction appears to have an important impact
on patient care (2, 3, 9).
Low levels of job satisfaction, in fact, prevent
health professionals to provide quality care to patients
and to create an environment conducive to care, impacting negatively on health outcomes (6-9). Other
authors have shown a strong association of job satisfaction with important variables of organizational
behavior such as absenteeism (10), turnover and voluntary redundancy (11-14), motivation and performance at work (9, 15). Other studies show that some
psychosocial factors such as work climate, professional
commitment and the value attributed to work, can be
considered predictive of the degree of job satisfaction
because they have an effect on the general welfare of
the professionals (9, 15, 16).
Team functioning
Closely related to the perception of job satisfaction is the concept of team functioning. The goal of
customer satisfaction may not be accompanied only by
the satisfaction of the operator. Therefore, the welfare
organization of the team, which organization’s ability
to promote and maintain, at all levels, the highest degree of physical, psychological, you also get the human
resources and enhancing their work, enhancing their
sense of belonging and satisfaction, spreading culture
and participation.
Also working groups cohesive can become the
place to grow professionally and to get answers to legitimate professional expectations (17). In this context,
climate dynamics and organizational methods of collaboration adopted by the team represent significant
variables: these are expressed through the perception
of a particular workplace, by people who are part of.
This perception is particularly strong and is able to influence the operational activities within the same context, and influence the experiences of the team members on the same professional environment to which
they belong. Within the team functioning, then, are
a number of perceptions related to variables such as,
for example, relationships with colleagues and other
health professionals and management style prevalent
in the group (18). The study found the operators acting
185
A cross selectional survey in a critical care
within the processes of care and the dynamics within
the operations team, would seem to favour, therefore,
the understanding of the dysfunctions that occur within a healthcare organization which, while relying on
environments, material and advanced technology, has
as its main resource personnel. This aspect takes on a
deeper meaning when transferred to specialized clinical settings such as the intensive care, where it has as
function the assistance of the critical patient that requires a high level of intensity of care.
In literature, however, job satisfaction and the operation of the team have never been considered with
respect to the three main figures that revolve around
the patient care process, ie, doctors, nurses and social
assistance (operators involved in primary the patient,
such as hygiene and personal care), especially in specific contexts, such as the critical area. The objective of
this study was therefore to investigate the level of job
satisfaction and perception of the degree of effectiveness and operation of the team of health professionals
doctors, nurses and Care workers (OSS).
Measures
Job Satisfaction was misurate with the McCloskey Mueller Satisfaction Scale. This scale (19), used
here in its Italian (20), measuring job satisfaction and
consists of 31 items measured on a Likert scale to 6
steps (1 = completely dissatisfied, 6 = completely satisfied), and measure 8 dimensions ( explicit recognition, balance family and work, organization and working hours, relationships with colleagues, opportunities
for social interaction, professional opportunities, and
praise recognition and supervision and liability) summarized in a general factor of job satisfaction in this
study showed a high internal consistency (α = .94).
Team Functioning was misurate with the Index of
Interprofessional Team Collaboration (21). This scale
measures the perception with respect to the operation of
the team and consists of 14 items measured on a Likert
scale in six steps (1 = very dissatisfied, 6 = very satisfied). The two dimensions, reflection on the processes
and interdependent roles, can be summarized in a general factor of team collaboration that, in this study, has
demonstrated high internal consistency (α = .95).
Method
Design
Results
Between January and September 2014, a survey at
the OU (UUOO) intensive care and sub intensive has
been made inside three hospitals in Emilia Romagna.
It’s been a multicentre cross-sectional quantitative
study by administering a self-report questionnaire designed to investigate the different constructs.
Preliminarily analysis
Procedure e partecipants
On 742 questionnaires were spread, 454 professionals gave it back (response rate = 73%). (response
rate = 73%). Of those, 273 (60.1%) were nurses, 119
(26.2%) were physicians and 62 (13.7%) were healthcare operators. 62 (13.7%) professionals had less than
31 years, 198 (41.2%) less than 41, 134 (29.6%) less
than 51 and 70 (15.5%) had 51 or more years. Two
participants did not report his/her age. Moreover, 138
(30.7%) were men and 312 (69.3%) were women (4
participants did not report his/her gender).
Before comparing mean scores among professionals, psychometrics properties of the team functioning scale were tested through confirmatory factor analysis (CFA). CFA was performed with Mplus
software (22) with maximum likelihood estimation
and robust standard error. A two-correlated-factor
model was tested and yielded satisfactory fit (x2(72)
= 188.78, p < .00, x2/df = 2.62. CFI = 0.96, TLI =
0.95, RMSEA = 0.060, 90%CI = 0.049-0.049, p =
0.06, SRMR = 0.035) and all items were significantly
represented by the relative dimension (all ps < .001).
Thus, the scores of both reflection on processes and
role interdependence dimensions were computed as
the mean of the intended items and higher scores indicated higher value of the measured construct. For
job satisfaction, dimension scores were computed as
the mean of intended items according to a-priori clas-
186
R. La Sala, K. Boninsegni, A. Tani, et al.
Table 1. Descriptive statistics and internal consistency of the
measured constructs
Job satisfaction and professions
M SD Cronbach’sα Nr.
Items
In order to analyze differences in job satisfaction
among physicians, nurses and healthcare operators, a
multivariate analysis of variance (MANOVA) was performed on the 8 dimensions of job satisfaction. Analysis yielded a significant multivariate effect of profession
(Wilks’ λ = 0.804, F(16,866) = 6.24, p < .001, η2 =
0.10). Univariate results evidenced that professionals
had significant different scores on satisfaction toward
scheduling (F(2,440) = 5.21, p < 0.01, η2 = 0.02) and
professional opportunities (F(2,440) = 9.89, p < 0.001,
η2 = 0.04). Post-hoc test evidenced that Physicians were
less satisfied of scheduling than both nurses and healthcare operators. For professional opportunities, instead,
healthcare operators showed the lower level of satisfaction. Moreover, univariate results indicated almost
significant effect on opportunities of social interaction
(F(2,440) = 2.85, p = 0.055, η2 = 0.01) and extrinsic
rewards (F(2,440) = 2.83, p =0.056, η2 = 0.01). As indicated in table 2, healthcare operators tended to show
the lower satisfaction on extrinsic rewards while physicians tended to show the lower satisfaction on social
interaction. Finally, an analysis of variance MANOVA
Satisfaction Extrinsic rewards 2.82 Family/work balance 3.43 Scheduling 3.43 Co-workers 4.26 Social Interaction 3.93 Professional opportunities 3.05 Praise/recognition 3.45 Control/responsibility 3.49 Total 3.45 0.99 1.19 1.01 1.05 0.98 1.11 1.09 1.02 0.81 0.67 0.74 0.80 0.76 0.82 0.83 0.84 0.84 0.95 3
3
6
2
4
4
4
5
31
Teamfunctioning Reflection on Process 3.34 1.02 Role Interdependence 3.73 0.94 Total 3.53 0.93 0.93 0.88 0.95 7
7
14
sification proposed by authors. Reliability was generally good for all dimensions. Table 1 shows descriptive statistics and internal reliability for dimensions of
both team functioning scale and job satisfaction scale
along with total scores.
Table 2. Means of the measured constructs according to profession
Nurses Physicians Healthcare operators M
SD M
SD M
SD
Satisfaction Extrinsic rewards^ Family/work balance Scheduling* Co-workers Social Interaction^ Professional opportunities* Praise/recognition 2.75a 3.39a 3.50b 4.22a 4.02a 3.16a 3.49a 0.98 1.20 0.97 1.04 0.95 1.11 1.07 2.99a 3.44a 3.17a 4.36a 3.75a 3.11a 3.39a 0.92 1.18 1.01 1.01 0.99 1.04 1.08 2.67a 3.58a 3.58b 4.26a 3.87a 2.53b .47a 1.11
1.21
1.11
1.19
1.15
1.15
1.22
Control/responsibility Total 3.57a 3.50a 0.98 0.80 3.43a 3.38a 1.01 0.78 3.30a 3.38a 1.17
0.91
Team functioning Reflection on Process 3.34a Role Interdependence 3.70a Total 3.52a 1.01 0.93 0.91 3.27a 3.74a 3.50a 0.96 0.87 0.87 3.46a 3.87a 3.66a 1.15
1.10
1.08
* significant differences among professionals for p < .01; ^ differences among professional for p < .06. M= mean; SD= standard deviation. For each row, different subscripts indicated different means at Bonferroni’s post-hoc test.
187
A cross selectional survey in a critical care
was conducted on the total score of job satisfaction and
revealed no significant differences among professionals
(F(2,451) = 1.01, p = 0.33, η2 = 0.00).
Team functioning and professions
Also in this case, a multivariate analysis of variance (MANOVA) was performed considering the two
dimensions of team functioning as dependent variables
and profession as independent variable. In this case,
no significant multivariate effect appeared (Wilks’ λ =
0.991, F(4,900) = 1.07, p < .001, η2 = 0.00). Accordingly, no significant univariate effect emerged. Mean
are shown in table 2.
Conclusion
Based on data obtained and analyzed it is noted
that, in general terms, between different professions
there are such clear differences, in fact, all professionals working in UU.OO. Intensive Care/subintensive
considered appear to be on average satisfied with their
jobs. The participants, in particular, said a degree of job
satisfaction more than relationships with colleagues, to
follow, tend to turn out to be satisfied for the other
dimensions: opportunities for social interaction, understood as the opportunity to have social contact with
colleagues outside the hours of service at even in the
workplace; control and responsibility, understood such
as awareness to supervise and control their work.
Compared to the other dimensions of satisfaction
such as work-family balance, (eg. The ability to take
advantage of maternity leave or permission for children), the organization of working time (eg. As the
flexibility of working hours, opportunities par - time),
the professional opportunity and the praise and awards
(eg. as the opportunity for career advancement or recognition of their work by superiors), the participants
said they were just satisfied with a result to barely
above the median theoretical scale. Among the participants prevails, however, the perception of dissatisfaction with the explicit recognition of professional, such
as salary, holidays and benefits.
Compared to the three professions considered, in
most of the dimensions of the satisfaction working in-
vestigated, there were no statistically significant differences. However, it should be noted, a difference with
respect to two specific factors: planning and organization, which is perceived to a lesser extent by nurses; the
professional opportunity that is perceived to a lesser
extent by the OSS.
Also with regard to the Team Functioning, the
study shows in general, the participants seem to perceive a high level of team effectiveness and therefore
the professionals involved in care of critically ill patients. Specifically, with respect to the two dimensions
analyzed, they declare a greater tendency to respect the
roles maintaining their professional autonomy, and a
lower tendency to use critical thinking in acting professional single operator, optimizing the reflection on
strategies to improve relations to ‘internal team, stimulating continuous feedback in order to improve the effectiveness of care provided (23).
The study results oriented healthcare administrators to take paths that feed the job satisfaction and the
collaboration of professionals such as: encouraging
greater flexibility in working hours; create favorable
conditions for career advancement and its recognition,
even economic; create formal moments of exchange
and discussion among professionals.
Considering the shared perception among the
professions studied, compared to the constructs under investigation, it appears to be clear that the routes
proposed above should be designed in a systematic,
in order to engage in an integrated manner the major
professionals (nurses, doctors and OSS) involved in
the care of critically ill patients.
References
1. Spector PE. Advanced Topics in Organization Behavior.
Job satisfaction: Application, assessment, causes, and consequences. Thousand Oaks, CA: Sage, 1997.
2. Fisher CD. Why do the people believe that satisfaction and
performance are correlated? Possible sources of common
sense theory. Journal of occupational behaviour 2003; 24:
753-77.
3. Avallone F. Psicologia del lavoro: storia, modelli, applicazioni
(Work Psycology: hystory, models, applications) Carocci editore, Roma, 2002.
4. Gunnar RM. -Vaughn, Strategies at work: Simple steps to
satisfaction. Nursing management 2003; 34 (5): 20-4.
188
5. Fournier P, Dufresne C, Zunzunegui MV, Haddad S. Réformes des Systèmes de santé et satisfaction du personnel:
les cas du Mali: Colloque International-Financement de la
santé dans le pays développement, CERDI, l’institut de la
Banque Mondiale et le Collège del Economistes de la santé,
2005.
6. Fako Thabo T, Ntonghanwah Forchen. Job satisfaction
among nurses in Botswana. T. Society in Transition 2000;
31 (1): 10-21.
7. Norrish BR, Rundall TG. Hospital Restructuring and the
Work of Registered Nurses. Milbank Quarterly 2001; 79
(1): 55-79.
8. Castle NG, Engberg J. Staff turnover and quality of care in
nursing homes. Medical Care 2005; 43: 616-26.
9. Judge TA, Thoresen CJ, Bono JE, Patton GH. The job satisfaction – job performance relationship and qualitative and
quantitative review. Psychological Bulletin 2001; 127: 376407.
10. Hackett RD, Guion RM. A reevaluation of the absenteeism-job satisfaction relationship. Organ Behav Hum Decis
Process 1985; 35 (3): 340-81.
11. Griffeth Rodger W, Hom Peter W, Gaertner Stefan. A meta-analysis of antecedents and correlates of employee turnover: Update, moderator tests, and research implications for
the next millennium. Journal of Management 2000; 26 (3):
463-79.
12. Shields MA, Ward M. Improving nurse retention in the
National Health Service in England: the impact of job satisfaction on intentions to quit. Journal of Health Economics
2001; 20 (5): 677-701.
13. Dolan LA. Management style and staff nurse satisfaction.
Dimentions of Critical Care Nursing 2003; 22 (2): 97-8.
14. Miracle V, Miracle J. The nursing shortage: why we stay,
why we leave, and why we never considered nursing as a
career in the first place. Dimens Crit Care Nurs 2004; 23
(5): 236.
15. Ostroff C. The relationship between satisfaction, attitudes,
and performance: An organizational level analysis. Journal
of Applied Psychology 1992; 77 (6): 963-74.
16. Caricati L, La Sala R, Marletta G, Pelosi G, Ampollini
M, Fabbri A, Ricchi A, Scardino M, Artioli G, Mancini T.
Work climate, work values and professional commitment as
predictors of job satisfaction in nurse, 2013.
17. Kinjerski V, Skrypnek BJ. The Promise of Spirit at Work.
Increasing Job Satisfaction and Organizational Commit-
R. La Sala, K. Boninsegni, A. Tani, et al.
ment and Reducing Turnover and Absenteeism in LongTerm Care. Journal of Gerontological Nursing 2008; 34
(10).
18. Strasser DC, Falconer JA, Herrin JS, Bowen SE, Stevens
AB, Uomoto J. Team functioning and patient outcomes in
stroke rehabilitation. Arch Phys Med Rehabil 2005; 86 (3):
403-9.
19. Mueller CW, McCloskey JC. Nurses’ job satisfaction: a proposed measure. Nursing Research 1990; 39 (2): 113-7.
20. Taddia P, Chiari P, Calanchi S, Martinelli B, Biavati C,
Ruffini B, Mosci D, Chiarelli P, Fontana S, D’Ercole F,
Tartari P, Parma D, Robb MC, Sansolino S, Farinella P.
Valutazione della soddisfazione per l’organizzazione basata
sulla valorizzazione di posizioni funzionali, tra gli infermieri del Policlinico S. Orsola-Malpighi [The assessment of
nurses satisfaction foran organization that values posts and
professional responsibilities]. Assistenza Infermieristica e
Ricerca 2007; 26 (4): 210-8.
21. Mellin EA, Bronstein L, Anderson-Butcher D, Amorose
AJ, Ball A, Green J. Measuring interprofessional team collaboration in expanded school mental health: Model refinement and scale development. J Interprof Care 2010; 24 (5):
514-23.
22. Muthén LK, Muthén BO. Mplus. The comprehensive modelling program for applied researchers: User’s guide, 5. 2012.
23. Aiken LH, Sermeus W, Van den Heede K, Sloane DM,
Busse R, Mckee M, Rafferty AM, Griffiths PD, MorenoCasbas T, Tishelman C, Scott PA, Brzostek T, Kinnunen J,
Schwendimann R, Heinen M, Zikos D, Sjetne IS, Smith
HL, Kutney-Lee A. Patient safety, satisfaction, and quality
of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ
2012; 20 (344): 1717.
Accepted: 3 december 2015
Correspondence:
La Sala Rachele
University Teaching Hospital, Parma,
Via Gramsci, 14
43126 Parma, Italy
Tel. 0521/703232
Fax 0521/702569
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 189-193
© Mattioli 1885
Original article: midwifery
Analysis of obstetric care variables associated with caesarean
section in low-risk pregnancy patients
Elena Tinelli1, Sara Vecchi2, Simona Illari3
Azienda Unità Sanitaria Locale of Romagna – Hospital of Ravenna; 2 Azienda Ospedaliero-Universitaria of Parma; 3 Azienda
Unità Sanitaria Locale of Piacenza
1
Abstract. Background and aim of the work: The excessive use of caesarean section (CS) is an issue that is at
the core of the political and healthcare management debate. This concern is particularly relevant for low-risk
pregnancies, which does not theoretically require CS. Indeed, in Robson’s classification, group 1 and 3 are
considered at low-risk and in these groups, CS rate should be near to zero. The aim of the present work was
to evaluate whether the non-compliance with guidelines by WHO is correlated to the increase in the rate of
CS in Robson’s class 1 and 3 in low-risk pregnancies. Methods: A retrospective patient record study carried out
in two hospitals of the northern Italy was used. Results: Admission in active phase of labour and one-to-one
care significantly decreased the likelihood of CS. On the contrary, an unjustified amniorrhexis and oxytocin
administration increased the rate of CS. Other considered variables, instead, had not significant effect on CS
rate. ROC curve on the computed risk index indicated a discrete sensibility and specificity, and that the better
cut-off was up to 1. Conclusions: This research confirms the importance of one-to-one midwifery in management of low-risk pregnancy and labour. Moreover, it stress the risk that an excessive medicalization of lowrisk pregnancy can drive to “unnatural” CS.
Key words: caesarean section, low-risk pregnancy, obstetric
Introduction
Low-risk pregnancy and obstetric care
The excessive use of caesarean section (CS) is an
issue that is at the core of the political and healthcare
management debate. Since 1985, the World Health
Organization (WHO) stated that the CS rate should
not exceed the 10-15% of deliveries, because this
would not have produced any additional benefits for
mother’s and baby’s health (1). This concern is particularly relevant for low-risk pregnancies, which does
not theoretically require CS. Nevertheless, national
and international literature shows that rate of CS in
low-risk pregnancy is not negligible (2-4). The aim of
this study is to evaluate the role of some care-oriented
behaviors in the increase or decrease of the CS rate in
low-risk pregnancy.
As is known, Robson (5) proposed a 10-group
classification of pregnancy aiming to supply a methodological tool that is able to define, monitor and compare the CS rate in different hospitals and in different
populations. These classes are mutually exclusive and
wholly inclusive, perspective and clinically relevant. As
is known, Robson’s taxonomy classifies patients basing
on the principal obstetric parameters which are detectable at the delivery, and that are reported in Table 1.
In Robson’s classification, group 1 and 3 are considered at low-risk and in these groups, the CS rate
should be near to zero. For this reason, midwives can
autonomously manage pregnancies in class 1 and
3 (DM 740 of 1994). However, the CS rate is also
190
E. Tinelli, S. Vecchi, S. Illari
Table 1. Robson’s Classification
No.
Groups
1 Nulliparous, single cephalic, >37 wks in spontaneous labor
2Nulliparous, single cephalic, >37 wks, induced or CS before labor
3Multiparous (excluding previous CS), single cephalic, >37
weeks in spontaneous labor
4Multiparous (excluding previous CS), single cephalic, >37
weeks, induced or CS before labor
5 Previous CS, single cephalic, >37 weeks
6 All nulliparous breeches
7 All multiparous breeches (including previous CS)
8 All multiple pregnancies (including previous CS)
9 All abnormal lies (including previous CS)
10 All single cephalic, <36 wks (including previous CS)
higher in these classes (2-4). Is it then possible that
some obstetric behaviors can shift a natural delivery
into a CS? Literature underlines, in fact, some healthcare actions that can limit the CS rate such as One to
One Midwives (6, 7), the presence of a continuity of
care and midwifery led-care model (8), the presence
of training courses conducted by midwives (9, 10) and
multidisciplinary audits (5, 11).
Moreover, different birth centers have different
CS rates despite patients belong to the same risk class.
This seems to suggest that different CS rates can be
due in part to different healthcare behaviors. As stated
by the 12^ Commissione Igiene e Sanità del Senato
della Repubblica (12), this means that detect and correct some behaviours may help to reduce the CS rate
in low-risk pregnancy. Accordingly, a teamwork of the
WHO (13) identified the guidelines for the care routine of women during uncomplicated labour and childbirth, which are independent from the characteristics
of the context in which labour and childbirth occur.
These guidelines are based on a wide analysis of available evidences in the effective care in pregnancy and
childbirth and, after that, in The Cochrane pregnancy
and childbirth database, and they indicate some operative actions that should be taken in order to correctly
manage low-risk pregnancy.
As a consequence, the aim of the present work is
to evaluate whether the non-compliance with guidelines by the WHO is correlated to the increase in the
rate of the CS in Robson’s class 1 and 3 in low-risk
pregnancies.
Method
The study is a retrospective patient record study
carried out in two hospitals of northern Italy.
Eligibility criteria
Medical records of all patients who have given
birth in the first semester of 2014 have been identified.
However, only medical records of patients classified in
Robson’s group 1 and 3 have been analyzed through a
checklist. Moreover, among those, medical records of
patients who had operative vaginal delivery were excluded from the analysis.
The checklist
The checklist used in this study was composed
by 14 items describing an action which has been indicated by the WHO (13) as useful for a good obstetric care. For each item, researchers stated whether the
described action was indicated in the medical record
(yes, no, not reported). Amniorrhexis and oxytocin administration were coded as unjustified when they were
reported in the clinical record, but a justification for
these procedures was not indicated. In the same way,
partograph was coded as complete when all parameters
were reported. In addiction, the outcome of the labour,
(CS vs. vaginal delivery) was also coded.
Procedure
Researchers scored each patient a medial record
according to the checklist. Moreover, for each checklist, patient’s nosological number was registered in order to give the possibility to identify the patient’s medical record without compromising patients’ privacy.
Results
Descriptive results from checklist
Five hundred and seventy nine medical records
were analysed. Overall, the CS had a relatively low
incidence of 8% (odd = 0.09, OR = 0.007). For what
191
Caesarean section in low risk pregnancy
concerns the checklist, table 2 shows frequencies and
occurrences of each item. In order to analyse their effect on the likelihood to CS, we considered only items
which have NR (not reported) frequencies lower than
5%. In the same way, we considered only variables
which had “yes” or “no” frequencies higher than 5%.
Thus, in the analysis, we considered only variables that
are marked with an asterisk in table 2.
Obstetric actions predicting CS
These variables were then inserted as predictor
in a probit logistic regression analysis in which the
dependent variable was the outcome of birth (CS vs.
natural). Results indicated that the regressive model
was better fitted to the data than the null model (χ2
(7) = 52.08, p < .001) indicating that considered vari-
ables were associated with likelihood of CS., as more
precisely shown in table 3.
As indicated, admission in active phase of labour
and one-to-one care significantly decreased the likelihood of CS. On the contrary, an unjustified amniorrhexis and oxytocin administration increased the rate
of CS. Other considered variables, instead, had not
significant effect on the CS rate.
In order to build a risk index, the items which
were significantly linked to CS in probit regression
have been scored as 1 (increase of the CS rate) and
0 (decrease of the CS rate) and then summed. More
precisely, the presence of unjustified amniorrhexis and
oxytocin administration received a score of 1, while
their absence received a score of 0. Conversely, the absence of One-to-one care and of Admission in active
phase of labour received a score of 1 and their presence
Table 2. Raw count and percentage of response for each item in the checklist
Shared care plan
Early prenatal risk assessment program
Continuous cardiotocography (CTG) Intermittent auscultation of fetal heart rate*
Admission in active phase of labour*
Unjustified amniorrhexis*
One-to-one care*
Non-pharmacological Pain Management in labor
Frequent changes of position during labor
Eating and drinking in labour
Supine position for giving birth
Complete partograph*
IV cannula during labour
Unjustified oxytocin administration*
Epidural analgesia*
NOYESNR
n%n% n%
579
14
2
522
326
455
79
6
1
1
182
190
0
445
485
100,00
2,42
0,35
90,16
56,30
78,58
13,64
1,04
0,17
0,17
31,43
32,82
0,00
76,86
83,77
0
565
577
57
253
124
491
287
482
20
212
389
579
134
94
0,00
97,58
99,65
9,84
43,70
21,42
84,80
49,57
83,25
3,45
36,61
67,18
100,00
23,14
16,23
0
0
0
0
0
0
9
286
96
558
185
0
0
0
0
Table 3. Results from probit logistic regression (CS rate as dependent variable)
Intercept
Intermittent auscultation of fetal heart rate
Admission in active phase of labour
Unjustified amniorrhexis
One-to-one care
Complete partograph
Epidural analgesia
Unjustified oxytocin administration
BS.E.Z p
-1.180.23-5.210.00
-0.23
0.39
-0.57
0.57
-0.69
0.21
-3.25
0.00
0.40
0.19
2.12
0.03
-0.530.21-2.470.01
0.12
0.19
0.62
0.53
0.00
0.23
0.01
0.99
0.60
0.21
2.88
0.00
0,00
0,00
0,00
0,00
0,00
0,00
1,55
49,40
16,58
96,37
31,95
0,00
0,00
0,00
0,00
192
E. Tinelli, S. Vecchi, S. Illari
received a score of 0. In this way, each medical document receives a score ranging from 0 (lower CS risk)
to 4 (higher CS risk). For example, the presence of
unjustified amniorrhexis and oxytocin administration
and the absence of one-to-one care and of admission
in active phase of labour represented the higher CS
risk condition. In this way, 171 record (30%) had score
0, 230 (40%) had score 1, 113 (20%) had score 2, 53
(9%) had score 3 and 12 (2%) had score 4.
The effect of this new risk score on the CS rate
was analyzed through the ROC curve. Results indicated a discrete sensibility and specificity as confirmed by
the AUC = 0.793 (85% C.I. 0.729-0.856), according
to Swets (14) recommendations. Analyzing specificities (true positive rate) and 1-sensitivities (false positive rate) of each considered threshold, it appeared that
the better cut-off was up to 1. In this case, indeed, the
test seems to be able to correctly detect a high percentage of CS (True positive = 78%) and a relatively low
portion of false positives (27%). Table 4 shows sensitivity and specificity for each threshold, and Figure 1
shows ROC curve.
Discussion and conclusion
The present research tried to analyse the correlation between the non-compliance with the WHO’s
guidelines for a correct management of low-risk labour, childbirth and the CS rate. To our knowledge,
this is one of the first studies to investigate the role of
obstetric behavior on the increase or decrease of the
CS rate.
The Results indicated that four obstetric behaviors
are associated with the CS rate. More precisely, UnjusTable 4. Sensitivity, specificity and 1-specificity for each
threshold
ThresholdsSensitivity Specificity
1-Specificity
(TP)(TN) (FP)
-inf
0
1
2
3
4
1,000,00
0,960,31
0,780,73
0,400,91
0,090,98
0,001,00
1,00
0,69
0,27
0,09
0,02
0,00
Figure 1. ROC curve
tified amniorrhexis and Unjustified oxytocin administration are associated with an increased CS rate, while
One-to-one care and an admission in active phase of
labour are associated with a decreased CS rate.
Amniorrhexis is one of the most used procedures
by midwives in order to quick the labour (15). In spontaneous labour, the use of amniorrhexis can be evaluated when cervical dilation slows down or stops and
when other obstetric actions have failed. Accordingly,
our results suggest that an unjustified use of amniorrhexis can increase the likelihood of CS. Also oxytocin administration can occur when cervical dilation
is normal, being thus a choice of professionals which
manage the labour. This however, may increase the risk
of CS. Accordingly, oxytocin has been inserted by the
Institute for Safe Medication Practices in the list of
the twelve drugs which can cause a damage when improperly used (15).
The Present results also show that epidural analgesia is not linked to CS rate. This is congruent with
evidences showing that epidural analgesia increases
the likelihood of CS when fetal distress is observable,
but it does not alter the CS rate in normal labours (16).
Contrary to literature (13), the present results indicate
that intermittent auscultation of fetal heart rate seems
to have no effect on the CS rate (even if the relation is
negative but not significant). This result is somewhat
surprising and need to be further investigated.
193
Caesarean section in low risk pregnancy
In conclusion, this research confirms the importance of one-to-one midwifery in the management of
low-risk pregnancy and labour. Moreover, it stresses
the risk that an excessive medicalization of low-risk
pregnancy can drive to an “unnatural” CS. Indeed, unjustified amniorrhexis and oxytocin administration, as
well as admission outside the active phase of labour –
which could be considered as proxies of medicalization
- seem to increase the CS likelihood.
References
1. W
HO. Appropriate Technology for Birth. Lancet 1985; 2:
436.
2. B
aronciani D, Basevi V, Battaglia S, Lupi C, Perrone E, Simoni S, Verdini E. La Nascita in Emilia Romagna. II Rapporto sui Dati del CedAP – Anno 2005, 2005.
3. Th
omas J, Paranjothy S. National Sentinel Caesarean Section
Audit Report 2001. RCOG Press, 2002.
4. M
c Carthy F, Rigg L, Cady L, et al. A New Way of Looking
at Caesarean Section Births. Aust N Z J Obstet Gynaecol
2007; 47: 316-20.
5. R
obson MS. Classification of Caesarean Sections. Fetal and
maternal review, 2001; 12: 23-39.
6. P
age L, McCourt C, Beake S, Vail A, Hewison J. Clinical Interventions and Outcomes of One-to-One Midwifery Practice. J Public Health Med 2005; 21(3): 243-48.
7. H
odnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous Support for Women During Childbirth. Cochrane
Database Syst Rev 2013; 15: 7.
8. S
andall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-Led Continuity Models versus other Models of Care for
Childbearing Women. Cochrane Database Syst Rev 2015;
15; 9: CD004667.
9. C
antone D, Lombardo A, Rizzo N, Labella AG. Partecipazione dei Corsi di Accompagnamento alla Nascita e
Riduzione dei Tagli Cesarei: uno Studio Preliminare. Psychofenia 2010; 23: 131-50.
10. Fainal I, Matinnia N, Hejar AR, Khodakarami Z. Why
do Primigravidae Request Caesarean Section in a Normal
Pregnancy? A Qualitative Study in Iran. Midwifery 2014;
30(2): 227-33.
11. Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M,
Wasiak J, Gruen RL. Non – Clinical Interventions for Reducing Unnecessary Caesarean Section. Cochrane Database
Syst Rev, 2011; 6: 1469-93.
12. 12^Commissione Igiene e Sanità del Senato della Repubblica.
Indagine Conoscitiva sul Percorso Nascita e sulla Situazione
dei Punti Nascita con Riguardo all’Individuazione di Criticità Specifiche circa la Tutela della Salute della Donna e del
Feto e sulle Modalità di Esercizio dell’Autodeterminazione
della Donna nella Scelta tra Parto Cesareo o Naturale. 2012;
retrived at: http://www.senato.it/leg16/3687?indagine=568.
13. World Health Organization. Care in Normal Birth: a Practical Guide. Ginevra, 1996.
14. Swets JA. Measuring the Accuracy of Diagnostic Systems.
Science 1988; 240 (4857): 1285-93.
15. Spandrio R, Regalia A, Bestetti G. Fisiologia della Nascita.
Dai Prodromi al Post Partum. Carocci, 2014.
16. Jones L et al. Pain Management for Women in Labour: an
Overview of Systematic Reviews. Cochrane Database Syst
Rev 2012; 3: CD009234.
Accepted: 26 november 2015
Correspondence:
Elena Tinelli
Azienda Unità Sanitaria Locale of Romagna
Hospital of Ravenna
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 194-204
© Mattioli 1885
Original article: professional education
Nursing students’ experiences of and satisfaction with
the clinical learning environment: the role of educational
models in the simulation laboratory and in clinical practice
Valeria Cremonini1, Paola Ferri2, Giovanna Artioli3, Leopoldo Sarli4, Enrico Piccioni5,
Ivan Rubbi6
PhD, MSN, RN, School of Nursing, ASL Romagna and University of Bologna, Italy; 2 MSN, RN, School of Nursing, Department
of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Italy; 3 MSN,RN, Surgical Department, University of Parma, Italy; 4 Department of Surgical Sciences, Parma University, Italy; 5 RN, Villa Nina, New Village of
the Child Foundation, Ravenna, Italy; 6 PhD, MSN, RN, School of Nursing, ASL Romagna and University of Bologna, Italy
1
Abstract. Background and aim of the work: Student satisfaction is an important element of the effectiveness of
clinical placement, but there is little consensus in the literature as to the preferred model of clinical experience for undergraduate nursing students. The aim of this study was assess, for each academic year, students’
perception of the roles of nurse teachers (NT) and clinical nurse supervisors (CNS) who perform tutoring in
both apprenticeship and laboratories and to identify and evaluate students’ satisfaction with the environment
of clinical learning. Method: This analytic cross-sectional study was conducted in a sample of 173 nursing students in the Northern Italy. The research instrument used is the Clinical learning environment, supervision
and nurse teacher (CLES+T) evaluation scale. Data were statistically analysed. Results: 94% of our sample
answered questionnaires. Students expressed a higher level of satisfaction with their training experiences. The
highest mean value was in the sub-dimension “Pedagogical atmosphere on the ward”. Third year students
expressed higher satisfaction levels in their relationship with the CNS and lower satisfaction levels in their
relationship with the NT. This result may be due to the educational model that is adopted in the course, in
which the simulation laboratory didactic activities of the third year are conducted by CNS, who also supervises experiences of clinical learning in the clinical practice. Conclusions: The main finding in this study was
that the students’ satisfaction with the supervisory relationship and the role of NT depend on how supervision
in the clinical practice and in the simulation laboratory is organized.
Key words: nursing education, undergraduate nursing student, clinical learning environment, clinical practice,
simulation laboratory, clinical nurse supervisor, nurse teacher, CLES+T
Introduction
The complexity of expertise required for efficient
and effective patient care needs has increased with the
explosion of scientific knowledge in nursing care and
the growing attention to the issues of patient-centred
care and patient participation. For these reasons the
education of nurses has shifted from a hospital-based
training model where the routine practice of tasks and
activities are emphasised, to a university-based preparation that educates students to understand situations
and seek and judiciously use evidence in practice (1,2).
Italian nursing education is part of higher education provided by the universities; the curriculum consists of 180 European Credit Transfer System (ECTS)
points, in accordance with the Bologna process, and
the duration of studies is 3 years. As part of vocational
training and qualifying, the training activity practice
Nursing students’ satisfaction with the clinical learning environment
and clinical training is particularly important, corresponding to at least 3 ECTS for professional labs and
60 reserved for the clinical training (3,4). The universities and various health care institutions have drawn
up contracts concerning clinical practice in nursing.
Each contract outlines the requirements mutually set
for the clinical learning environment (CLE); this allows the nursing degree course to assess and control
clinical practice in nursing education (5). In its general
plan the Italian Ministry of Education, University and
Research in agreement with the Ministry of Labour,
Health and Social Policy (2009) states that each student has the right to receive expert advice, supervision
and support to facilitate learning in clinical practice.
How this is arranged may vary between the different
university programmes and clinical sites (3,6).
One of the main features of nursing as a science
and a profession is that nursing education is characterized by a close relationship between theory and practice, meaning that nursing cannot be learned through
either theory or practice only (7). In addition to practice in the clinical learning environment (in-patient and
out-patient services), one of the most common places
for nursing students to learn clinical and practical skills
is in the simulation laboratory (SL) (8,9). The SL is
designed to simulate real clinical practice in a safe and
secure environment, without the pressure of real-word
performance, for practising skills; it constitutes a bridge
between the university and the clinical setting in which
students integrate theory and practice and develop a
reflective stance (9-14). Simulation is a widely used
educational strategy, which can be presented through
different approaches, methods and levels including
low- and medium-fidelity simulations such as case
studies, written clinical scenarios, live actors, standardized patients, role playing, games, static mannequins
and part-task trainers. High-fidelity simulation is a
relatively new method in nursing education, utilizing
high technology simulation monitors and computers where different healthcare scenarios are built with
computerized models (2,14-20). To be effective, simulation must reflect reality; students need authenticity
of the situation and an understanding of its relevance
for clinical practice (9,21,22). The involvement of both
didactic and clinical faculties in simulations is another
way for students to visualize the connections between
195
the classroom and the clinical setting, helping them to
overcome their perception of a disconnection between
the academic ideals learned in the classroom and the
real life applications experienced in clinical practice
(23-26). In accordance with Ewertsson et al. the theoretical origin for simulation situations in the SL could
be related to the Theory of Experiential learning (14).
In such a way, the use of simulation offers a process
that can facilitate learning through active participation,
integration, repetition, evaluation and active reflection,
which are all important elements of the future education
of the “reflective practitioner” (2,22,27,28). Literature
highlights a number of advantages and positive outcomes that can be obtained with the use of simulation
for undergraduate nursing students. In the SL students
can develop practical psychomotor and communication skills, which may improve problem solving, decision making and critical thinking skills, by encouraging
them to think deeply and ask appropriate questions
and by providing immediate feedback (9,16,19,25,2931). Other advantages offered by simulation-based
learning are the reduction in students’ anxiety before
entering clinical practice (32,33) and improved levels
of satisfaction, self-confidence, knowledge, safety and
clinical competence (15,16,19,21,27,34,35). The literature shows further motives supporting the use of SL in
undergraduate nursing education, such as the reduction
in the number of hospital beds, the reduced length of
in-patient stay and the shortage of nurses, which unintentionally have decreased the educational opportunities supplied by the learning practicum (14,36). Despite the accepted efficacy of SL, several scholars point
out that simulation should be integrated and linked to
clinical placements, since experiences in the laboratory
need to be strengthened and repeated in real clinical
practice (36-41).
A mixture of simulation and training in practice
may be preferred and vital for undergraduate nursing
students’ learning (2,42). Clinical placement, clinical
practical experience, clinical practicum and clinical
learning environment (CLE) are terms used to describe the placement of a student within a clinical venue such as a hospital, aged care facility or other nonuniversity location to support an aspect of experiential
learning (43). Clinical placements provide students
with the opportunity to combine knowledge, cogni-
196
tive, psychomotor, and affective skills, attitudes and
values of a registered nurse. The CLE is necessary for
nursing students to become competent in their profession (5,36,42-45). Experience in the clinical setting
provides for circumstantial learning, where the student
can socialize into the profession and develop a professional identity, while time management skills essential
for registered nurses are being developed (43,46-51).
Various research studies highlight the factors that may
influence the effectiveness of clinical learning.
According to the theoretical framework by
Saarikoski and Leino-Kilpi (2002), the CLE has a dyadic nature: one is the learning environment including
the ward atmosphere, the culture and the complexities of care, and the other is the supervisory relationships between students, clinical and school staff (7,52).
The study by Warne et al. (2010), conducted in nine
European countries, explored the CLE experiences
of nursing students utilizing the Clinical Learning
Environment, Supervision and Nurse Teacher evaluation scale (CLES+T) (53). This study confirmed that
students greatly valued individualized supervisory
relationships (41). Studies have also shown that student nurses consider clinical nurse supervisors to be
the best suited to teaching practical skills and do not
want to receive “hands on” education from the nurse
teacher (NT) (54-56). Other factors enabling quality in clinical placements include teamwork and good
staff morale, a positive staff attitude toward patient
care, a quality best-practice culture and active support
for learning with feedback and positive role models
(42,45,49,50,57-63). Regarding the CLE, the leadership style of the ward manager holds a pivotal role in
creating a positive ward atmosphere that is conducive
to learning (6,7,52,64). A good clinical learning environment is established through good co-operation and
strong partnerships between the nurse teachers (university educators) and placement areas (clinical nurse
supervisors, ward manager and staff nurse (5,41).
It has been suggested that the success of nurse
educational programmes depends on the effectiveness
of clinical placements (1,41,50), and that nursing students perceive the clinical setting as the most influential context for acquiring knowledge and nursing skills
(42,65). To this end, it is important that the nurse
educators should provide clinical placements offering a
V. Cremonini, P. Ferri, G. Artioli, et al.
positive learning environment to support the achievement of clinical learning outcomes (5,42,44,45,50,66),
and make a systematic monitoring of CLE quality (1).
Given the correlation between student satisfaction and
clinical learning outcomes, the opinion of students is
important, since it may help to identify factors which
obstruct or favour the learning process (67), and also
to reduce course withdrawal rates (68,69). Student satisfaction is an important element of the effectiveness
of clinical placement, although there is still a lack of
quantitative studies evaluating the CLE in the Italian
context and little consensus in the literature as to the
preferred model of clinical experience for undergraduate nursing students.
Aims of the study
The aim of this study was to explore the students’
experiences and satisfaction of the clinical learning environment and supervision of the educational model
adopted.
The specific objectives were:
1. To assess and evaluate, for each academic year,
students’ perception of the roles of nurse teachers and clinical nurse supervisors who perform
tutoring in both apprenticeship and laboratories;
2. To identify and evaluate, for each year, students’
satisfaction with the environment of clinical
learning;
3. To create a data base of clinical learning and
supervision that will form a starting point for
future studies in Italy.
Method
Design
This analytic cross-sectional study was conducted
in the academic year 2013-14 in Northern Italy.
Setting
In a Nursing undergraduate course in Northern
Italy, the simulation laboratory is characterized by a
197
Nursing students’ satisfaction with the clinical learning environment
classroom equipped with simulators including SimMan® of Laerdal, which allow realistic scenarios to
be built using advanced technology and equipped environments (20). The SL reproduces many hospital
rooms for adults with a total of 5 beds in accordance
with the model for intensive care, in which there are
several mannequins (1 SimMan®, 3 Nursing Anne®
with VitalSim® and SimPad® and 1 Convalescent
Kelly® system). The area is also equipped with ECG
monitor, vacuum cleaners, an electrocardiograph and
medical-surgical devices that enable a realistic reproduction of the educational activities in the simulations.
For the paediatric patient, the SL offers 1 Nursing
Baby® with SimPad® system, some infant mannequins for basic care, simulators for venous access on
newborns and specific devices. The educational model
adopted by the undergraduate course requires Nurse
teachers (NT) to conduct simulations with 1st and
2nd year students, while the 3rd year teaching laboratory is entirely conducted by clinical nurse supervisors (CNS), as experts of the specialized topics covered
in the course (Table 1). The planning of educational
laboratory activities is integrated with, and is closely
related to, the content of the nursing disciplines and
learning objectives of the curricular training. Finally,
the student planning assigned clinical cases by adopting the taxonomy of nursing diagnoses approved by
NANDA-I (North American Nursing Diagnosis
Association-International) (70) and the nursing bifocal model of L.J. Carpenito (71), with the use of the
course nursing documentation. The supervision activities of care planning are conducted by NTs who follow students in each year of the course. The NTs hold
university posts involving both teaching and research.
They visit the clinical settings for meetings with students and the CNS, but do not participate in the daily
clinical work. In the clinical placement, the students
are assigned a personal supervisor from among the
clinical nurses and the preceptor’s role is to supervise
the students in the daily patient care, facilitate their
learning of practical skills and take part in the assessment and grading of the students’ performance.
Participants and procedure
The degree programme board decided to investigate the climate of learning environments training
involving, in 2013/14, 173 students enrolled in the
three-year course. Participation was voluntary; on delivery of the documents required for the internship, the
students were reserved a space in which the aims of the
study and the operating procedures for the completion
of the questionnaire were explained. Learners were
asked to complete the questionnaire at the end of each
internship period and to place it in an urn, in order to
guarantee the anonymity of both the student and the
CU in which the internship was done.
The research instrument
The research instrument used in the study is the
Clinical learning environment, supervision and nurse
teacher (CLES+T) evaluation scale. The CLES+T was
developed for evaluating the learning environment
in the clinical placement from the perspective of the
students (52,72) and the Italian version has proved
to be a reliable and valid instrument in psychometric tests among Italian student nurses (73). The scale
Table 1. Student and staff distribution according to the year of the course
Academic supervision by
Clinical Simulation Laboratory by
Nurse Teacher (NT)
NT in 1st and 2nd year
CNS in 3rd year
Students
n(%)
1st Year
59(34.1)
2nd Year
60(34.7)
3rd Year or + 54(31.2)
NT
n(%)
2(33.3)
2(33.3)
2(33.3)
or + = Students after the 3rd Year
Ratio
(NT/Students)
1/29.5
1/30
1/27
NT-CNS
Modules/ Ratio (NT-
n(%)
Students for group CNS/Students)
11(33.3)
10(30.3)
12(36.4)
7/12
5/5
3/9
NT 1/5
NT 1/12
CNS 1/6
Clinical Learning
Environment by
Clinical Nurse (CNS)
Supervisor
CNS
n(%)
Ratio (CNS/
Students)
97(30.1)
118(36.6)
107(33.3)
1.5/1
2.1/1
1.4/1
198
V. Cremonini, P. Ferri, G. Artioli, et al.
has also been used extensively in international nursing
studies (6,53,56,67). The evaluation scale consists of
34 statements, which form 5 sub-dimensions: Pedagogical atmosphere on the ward (9 items); Supervisory
Relationships (8 items); the Leadership Style of the
Ward Manager (4 items); Premises of Nursing in the
ward (4 items); and the Role of the Nurse Teacher (9
items). A 5-point Likert scale on all 34 statements of
the CLES+T was used: (1) fully disagree; (2) disagree
to some extent; (3) neither agree nor disagree; (4) agree
to some extent and (5) fully agree (53). The CLES+T
asks participants to express their agreement with each
statement.
Statistical analysis
Statistical analysis was conducted with SPSS
20.0 (IBM, Statistics demo-version) software. Internal consistency was analysed using Cronbach’s Alpha (74). Quantitative variables were described with
mean, standard deviation, median and median. Mean
differences in the five dimensions of CLES+T across
years were tested with multivariate analysis of variance
(MANOVA), with Bonferroni correction for multiple
comparisons.
Demographic variables were described with frequency and percentage, and the chi-squared test was
used to analyse distribution differences. Statistical significance was set for P < 0.05.
Results
Considering the number of students attending
the course, 780 questionnaires were expected in all; the
actual number of collected questionnaires was 733 (response rate = 94%). Some questions regarding personal
details were skipped; for example, age was reported by
only 689 participants (88.3%).
The total CLES+T had a good internal reliability
(Cronbach’s α = >.90, see Table 2).
583 (84.6%) participants were aged between 19
and 25 years. Table 3 reports characteristics of the sample. First year students had a mean age of 22.08 years
(SD = 7.867), second year students 23.66 (SD = 5.449)
and third year students 24.13 (SD = 4.699). Participants were primarily women (79.9%), with a difference
among years. In the first, second and third year, the
percentages of women were 84.8%, 80.7% and 75.6%
respectively (P = .040) 29.1% of third year students
had a job, while the percentages were lower for students in the first (20.4%) and second (20.9%) year (P =
.037). First year students attended mainly internships
in medical areas (96.2%), while second year students
attended mainly internships in surgical and paediatric
areas (87.7%). Third year students attended mainly internships in critical areas, mental health and primary
care (74.8%). Except for medical and specialist areas,
other areas have been labelled “other” in Table 3.
Table 4 shows the student nurses’ ratings of perceptions of the clinical learning environment according to the 5 sub-dimensions “Pedagogical atmosphere”
(PA), “Leadership style of the ward manager” (WM),
“Premises of nursing in the ward” (PN), “Supervisory relationship” (SR) and “Role of the nurse teacher”
(NT).
The results indicated that students were generally
satisfied with their training. The sub-dimension “Pedagogical atmosphere” received the highest score independently of course year. Similar scores emerged for
Table 2. Dimensions of CLES+T and reliability
Domains
Pedagogical atmosphere
Leadership style of the ward manager
Premises of nursing in the ward
Supervisory relationship
Role of the nurse teacher
Total
Item
n.
9
4
4
8
9
34
Reliability Scale of items
783 (86.7)
782 (86.6)
782 (86.6)
782 (86.6)
770 (85.3)
α = .915
α = .868
α = .825
α = .964
α = .949
5 points
Likert scale:
fully disagree = 1
fully agree = 5
768 (85)
α = .965
n. (%)
199
Nursing students’ satisfaction with the clinical learning environment
Table 3. Demographic characteristics of participants
1st year
2nd year
3rd year
Total
n.%n. %n.%N (%)X²
P
Gender
Female
Male
168
30
84.8
15.2
176
42
80.7
19.3
227
73
75.6
24.4
571 (79.7)
6.415 .040*
145 (20.3)
Working students
Yes
No
39
152
20.4
79.6
44
167
20.9
79.1
86
210
29.1
70.9
169 (24.2)
6.577 .037*
529 (75.8)
Already graduated
Yes
No
11
174
6
94
9
198
4.4
95.6
18
281
6
94
38 (5.5)
.755 .686
653 (94.5)
Area of placement
Medicine Other areas
177
7
96.2
3.8
25
179
12.3
87.7
58
210
21.6
78.4
260 (39.6)
659.444 .000**
396 (60.4)
** P = < .01
* P = < .05
Table 4. Student nurses’ evaluation on CLES+T sub-scales
1st Year (n = 204)
2nd Year (n = 228)
3rd Year
(n = 301)
Range
Mode Median Mean SD ModeMedian Mean SD ModeMedianMean SD MinMax F
Pedagogical atmosphere
45
39.50 38.465.851 45
Leadership
style of the
ward manager
20
16
Premises of nursing in the
ward
20
Supervisory
relationship
40
Role of the nurse teacher
45
P
38
37.566.364 45
41 38.716.543 9 45 2.222 .109
15.973.489 20
16
16.203.314 20
17 16.363.466 4 20 .813 .444
17
16.72 2.862 16
16
16.28 2.690 20
17
35
33.257.611 40
34
32.707.570 40
37 34.277.031 8 40 3.073.047*
36
34.36 9.098 45
32
35.50 35.00 8.054 45
16.69 3.095 4
31.75 10.14 9
20 1.667 .190
45 8.809 .000**
** P = < .01
* P = < .05
“Supervisory relationship” and “Premises of nursing
in the ward” subscales. The “Role of the nurse teacher” subscale received the lowest score. No differences
across years appeared regarding the “Leadership style
of the ward manager” and “Premises of nursing in the
ward” subscales. However, significant differences appeared regarding “Supervisory relationship” (P = .047)
and “Role of the nurse teacher” (P = <.000). The rela-
tionship with the clinical tutor is better appreciated by
third year students (M = 34.27; SD = 7.031) than by
first (M = 33.25; SD = 7.611) and second (M = 32.70;
SD = 7.570) year students. Third year students scored
lower on their relationship with their university tutor
(NT, M = 31.75; SD = 10.14) than second (M = 34.36;
SD = 9.098) and first (M = 35.00; SD = 8.054) year
students.
200
V. Cremonini, P. Ferri, G. Artioli, et al.
Table 5. Contingency table of items with significant differences
1st Year 2nd Year 3rd Year
Domain
Items
∑ Likert 4 & 5 ∑ Likert 4 & 5 ∑ Likert 4 & 5 Pedagogical atmosphere
The staff got to know the students by their personal names
∑%∑%∑
%
Tot (%)
X²
P
184
90.1
202
88.5
261
86.7 674(91.9) 17.544 .025*
Leadership style of the ward manager (WM)
The WM was a team member
126
66.7
166
73.1
207
68.7 499(68.1) 17.793 .023*
Premises of nursing care
Patients received individual nursing care
169
82.8
176
77.5
251
83.3 596(81.4) 22.389 .004**
158
77.4
166
73.1
232
172
84.7
186
81.5
266
88.3 624(85.2) 15.977 .043*
76
176
77.8
189
64.2 517(71.8) 16.922 .031*
82
171
75.6
183
62.2 518(71.9) 30.092 .000**
There were no problems in the information flow related to patients’ care
Supervisory relationship
Mutual respect and approval prevailed in the supervisory relationship
Role of the nurse teacher (NT)
In my opinion, the NT was capable of integrating 152
theoretical knowledge and everyday practice of nursing
77
556(75.9) 16.770 .033*
The NT was capable of operationalizing the learning
goals of this placement
164
The NT was capable of bringing his or her pedagogical expertise to the clinical team
121
60.5
135
59.7
140
47.6
The common meetings between myself, mentor and
NT were comfortable experiences
133
66.5
134
59.2
140
47.6 407(56.5) 25.591 .001**
Climate of the meetings was congenial
142
71
137
60.6
162
55.1 441(61.2) 17.453 .026*
Focus of the meetings was on my learning needs
141
70.5
139
61.5
161
54.7 441(61.2) 18.224 .020*
396(55)
17.718 .023*
** P = <.01
* P = <.05
A post hoc test indicated that scores on Supervisory relationship of second and third year students were
significant (MD = -1.57; P = .048). On Role of the nurse
teacher, differences appeared between third and first
years (MD = -3.24; P = .000) and third and second
years (MD = -2.61; P = .005).
Summing points 4 and 5 of the Likert scale (see
Table 5), third years students showed higher levels of
satisfaction with their relationship with the CNS and
lower satisfaction levels with their relationship with
the NT.
The variables that have the greatest impact on the
third year students’ perception of their relationship
with the NT concern the NT’s ability to share his/her
pedagogical skills with the nursing staff and the pleas-
antness of the regular meetings between the CNS, NT
and students. These two items received an approval
that was lower than 50%. Overall, the sub-scale on the
role of NT indicated a reduction in student satisfaction
from the first to the last year of the course. The other
four sub-scales, while showing significant differences
between course years, do not show such a marked reduction in the same direction.
Discussion
Firstly, a higher response rate appeared in this
research, with a percentage (94%) similar to (73) or
higher than that of other studies (67,75), suggesting a
Nursing students’ satisfaction with the clinical learning environment
strong interest for nursing students. This enabled the
creation of a database that will be useful for future research on learning environments and supervision.
Nursing students in our sample were similar in
gender and age distribution compared with the Italian
literature on this topic (53,67,73,75). Cronbach’s Alpha of the questionnaire was excellent (74) and similar
to that obtained in the Italian validation of the scale
(73).
Students expressed a higher level of satisfaction
with their training experiences, with levels of satisfaction that were equal to or greater than those reported
in other Italian and European studies (6,53,67,75,76).
The highest mean value was in the sub-dimension
“Pedagogical atmosphere on the ward”, similarly to
other studies (67,75), confirming that the PA was seen
to be an important aspect of the clinical learning environment (52) by students who may experience a feeling of vulnerability during their internship and need
the understanding and respect of all those involved in
their education (77,78). As stated by Warne et al, the
most important feature of a good learning environment is a sense of ontological security (53). Other domains that were positively evaluated were “Supervisory
relationship” and “Premises of nursing in the ward”.
Student nurses emphasized the quality of clinical practice, as both the quality of mentoring and the quality
of patient care (5,50). Third year students expressed
higher satisfaction levels in their relationship with the
clinical nurse supervisor and lower satisfaction levels
in their relationship with the NT. This result may be
due to the educational model that is adopted in the
course, in which the SL didactic activities of the third
year are conducted by the CNS, who also supervises
experiences of clinical learning in the clinical practice.
In this sense, for the CNS to meet again, at the units
at which the training takes place, the same nurses who
conducted simulations in the laboratory not only facilitates the relationships between them, but also helps
to reinforce the knowledge and skills learned in the
SL, furthering the sharing of learning goals (36-41).
As stated by Riley (2011), knowing that an attachment figure is available and responsive can lead to
a feeling of security (27), and good interpersonal relations, support and feedback are factors influencing
student learning in CLE (1,41,45,49,50). Moreover, in
201
this way, there is increased integration between theory
and practice for the education of a “reflective practitioner nurse” (2,14,22-28,79). Nursing as a science
and a profession requires a close relationship between
theory and practice (7). According to Fool and Robinia (2014), the overcoming of the classroom-clinic gap
has the potential to positively impact future nursing
practice and ultimately patient care (26). The education model used allows for the achievement of what
was affirmed by Kaphagawani and Useh (2013), that is
to say that if students are given opportunities to practice what they have learnt in the classroom and skills
laboratory and are supervised and supported and provided with feedback in an environment where there is
a good interpersonal relationship and communication,
the learning is effective (63). In line with our findings,
other studies claim that student nurses consider the
CNS to be the best suited to teaching practical skills
and do not want to receive “hands on” education from
the nurse teachers (54-56). Students in the third year
seem to consider the NT as not being an important
facilitator of their clinical learning experiences, in accordance with results by Papp et al. (5) showing that
the teacher was considered mainly as an additional
support and an organizer of the clinical placement.
First year students, on the other hand, expressed a less
critical opinion of the NT. According to the educational model used, in this case the NT is the expert
tutor who conducts all activities of simulation in the
laboratory, with a tutor/student ratio of 1:5. Supposedly, this educational model favours satisfaction with this
figure, which presents the nursing profession to novice
students and which may thus be appreciated because
of the new learning experience which contributes to
the building of a positive role model. It is worth noting that the first apprenticeship experience represents
the opportunity for undergraduate nursing students to
experience motivations and meanings that they have
symbolically connected with their educational choice.
Moreover, the preparation and tutorial support at this
initial phase are fundamental both for effective learning and to avoid withdrawal from the course of studies (68,75). Our data, in accordance with other studies, show that the sub-dimension of “Role of the NT”
tends to receive scores which are slightly lower than
other domains of CLES+T (56,67,75,76). It is difficult
202
to interpret this result univocally. One way of interpreting this may be that because of the change of nursing
education from hospital-based to university education,
the role of the NT is changing and is still in search of a
definition and of an easier and more efficient integration with clinical education practice. For this reason,
it is possible that some items of the sub-scale “Role of
nurse teacher” tend to receive a lower score.
Conclusion
Overall, students are satisfied with the clinical
learning environment. The main finding in this study
was that the students’ experiences of and satisfaction
with the supervisory relationship and the role of nurse
teacher depend on how supervision in the clinical
practice and in the simulation laboratory is organized.
The strong involvement of clinical nurse supervisors in
the simulation laboratory can, in our opinion, successfully bridge the theory-laboratory-practice gap, with a
positive effect on the training of the future professional
nurse.
Limitations and advantages
The limitations of this study are that the results are
restricted to one university, thereby reducing the external validity of results that must then be interpreted in
the light of the limitations connected to cross-sectional study design and self-reporting on variables. Nevertheless, the study offers a contribution to a greater
appreciation of the influence of educational models on
nursing students’ perceptions of experiences of clinical
learning environment and supervision.
References
1. Henderson A, Cooke M, Creedy DK, Walker R. Nursing
students’ perceptions of learning in practice environments: a
review. Nurse Educ Today 2012; 32: 299-302.
2. Sundler AJ, Pettersson A, Berglund M. Undergraduate nursing students’ experiences when examining nursing skills in
clinical simulation laboratories with high-fidelity patient
simulators: A phenomenological research study. Nurse Educ
V. Cremonini, P. Ferri, G. Artioli, et al.
oday 2015; 25. pii: S0260-6917(15)00162-8. [Epub ahead
T
of print]
3. Ministro dell’Istruzione, dell’Università e della Ricerca,
Ministro del Lavoro, della Salute e delle Politiche sociali.
Decreto Interministeriale 19 febbraio 2009. Determinazione
delle classi delle lauree delle professioni sanitarie. Available
from: http://attiministeriali.miur.it/anno-2009/febbraio/di19022009.aspx
4. Saiani L, Palese A, dal Ponte A, et al. Proposta di Regolamento Didattico del Corso di Laurea in Infermieristica.
Obiettivi, metodo e principali risultati. Med Chir 2011; 52:
2302-6.
5. Papp I, Markkanen M, von Bonsdorff M. Clinical environment as a learning environment: student nurses’ perceptions
concerning clinical learning experiences. Nurse Educ Today
2003; 23: 262-8.
6. Skaalvik MW, Normann HK, Henriksen N. Clinical learning environment and supervision: experiences of Norwegian
nursing students - a questionnaire survey. J Clin Nurs 2011;
20: 2294-304.
7. Papastavrou E, Lambrinou E, Tsangari H, Saarikoski M,
Leino-Kilpi H. Student nurses experience of learning in the
clinical environment. Nurse Educ Pract 2010; 10: 176-82.
8. Houghton CE, Casey D, Shaw D, Murphy K. Staff and students’ perceptions and experiences of teaching and assessment in Clinical Skills Laboratories: interview findings from
a multiple case study. Nurse Educ Today 2012; 32: e29-34.
9. Haraldseid C, Friberg F, Aase K. Nursing students’ perceptions of factors influencing their learning environment in
a clinical skills laboratory: A qualitative study. Nurse Educ
Today 2015; 35: e1-6.
10. Morgan R. Using clinical skills laboratories to promote theory–practice integration during first practice placement: an
Irish perspective. J Clin Nurs 2006; 15: 155-61.
11. D urham CF, Alden KR. Enhancing Patient Safety in Nursing Education Through Patient Simulation. EditorsIn:
Hughes RG, editor. Source Patient Safety and Quality: An
Evidence-Based Handbook for Nurses. Rockville (MD):
Agency for Healthcare Research and Quality (US), Apr.
Chapter 51, 2008.
12. Ward-Smith P. The effect of simulation learning as a quality
initiative. Urol Nurs 2008; 28: 471-3.
13. Arthur C, Levett-Jones T, Kable A. Quality indicators for
the design and implementation of simulation experiences: a
Delphi study. Nurse Educ Today 2013; 33: 1357-61.
14. Ewertsson M, Allvin R, Holmström IK, Blomberg K.
Walking the bridge: Nursing students’ learning in clinical
skill laboratories. Nurse Educ Pract 2015; 15: 277-83.
15. Jeffries PR. A framework for designing, implementing, and
evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect 2005; 26: 96-103.
16. Cant RP, Cooper SJ. Simulation-based learning in nurse
education: systematic review. J Adv Nurs 2010; 66: 3-15.
17. Harder BN. Use of simulation in teaching and learning in
health sciences: a systematic review. J Nurs Educ 2010; 49:
23-8.
Nursing students’ satisfaction with the clinical learning environment
18. Sanford PG. Simulation in nursing education: a review of
the research. Qual Rep 2010; 15: 1006-11.
19. Khalaila R. Simulation in nursing education: an evaluation
of students’ outcomes at their first clinical practice combined with simulations. Nurse Educ Today 2014; 34: 252-8.
20. Tosterud R, Hedelin B, Hall-Lord ML. Nursing students’
perceptions of high- and low-fidelity simulation used as
learning methods. Nurse Educ Pract 2013; 13: 262-70.
21. Leigh GT. High-fidelity patient simulation and nursing
students’ self-efficacy: a review of the literature. Int J Nurs
Educ Scholarsh 2008; 5: article 37.
22. Bland AJ, Topping A, Wood B. A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Educ Today 2011; 31: 664-70.
23. Meyer T, Xu Y. Academic and clinical dissonance in nursing
education: are we guilty of failure to rescue? Nurse Educ
2005; 30: 76-9.
24. Norman L, Buerhaus PI, Donelan K, McCloskey B, Dittus
R. Nursing students assess nursing education. J Prof Nurs
2005; 21: 150-8.
25. Benner et al., 2010 P. Benner, M. Sutphen, V. Leonard, L.
Day Educating Nurses: A Call for Radical Transformation.
San Francisco: Jossy-Bass 2010.
26. F lood LS, Robinia K. Bridging the gap: strategies to integrate classroom and clinical learning. Nurse Educ Pract
2014; 14: 329-32.
27. Reilly A, Spratt C. The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: a
case report from the University of Tasmania. Nurse Educ
Today 2007; 27: 542-50.
28. Murray C, Grant MJ, Howarth ML, Leigh J. The use of
simulation as a teaching and learning approach to support
practice learning. Nurse Educ Pract 2008; 8: 5-8.
29. Lasater K. High-fidelity simulation and the development of
clinical judgment: students’ experiences. J Nurs Educ 2007;
46: 269-76.
30. Mikkelsen J, Reime MH, Harris AK. Nursing students‘
learning of managing cross-infections--scenario-based
simulation training versus study groups. Nurse Educ Today
2008; 28: 664-71.
31. Szpak JL, Kameg KM. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clin Simul Nurs 2013; 9:e13–e19.
32. Bremner MN, Aduddell K, Bennett DN, VanGeest JB. The
use of human patient simulators: best practices with novice
nursing students. Nurse Educ 2006; 31: 170-4.
33. Shin S, Park JH, Kim JH. Effectiveness of patient simulation in nursing education: meta-analysis. Nurse Educ Today
2015; 35: 176-82.
34. Liaw SY, Scherpbier A, Rethans JJ, Klainin-Yobas P. Assessment for simulation learning outcomes: a comparison
of knowledge and self-reported confidence with observed
clinical performance. Nurse Educ Today 2012; 32: e35-9.
35. Norman J. Systematic review of the literature on simulation
in nursing education. ABNF J 2012; 23: 24-8.
36. Roh YS, Lim EJ. Pre-course simulation as a predictor of
203
satisfaction with an emergency nursing clinical course. Int J
Nurs Educ Scholarsh 2014; 11.
37. Zilembo M, Monterosso L. Towards a conceptual framework for preceptorship in the clinical education of undergraduate nursing students. Contemp Nurse 2008; 30: 89-94.
38. Parker B, Myrick F. Transformative learning as a context for
human patient simulation. J Nurs Educ 2010; 49: 326-32.
39. Bultas MW. Enhancing the pediatric undergraduate nursing curriculum through simulation. J Pediatr Nurs 2011; 26:
224-9.
40. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH,
Wayne DB. Does simulation-based medical education with
deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the
evidence. Acad Med 2011; 86: 706-11.
41. Stayt LC, Merriman C. A descriptive survey investigating pre-registration student nurses‘ perceptions of clinical
skill development in clinical placements. Nurse Educ Today
2013; 33: 425-30.
42. Al-Kandari F, Vidal VL, Thomas D. Assessing clinical
learning outcomes: a descriptive study of nursing students
in Kuwait. Nurs Health Sci 2009; 11: 252-62.
43. Donnelly F, Wiechula R. Clinical placement and case study
methodology: a complex affair. Nurse Educ Today 2012; 32:
873-7.
44. Henderson S, Happell B, Martin T. Impact of theory and
clinical placement on undergraduate students‘ mental health
nursing knowledge, skills, and attitudes. Int J Ment Health
Nurs 2007; 16: 116-25.
45. Levett-Jones T, McCoy M, Lapkin S, et al. The development and psychometric testing of the Satisfaction with
Simulation Experience Scale. Nurse Educ Today 2011; 31:
705-10.
46. Myrick F, Yonge O. Preceptor behaviors integral to the
promotion of student critical thinking. J Nurses Staff Dev
2002; 18: 127-33.
47. Stockhausen LJ. Learning to become a nurse: students’
reflections on their clinical experiences. Aust J Adv Nurs
2005; 22: 8-14.
48. Ousey K. Socialization of student nurses: the role of the
mentor. Learn Health Soc Care 2009; 8: 175-84.
49. O’Mara L, McDonald J, Gillespie M, Brown H, Miles L.
Challenging clinical learning environments: experiences of
undergraduate nursing students. Nurse Educ Pract 2014;
14: 208-13.
50. D’Souza MS, Karkada SN, Parahoo K, Venkatesaperumal
R. Perception of and satisfaction with the clinical learning
environment among nursing students. Nurse Educ Today
2015; 35: 833-40.
51. Hegenbarth M, Rawe S, Murray L, Arnaert A, ChambersEvans J. Establishing and maintaining the clinical learning
environment for nursing students: a qualitative study. Nurse
Educ Today 2015; 35: 304-9.
52. Saarikoski M, Leino-Kilpi H. The clinical learning environment and supervision by staff nurses: developing the instrument. Int J Nurs Stud 2002; 39: 259-67.
204
53. Warne T, Johansson UB, Papastavrou E, et al. An exploration of the clinical learning experience of nursing students
in nine European countries. Nurse Educ Today 2010; 30:
809-15.
54. Forrest S, Brown N, Pollock L. The clinical role of the nurse
teacher: an exploratory study of the nurse teacher’s present
and ideal role in the clinical area. J Adv Nurs 1996: 24:
1257-64.
55. Corlett J, Palfreyman JW, Staines HJ, Marr H. Factors influencing theoretical knowledge and practical skill acquisition in student nurses: an empirical experiment. Nurse Educ
Today 2003; 23: 183-90.
56. Gustafsson M, Kullén Engström A, Ohlsson U, Sundler AJ,
Bisholt B. Nurse teacher models in clinical education from
the perspective of student nurses - A mixed method study.
Nurse Educ Today 2015. [Epub ahead of print]
57. Hart G, Rotem A. The best and the worst: students’ experiences of clinical education. Aust J Adv Nurs 1994; 11: 26-33.
58. D unn SV, Hansford B. Undergraduate nursing students’
perceptions of their clinical learning environment. J Adv
Nurs 1997; 25: 1299-306.
59. Löfmark A, Wikblad K. Facilitating and obstructing factors
for development of learning in clinical practice: a student
perspective. J Adv Nurs 2001; 34: 43-50.
60. Robinson AL, Andrews-Hall S, Fassett M. Living on the
edge: issues that undermine the capacity of residential aged
care providers to support student nurses on clinical placement. Australian Health Review 2007; 31: 368-78.
61. Hope A, Garside J, Prescott S. Rethinking theory and practice: pre-registration student nurses experiences of simulation teaching and learning in the acquisition of clinical
skills in preparation for practice. Nurse Educ Today 2011;
31: 711-5.
62. Courtney-Pratt H, FitzGerald M, Ford K, Marsden K,
Marlow A. Quality clinical placements for undergraduate
nursing students: a cross-sectional survey of undergraduates
and supervising nurses. J Adv Nurs 2012; 68: 1380-90.
63. Kaphagawani NC, Useh U. Analysis of Nursing Students
Learning Experiences in Clinical Practice: Literature Review. Ethno Med 2013; 7: 181-5.
64. Bezuidenhout MC, Koch S, Netshandama VO. The role of
the ward manager in creating a conducive clinical learning
environment for nursing students. Curationis 1999; 22: 4652.
65. Chan DSK. Validation of the clinical learning environment
inventory. West J Nurs Res 2003; 25: 519-32.
66. Lockwood-Rayermann S. Preceptors, leadership style, and
the student practicum experience. Nurse Educ 2003; 28:
247-9.
67. Magnani D, Di Lorenzo R, Bari A, Pozzi S, Del Giovane
C, Ferri P. The undergraduate nursing student evaluation of
clinical learning environment: an Italian survey. Prof Inferm
2014; 67: 55-61.
V. Cremonini, P. Ferri, G. Artioli, et al.
68. Leducq M, Walsh P, Hinsliff-Smith K, McGarry J. A key
transition for student nurses: the first placement experience.
Nurse Educ Today 2012; 32: 779-81.
69. Ferri P, Rovesti S, Saguatti K, Pisani M, Magnani D. El
abandono universitario: Qué motiva a los estudiantes a dejar
el Curso de Grado en Enfermería? AgInf 2014; 71: 114-9.
70. Herdman TH, Kamitsuru S. Nanda International, Diagnosi
infermieristiche. Definizione e classificazione. Milano: Casa
editrice ambrosiana 2015.
71. Carpenito – Moyet LJ. Piani di assistenza infermieristica e
documentazione. Diagnosi infermieristiche e problemi collaborativi. Milano: Casa editrice ambrosiana 2011.
72. Saarikoski M, Isoaho H, Warne T, Leino-Kilpi H. The
nurse teacher in clinical practice: developing the new subdimension to the Clinical Learning Environment and
Supervision (CLES) Scale. Int J Nurs Stud 2008; 45: 12337.
73. Tomietto M, Saiani L, Palese A, et al. Clinical learning environment and supervision plus nurse teacher (CLES+T)
scale: testing the psychometric characteristics of the Italian
version. G Ital Med Lav Ergon 2012; 34: B72-80.
74. Nunnally JC, Bernstein IH. Psychometric Theory. New
York: McGraw-Hill 1994.
75. Comparcini D, Simonetti V, Tomietto M, et al. Nursing
students’ satisfaction and perception of their first clinical
placement: observational study. Prof Inferm 2014; 67: 41-7.
76. Sundler AJ, Björk M, Bisholt B, Ohlsson U, Engström AK,
Gustafsson M. Student nurses’ experiences of the clinical
learning environment in relation to the organization of supervision: a questionnaire survey. Nurse Educ Today 2014;
34: 661-6.
77. Papathanasiou IV, Tsaras K, Sarafis P. Views and perceptions of nursing students on their clinical learning environment: Teaching and learning. Nurse Educ Today 2014; 34:
57-60.
78. Cooper J, Courtney-Pratt H, Fitzgerald M. Key influences
identified by first year undergraduate nursing students as
impacting on the quality of clinical placement: A qualitative
study. Nurse Educ Today 2015; 35: 1004-8.
79. Ekebergh M. Lifeworld-based reflection and learning: a
contribution to the reflective practice in nursing and nursing education. Reflective Pract 2007; 8: 331-43.
Accepted: 1 october 2015
Correspondence:
Paola Ferri
First Level Degree Course in Nursing, section of Modena,
via del Pozzo n. 71
41124 Modena
Fax 059/4222520
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 205-211
© Mattioli 1885
Original article: professional education
Peer Tutoring and Clinical Stage: analysis of experience and
potential applications in the First Level Degree Course in
Nursing, section of Desenzano Del Garda
Paolo Lo Biondo1, Nicola Avino2, Enrica Podavini3, Matteo Prandelli4
Nurse Preceptor and Teacher, First Level Degree Course in Nursing, section of Desenzano del Garda; 2 Freelance Nurse, formerly student of First Level Degree course in Nursing, section of Desenzano del Garda; 3 Nurse Coordinator and Teacher, First
Level Degree Course in Nursing, section of Desenzano del Garda; 4 Nurse Preceptor and Teacher, First Level Degree Course in
Nursing, section of Desenzano del Garda
1
Abstract. Among the various methods of learning and experience in the literature, the methodology of Peer
Tutoring is particularly important for the formation of the student nurses. The Peer Tutoring identifies a
model of cooperative learning, aiming to activate a spontaneous process to transfer knowledge, emotions and
experiences from some members of a group to other members of equal status but with a difference in the
knowledge and cognitive skills or relational. The First level degree course in Nursing, section of Desenzano
del Garda (Brescia, Italy) has been applying a methodology that can be defined as Peer Tutoring for the last
four years. The applicability of the method is based on the coupling of an expert student of the 3rd year of the
course to a group of students from the 1st or 2nd year. The study has the main objective to analyze the experience in the branch of Desenzano del Garda and see if the learning method of the Peer Tutoring is valid within
the context of clinical internship. The study, of descriptive-observational type, was conducted in the academic
year 2013-2014. The samples in the research are two: the first sample consisted of 53 students in their first
year of studies, 46 students of the 2nd year of the course and 30 students of the 3rd year of the course who
attended the experience as tutoring students (students tutors), for a total of 129 students; the second sample
consisted of 15 students of the 3rd year of the course who attended the experience of the Peer Tutoring applied to the Stage clinical students as tutors (students Tutor). The research allowed important information
to be gathered regarding the utility and interventions to improve the quality of the project of Peer tutoring.
Peer Tutoring is a learning methodology that works and that can be applied in learning pathways for nursing
students. The training of students Tutor is a matter of considerable importance: in fact the students ask to be
trained to respect the structure and functions of the organizations in which they are inserted, in the management of the groups, the educational skills and techniques and teaching strategies.
Key words: peer tutoring, students partnership, cooperative learning, nursing students learning, peer learning
Introduction
As with all professions, especially those that
deal with health, education plays a fundamental role.
Training that can not only come from the lectures in
the classroom but that, in the specific field of nursing, must actualize, realize, implement the theoretical
knowledge in educational skills, relational practices,
etc. within the experiences of clinical internships provided by the study plan.
Among the various methods of learning experience
and literature proposals (1), the methodology of Peer
Tutoring is particularly important for the formation of
the student nurses. The Peer Tutoring identifies a model
206
of cooperative learning, aiming to activate a spontaneous
process to transfer knowledge, emotions and experiences from some members of a group to other members of
equal status but with a difference in the knowledge and
cognitive skills or relational. We talk about Peer Tutoring when switching between students with more knowledge (Tutor) and students with less knowledge (Tutee)
where a plan occurs that includes goals, timing, ways,
roles and structured materials. Peer Tutoring is linked to
the theory of the “zone of proximal development” (2),
enunciated by LS Vigotsky, according to which contact
with peers within a group, allows the achievement of
results more advanced than those achievable through
individual activities. Similar approaches were described
for the first time in 1806 by the English Lancasterian
System (3), and introduced later in the United States
in the field of primary and secondary education (4).
The interaction between teacher and learner shows the
learner has significantly higher anxiety than that found
in the interaction with that of their own age: this is the
basis that prompted the application of the method of
the Peer Tutoring in primary and secondary schools.
Since the ‘70s the peer teaching methodology began to show how it produced better effects than conventional methods (5, 6) and the merit of this was attributed to individualized instruction and the feedback
received by the educator. Similarly, years later another
Study (7) showed how the strategy was going to improve the students’ motivation, participation, communication, and empowerment in learning and self-confidence. Davidson and McArdle (8) of highlighted the
interpersonal growth and the development of learning
to apply affective relations within the group. Other aspects were highlighted by Erikson, who showed that
the experience of learning with a peer made the learning easier for the students tutoring, gave a responsibility to the student tutors, and for both a better evaluation in performance (9). Also, tutoring provides a
strong model in the learning of solidarity, mutual support and the acceptance of others (10).
Objective of the study
Starting from the experience of the First Level
Degree Course in Nursing, section of Desenzano del
P. Lo Biondo, N. Avino, E. Podavini, M. Prandelli
Garda, the main objective was to evaluate the learning methodology of Peer Tutoring in clinical internship. Secondary objectives were to detect any potential
problems, strengths and to find out the general opinions of the usefulness and acceptance of the project by
the students who took part in the experience.
The experience of the First Level Degree Course in
Nursing, section of Desenzano del Garda
The First Level Degree Course in Nursing in the
section of Desenzano del Garda, together with the
University of Brescia, has applied a methodology for
the past four years, that can be defined as Peer Tutoring for the students in apprenticeship. The applicability of the method is in fact based on the coupling of an
experienced student of the 3rd year of the course to a
group of students from the 1st or 2nd year. The idea of​​
using this method to facilitate the learning of students
came about after some considerations: the first aspect
regarded the path of the study of the students, or the
lack/absence of a specific area in which the student
could put to use their abilities in the management of
groups of colleagues, or support staff or other support
workers. The second aspect regarded the possibility of
offering the tutor students the chance of putting their
knowledge to use, elaborating them to make them usable by someone else. The third and last aspect could
be defined as “tutorial:” the first training in the 1st year
and the 2nd year, respectively represent the first approach of the students in a hospital and to the testing
of activity and complex procedures. The time of crisis
experienced by hospitals and the consequent shortage
of nursing staff available to devote to specific activities
such as managing groups of beginner students, therefore represented an opportunity for the inclusion of
the experienced students of the third year, who would
be able to “protect” and help the group of students
from the 1st and 2nd years.
The project of internship of 40 hours a week, lasts
for approximately two months. The first shift is prefered
for the duration of the internship, so as to ensure a continuity in the take over by the assistant internship who,
for most of the time and within the limits of organizational possibilities, is dedicated. Participants in the pro-
207
Peer Tutoring and Clinical Stage
ject, students of 1st and 2nd year (Tutee) and students
of the 3rd year (Tutor), have different tasks, still aim to
achieve a common goal, thus making them participants
in a cooperative learning model. The former have the
opportunity in assisting people taken into care through
interventions provided by a schedule for goals, the latter
experience in taking charge of a group of people assisted, and the ability to assign and evaluate nursing interventions to other operators. On average, to each student
tutor and Ward, a group of 6-8 students are assigned,
managed and supervised, above all in the initial stages,
by students training. The taking over by the students of
the 1st and 2nd year occurs gradually, in parallel with
the planning and agreement of the Student Tutor and
Assistant Internship. Therefore, even structurally, a division in the Ward leading to the formation of a “zone
of action” is created, where teams composed of Tutee
and Tutor programme, manage, put into act and verify
the various nursing activities; thus ensuring a total continuity of caring and assistance. This step allows an organization that is most orientated to obtaining results,
and that remains the final idea for the entire group.
In preparation to the internship, a meeting is held
in which the project is presented to all of the students
involved. They are presented with the main characteristics of the project and the role of student tutors, valuing the business of micro-team work and work in collaboration. After this meeting, the group of students
of the 1st or 2nd year have the chance of meeting the
“expert” students of the 3rd year in order to meet, exchange ideas and shed doubts.
Materials and methods
The study was conducted in the academic year
2013-2014 and involved all three years of the course.
Sampling
Through a non-probability sampling of convenience, the participants were:
- 53 students of the 1st year of the course, 46 Students of the 2nd year of the course and 30 Students of the 3rd year; for a total of 129 students,
all participants of the Peer Tutoring experience
applied clinically to the internship as student
tutors (as from now referred to as “Tutee”);
- 15 Students of the 3rd year participated in an
experience of Peer Tutoring, and then applied
to the internship as clinical tutor students (from
now on referred to as “Tutor”).
Survey instruments
The survey instruments have been two self-reports
of which one was administered to the student Tutor
and one to the student Tutee. The period administered
was from 8th September 2014 to 8th October 2014.
The questionnaire for student Tutees is divided
into five parts:
1) generic profile: 3 multiple choice questions
(gender, age and academic year of membership);
2) value of experience: 3 multiple choice questions
to assess the pleasure and usefulness of the experience;
3) role of the student tutors: 5 multiple choice
items, designed to investigate the characteristics of the student tutors who have or should
have the project Peer tutoring and its contribution to the path of learning;
4) skills of the student tutors: one open question
that is asked to the Tutee students: Which
skills should tutor student have;
5) elaboration of each personal experience: 4 open
questions, in which students are asked to explain positive and negative aspects of the experience, problems
and any suggestions.
Similarly, the questionnaire that is addressed to
the Tutor is also divided into five parts:
1) generic profile: 3 multiple choice questions
(gender, age and academic year of membership);
2) value of experience: 4 multiple choice questions
where the tutor is asked how clear their role
is, and how useful the experience in terms of
growth and learning has been;
3) skills learned: 2 items to be valuated by the
skills of the student regarding what they have
learned during the Tutor Peer course and how
they applied it to clinical internship;
208
4) the role of the student tutors: 2 items of which
a multiple-choice and open-ended one, investigating the characteristics and skills of the
“good Tutor” according to the student involved;
5) Re-elaboration of each personal experience: 5
items; a multiple choice and four open questions, where students describe positive and
negative aspects of their experiences and gave
any suggestions to improve it.
The questions for both questionnaires were structured in a simple, clear language. Questionnaires were
also pre-tested by three people who didn’t find any critical problems in the completing of the test. The results
from the pre-tests show that the estimated time for the
completion of both questionnaires is 7/8 minutes.
Procedure
The questionnaires were created by software
which have allowed us to send them to students via
email. The questionnaires were addressed to students
on an Excel file, that was received while maintaining
the anonymity of the respondent.
Search results
Personal characteristics of the participants
The students who responded to the “Tutee Questionaire” were 89/129 with a compliance of 69%. 78%
were female, 22% male. The sample aged between 1825 years was 85%, from 26-35 years 14% and 1% were
36-45 years. Of which 39% belonged to the 1st year of
the course, 37% to the 2nd year of study and 24% to the
3rd year of the course (in the last ones only those who
had not participated in the project as “student Tutors”).
The “Tutor Questionnaire” demonstrated 15 students out of 15 who responded, for a total rate of 100%,
all female. 93% of the sample were aged between 1825 years, 7% between 26-35 years. As shown by the
project, 100% of the students belonged to the 3rd year
of the course.
Data “Tutee questionnaire”
In the aspect of utility, the experience was overall
judged very positively by the students tutoring (47%
answered “very much”, 24% “a lot”, 21% “fairly”, 7%
P. Lo Biondo, N. Avino, E. Podavini, M. Prandelli
“little”, no one answered “very little”). In fact ‘85% of
the sample declared “agreement” or “total agreement”
in stating that the purpose of their learning experience
was significant.
87% of respondents claimed to have experienced
critical reflection, comparisons, personal growth and
professional characteristics during the experience.
According to 72% of the sample, the presence of the
student tutors helped to make the clinical context of
the Operating Units less intense regarding anxiety and
more appropriate to their learning needs.
When in doubt, most of the students Tutee (70%)
in the first instance turned to the student tutors, while
27% turned to the training assistant, and the remaining
13% turned to both or the nurses who were present.
In relation to “facilitating role” that the experienced students of the 3rd year will do for learning and
skills development, 43 (48%) students answered that
they “agreed” and 25 (28%) “fully agree”; the remainder
(24%) were “uncertain” or “disagreed”.
The experience of the peer internship has contributed positively in the technical, relational and educational development.
Finally, in relation to their personal experiences,
91% of students said that the presence of the student
tutors represented an added value that should always
be present for ‘new’ students; 9% of the sample said
they were “uncertain” regarding this statement.
Students who had lived the Tutee experience were
asked to indicate which skills were required to play the
role of “Tutor student”. Having the option in the questionnaire to indicate a maximum of 3 answers, showed
that soft skills, technical, organizational, management
groups, education and adequate training in peer tutoring are among the most important, together with good
personal characteristics as humility, passion for the role
and the profession, sincerity and transparency in relationships and good predisposition to listening and peer
relationship tutorial.
Compared to the difficulties faced by students
in the tutoring project of Peer Tutoring, 29 students
(33%) have not found any, but 26 students (30%) claim
to have found difficulties in the relationship with the
student tutors; 16 students (18%) mentioned difficulties of organizational type (for example, and especially
in the too high number of students assigned to an in-
209
Peer Tutoring and Clinical Stage
dividual student Tutor); 7 (8%) instead indicated “personal” difficulties (for example, the initial fear, the difficulties of performing procedures never experienced
previously or skepticism towards the project); 11 students did not answer the question.
Among the positive aspects mainly the figure of
the student tutors are mentioned (71%): their availability, collaboration, patience, kindness, listening and
their point of reference. Other aspects relate to the
facilitation of learning, the organization of the experience and the development of personal characteristics.
Finally the Tutee students were asked to make
suggestions in order to improve the quality of “peer
training” in the future experience: 46 students (48%)
have made proposals relating to the organization, such
as fewer students for each tutor or an environment
with optimal characteristics for the implementation of
the project; 24 students (25%) have put forward proposals for the Tutor (such as training, selection criteria
clearly defined); 6 students (6%) have asked to extend
the experience even for internships which have not
yet been scheduled, 3 (3%) people have not made any
statement, and 1 (1%) student asked to eliminate the
experience, 16 students did not respond.
Data “Questionnaire Tutor”
Even the majority of the Tutor students considered the experience particularly significant (53% said
“very” significant; 40% “very much”), aboveall in terms
of learning (93%).
These also declared with “agree” or “strongly agree”
in saying that the experience of the internship peer is
cause for critical reflection, comparison and personal/
professional growth.
The internship peer allowed tutor students the development of skills, especially interpersonal and educational; to a lesser extent those technical and organizational. Students themselves have stated, however,
in being aware that there are also necessary organizational skills and techniques, in fact among the areas
where training would be useful, (28%) indicated organizational, (23%) group management, teaching and
critical development (17%) both teaching and critical
development, (9%) education and (6%) relational.
Among the difficulties faced, above all organizational aspects emerged (76%); to a lesser extent the
relational aspects with assistant training (12%), minor
opportunities for personal learning in respect to procedures and clinical activities (because we are committed to managing the group of students) (6%) and
difficulties “in developing critical thinking colleagues
(students) “(6%).
On the plus side it was found that the experience was a source of satisfaction and personal growth
(44%), it enabled the development of soft skills (28%),
it had a positive effect on learning (24%) and it allowed
students to grasp new organisational aspects (4%).
To whoever is going to live the experience as a
Tutor, students have suggested they do not show anxiety, fear or worry (28%), to have a spirit of sacrifice
(10%), patience (10%), to be organized ( 7%) and ready
to listen (7%), team up and work with assistant training (7%), to be available (7%), proactive, enthusiastic,
empathetic, authoritative and non-intrusive, willing to
listen and understand if you are suited to the role (respectively 3%).
In comparison, however, with the guidelines
to improve the quality of peer training, the students
suggested improving their organization (45%), the
training of assistants training (27%), and student Tutors (9%), of giving students the freedom to join or
not to join the project, so no specific criteria for inclusion (9%), to improve relations between the degree
program and operating units (5%) and provide a final
detail of the experience (5%).
Discussion
Compared with the results collected and analyzed,
it is totally possible to judge a positive experience of
Peer Tutoring applied to the internship from the proposed clinical degree program in the section of Desenzano del Garda: as already mentioned, in fact, 91%
of the Tutee students said that the presence of the
student Tutor represented an added value that should
always be present in the experience of internship. The
student Tutors represented a true point of reference to
turn to more, especially if well trained and prepared
for the role. As already mentioned in literature (11),
this is probably due to the fact that the student is more
comfortable in the company of a peer, rather than with
210
a more experienced nurse who has, (according to the
student), a much higher level of expectations. Moreover, the presence of the student Tutors allows both the
student Tutor and the Student Tutee, the development
of soft skills and education, as well as technical (the
latter to a lesser extent to the student Tutors, probably because they are involved in the management of
a group).
Other positive aspects regarded on one hand (student Tutor), is a strong personal gratification, the development of soft skills and the opportunity to seize
new organizational realities experienced; on the other
(student Tutee) the presence of the student Tutor (in
terms of availability, patience, kindness, listening), facilitating learning and the development of personal
characteristics that arise from the comparison between
peers (which are probably inhibited in the student in
comparison to training assistants and nurses experienced).
However, despite this, difficulties have emerged
in the implementation of the methodology and the
proposals made by students to improve the quality of
this experience:
- Among the proposals for improvement, the
possibility of reducing the number of Tutee students assigned to each student Tutor, 6-8 (as
provided in the project) to 3-4 students. Since
the organizational requirements of the degree
course are many and complex, the number of
students undoubtedly could not be reduced;
also learning how to organise and work with a
larger group, represents an opportunity for the
student to prepare for the management of even
the largest groups that the professional future
may offer.
- The proposal to adjust the characteristics of the
Operating Units were put forward, functionally
regarding the performance of the internship: the
adequate number of nurses, enough space and
suitable environment, exchange of information
and direct involvement with the Coordinators.
Being aware of the real difficulties that the Italian public health faces throughout the years in
respect to the first three features given, much
more could be done in the exchange of information and the involvement of the coordinators, as
P. Lo Biondo, N. Avino, E. Podavini, M. Prandelli
emerged and was suggested by another study
conducted in the same Public Health Hospital
(11), in the role of coordinator in the process of
student learning.
- Among the various proposals put forward, the
training of students Tutor has been a matter of
considerable importance: the students ask for
this to be formed with respect regarding the
structure and functions of the organizations in
which they are inserted, in the management of
the groups, the educational skills and the techniques and teaching strategies. The training,
along with specific objectives designated for the
role of student Tutors, could increase the quality of the experience of Peer Tutoring by both
partecipants involved (Tutor and Tutee). Regarding this, the identification of (mini) specific
training courses organized within the hours of
training (therefore without affecting the programs and study plans) could be further development of research with respect to this study.
Along with the training of students, including
the training of assistants training, it would bring
added value that would help to improve the
quality of experience (3).
Compared to the answers provided by a student
Tutor, the definition of specific criteria for inclusion in
the project would also be useful, as the apparently unjustified choice by the Tutor of teaching and involvement in the project was complained about. In contrast,
however, other students initially skeptical, would be
prepared to recommend the experience to anyone who
has the desire to experience new skills and aspects of
the profession.
The training and the identification of inclusion
criteria for students Tutor therefore represent, the
critical aspects of the experience: compared to the specific training of the student Tutor, since it is not provided in the curriculum, few moments are dedicated
together with tutor teaching that guides the student
to the group management; in contrast with the criteria
of identification of the student in the role of tutor, the
tutor of the course is the one who agrees to the plan
and the personal and professional characteristics of the
student and chooses and agrees with the latter the opportunity to insert them into the project.
Peer Tutoring and Clinical Stage
Conclusions
Research conducted within the First Level Degree Course in nursing in the branch of Desenzano
del Garda, belonging to the University of Brescia, has
allowed us to collect important information about the
usefulness and interventions to improve the quality of
the project of Peer Tutoring . Summarily, the experience was considered very positively by the students
involved, although several aspects deserve improvements.
Peer Tutoring is therefore a learning methodology that works and that can be applied in learning
pathways for nursing students. The comparison among
peers is a means through which the student learns in a
friendly environment, with minor anxieties and apprehensions: learning experienced in this way, has a positive connotation in the mind of the student, because it
is supported by positive emotions.
If properly supported by specific training and
specification of the inclusion criteria for the student
Tutors, the quality of the experience could further improve.
211
La supervisione e l’insegnamento tra pari: la percezione degli studenti e del tutor clinico, Professioni infermieristiche.
Torino, 2009; 62(1): 17-22
4. Lippit P. Students teach students, Phi Delta Kappa Foundation, Bloomington, Indiana, 1975; 6-42.
5. Cason C, Cason G, Bartnik D. Peer instruction in professional nurse education: a qualitative-case study. Journal of
Nursing Education 1977; 16: 10-22.
6. Alice JT, Yuen Loke, Filomena LW, Chob, Learning partnership - the experience of peer tutoring among nursing
students: A qualitative study. International Journal of Nursing Studies 2007; 44: 237-244.
7. Kammer C. Using peer groups in nursing education. Nurse
Educator, 1982; 7 (6): 17-21.
8. Davidson M, McArdle P. Peer analysis of interpersonal responsiveness and plan for encouraging effective reshaping,
Journal of Nursing Education 1980; 19 (3): 8-12.
9. Erikson G. Peer evaluation as a teaching-learning strategy
in baccalaureate education for community health nursing.
Journal of Nursing Education 1987; 26 (5): 204-206.
10. Chiari G. Educazione interculturale e apprendimento cooperativo: teoria e pratica della educazione tra pari, 2011,
Trento, Quaderni del Dipartimento di Sociologia e Ricerca
Sociale; 57.
11. Oliosi M. Il Coordinatore e la qualità dei contesti di apprendimento clinico: indagine conoscitiva nell’Azienda
Ospedaliera di Desenzano del Garda, 2015, Tesi master in
Coordinamento, Brescia, Università Cattolica Sacro Cuore,
Fondazione Poliambulanza.
References
1. Maioli S, Mostarda PM. La formazione continua nelle organizzazioni sanitarie, tra contributi pedagogici e modelli
operativi. McGraw-Hill, Milano, 2008: 2-6.
2. Vygotsky LS. Il processo cognitivo, Boringhieri, Torino, 1980.
3. Bulfone G, Cremonini R, Zanini A, Tesolin S, Bresadola V.
Accepted: 15 october 2015
Correspondence:
Dr. Paolo Biondo
Nurse Preceptor and Teacher, First Level Degree Course in
Nursing, section of Desenzano del Garda
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 212-222
© Mattioli 1885
Original article: professional education
Being an overseas student at the Faculty of Medicine and
Surgery of the University of Parma: the perceptions of
students from Cameroon
Giuliana Masera 1, Catherine Jolie Ngo Bikatal 1, Annavittoria Sarli2, Leopoldo Sarli3
Corso di laurea in Infermieristica, Università degli studi di Parma, sede didattica di Piacenza; 2Fondazione ISMU - Iniziative
e studi sulla multietnicità, Milano; 3Dipartimento di Scienze Chirurgiche dell’Università degli studi di Parma, Centro Universitario per la Cooperazione Internazionale (CUCI)
1
Abstract. There is a steady rise in the number of overseas students taking degree courses at the Medicine and
Surgery faculties of Italian Universities. Numerous scholars, mainly from the English speaking world, have
testified to the fact that a university teaching organisation aimed at attaining good levels of integration among
students of differing cultural appurtenance is a prerequisite for success in the acquisition of good treatment
practices. Aim: To explore the experience of students from Cameroon studying on the degree courses in Medicine and Surgery and in Nursing at the University of Parma, in order to discover the strong and weak points
of the organisation of the courses so as to achieve a good process of integration. Materials and methods: An
ethnographic study plan was adopted. In-depth interviews were conducted with 20 students from Cameroon
enrolled in the Faculty of Medicine of Parma University: 10 in the Degree Course in Medicine and Surgery
and 10 in the Degree Course in Nursing. The interviews were recorded and analysed independently by two
researchers, who then pooled their results. The age of the interviewed ranges from 24 to 31, the average age is
26,5. Results: Independently from the attended degree course, most of the students interviewed claim that the
process of integration has not been very successful: despite attempts to open up a dialogue with their Italian
counterparts in order to get to know them, the latter showed no signs of willingness to integrate. Some students develop a self-critical attitude, maintaining that it would be a good idea to strengthen their awareness of
their own cultural identity so as to start from a firm base in the attempt to open up to the host society without
defensive attitudes that lead to ostracism. The difficulties of socialisation are compounded by those of learning, which many attribute to the language difficulties and some to the differing academic organisation between
country of origin and host country. Discussion: The problem of the difficulties of integration of overseas students
is not new. In other geographical locations, changes to syllabuses designed to solve the problem, at least in part,
have been proposed and successfully implemented. The Italian situation is a particular one, and this preliminary
study yields some ideas for the implementation of changes to the syllabuses of the Italian universities.
Key words: overseas students, phenomenology, university study course, integration
Background
The learning experience, both theoretical and
practical, gained during their training period by overseas students studying for medical degree courses represents an important opportunity for socialisation.
The changes that are taking place in Italian society
involve to an ever greater degree the issue of cultural,
linguistic, social and religious diversity, which is one
of the crucial points in the daily relationships between
autochthonous and overseas students (1). Numerous
scholars, mainly from the English speaking world,
Being an overseas student at the Faculty of Medicine and Surgery of the University of Parma
have testified to the fact that a university teaching
organisation aimed at attaining good levels of integration among students of differing cultural appurtenance
is a prerequisite for success in the acquisition of good
treatment practices (2). Recent international literature attests to the efficacy of didactic measures geared
towards interculturalism and antiracism, in order to
guarantee cultural training designed to tackle cultural
and religious differences, including those encountered
in the administering of welfare services (3).The American Academy of Nursing has emphasised the necessity
for a university reform capable of limiting discriminatory and xenophobic behaviour in the educational context, so as to reduce the disparities in the field of health
Figure 1. The Cameroonian educational system
213
care and to make patients feel more at ease (4,5). Some
studies carried out in the USA report the disparity in
educational opportunities affecting ethnic minorities
as being due both to the economic and social situation
of the students themselves and to the organisation of
University education (6). There are no studies analysing the phenomenon in Italian universities, despite the
fact that nurses from overseas today make up 10 per
cent of the human resources employed in the public
and private health care sectors, many of these professionals having been trained at Italian universities. The
Cameroonian educational system is quite similar to the
Italian one (Fig. 1) and this fact supports the migration from this country since Italy and Cameroon has
214
the same number of years in order to access the University. Prompted by these considerations, we decided
to conduct a research study utilising the personal experience and perceptions of students from Cameroon
attending degree courses in Medicine and Surgery and
in Nursing at the Faculty of Medicine and Surgery of
Parma University, in order to analyse the strong and
weak points of the organisation of the courses with a
view to achieving a good process of integration.
Methods
Research plan
The research study-­was carried out using a qualitative ethnographic method, since we considered this
to be appropriate to the context of analysis. The ethnographic method, utilised in anthropology and for some
time now also in nursing sciences, enables the study
of the customs, representations and experiences of individuals and is indicated on account of its capacity
to examine in-depth the various aspects of the culture
under study (7). The salient feature of an ethnographic
approach is its emphasis on the cultural interpretation;
it can be applied to the study of healthcare experiences, the organisation of human health services and the
practice of nursing and medical treatment. Madeleine
Leininger maintains that it is essential to use the qualitative ethnographic method for an adequate awareness
of the phenomena correlated to medical assistance in
the differing cultures (8).
Method
The instrument utilised for the research was the
in-depth interview. By this means, the ethnographer
can approach the world of his subjects in order to consider their experience in depth. Moving away from an
essentialist conception of culture, we chose not to consider our subjects as exponents of a homogeneous cultural group. This is because we regard our subjects as
individuals who are carriers of values that, far from being unchangeable and inherited once and for all from
their group of appurtenance, are instead the fruit of a
process of individual and creative reprocessing influenced by continuous external stimuli (9). In this light,
G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
relating to a migrant means having to do with a person with a complex individuality that, besides having
developed his own life history, has also developed his
own version of his culture of origin.
The study was designed for students coming from
Cameroon attending the Parma University Faculty of
Medicine and Surgery and resident in Italy for at least
a year. We considered it opportune, at this first stage
of a wider study that is to involve students of other nationalities, to limit the number of interviews to a small
experimental sample so as to be able to analyse them in
depth with a view to identifying themes to be tackled
more deeply at subsequent stages of the study.
The students were asked to take part in the study
by telephone or e-mail after adequate information had
been provided as to the aims and procedures of the
research. Twenty students participated in the study:
10 were studying for the Degree course in Medicine
and Surgery (7 men and 3 women), and 10 in Nursing
(5 men and 5 women). Four students declined to take
part in the study, citing lack of time due to their heavy
study schedule.
Anonymity was guaranteed to all participants, as
well as absolute privacy concerning the data gathered.
Procedure for gathering the experiences
The interviews were, in some cases, “guided” so
as to help the student to express himself with greater
freedom and confidence. They were then recorded,
codified and analysed independently by two researchers, who subsequently pooled their results.
The themes tackled were of a predominantly didactic, social and cultural nature.
The questions covered mainly the following thematic areas:
•A
ccounts of their experience as a student
•L
evel of correspondence of the reality to their
pre-migratory expectations
• I ntentions for the future after their degree
course.
No significant differences in behaviour were observed between women and men during the interviews,
although the men appeared at times more precise and
direct than the women. Most of those participating in
the study showed no difficulty in answering the ques-
Being an overseas student at the Faculty of Medicine and Surgery of the University of Parma
tions. Those conducting the interviews were themselves
from Cameroon, and this may have constituted an advantage, their shared geographical area of provenance
hopefully creating a climate of trust and complicity.
Analysis of the interviews
Differently from what occurs in quantitative research, in which the presence of the researcher is considered a neutral element with respect to the results
yielded, in qualitative research account must be taken
of the consequences of the presence of the observer
within the research study and of his influence on the
construction of the object of the enquiry and on the
course of the field research and the processing of the
results. While the point of view of those studied (emic)
is the main focus of an ethnographic research study,
the representation of the same phenomena by the researcher (etic) is what is expressed in the written report
of the results of the analysis (10-12). In order to weigh
the effects of the influence of the researcher in the passage between data gathered and final account, in this
study the analysis of the interviews was done autonomously by two researchers, who subsequently pooled
their results.
The interviews were translated in their entirety
into Italian. They were then categorised, first by identifying the concepts emerging from them and using
the words of the participants, and then by attributing
to each group of concepts categorised into themes a
denomination utilising the areas of meaning identified
by the researchers (1).
Results
Analysis of the interviews transcribed in their entirety yielded five thematic areas. No significant differences between the answers of Medicine students and
Nursing students were observed.
a) Correspondence between pre-migratory expectations and present condition.
b) Development of social life and relationships of
the students in the university context.
c) Cultural influence of the host society on the
process of integration.
215
d) Considerations on the education system.
e) Plans for the future
Correspondence between pre-migratory expectations and
present condition
Many young Africans choose to emigrate to Europe because they expect to find there a world totally
different from theirs: a marvellous world without
problems or obstacles. Once they arrive in Italy, however, they experience difficulties and disappointment.
There is a huge difference between the contemporary
conditions and the pre-migration expectations, since we
have an idea of Europe (actually based on TV) that is totally different (Student of Nursing).
This appears not to be the case of these young
interviewees from Cameroon, who emigrated for the
purpose of studying. In fact, students from Cameroon
declare themselves to be generally satisfied at having
emigrated to Italy in that this enables them to build a
better future for themselves.
- “Italy has many advantages to offer me. I owe this
country a lot, it has made my dream come true of being able
to study medicine. In Cameroon I’d never have been able
to do it, because in Cameroon you have to buy a place and
this wasn’t possible for me, for the simple reason that my
parents were too poor and couldn’t afford it. For me Italy is
a generous country” (Student of Medicine).
Among those interviewed, however, there is also a
minority that claim to be dissatisfied with their experience despite the success of their study course.
- “I wanted to change my reserved nature. That
didn’t happen. Practically, I’m not satisfied: it’s true that I
achieved my aim (grades and knowledge), but I don’t consider myself happy because of my many frustrations” (Student of Nursing).
Development of social life and relationships of the students
in the university context
When the interviews start to explore in-depth the
theme of the level of satisfaction, going in closer to
tackle, for example, the issue of integration in the academic world, some problems arise. For instance, many
share the perception of having experienced a process of
integration that has not been particularly satisfactory.
First of all we identified certain categories of people
216
with whom these students have dealings within the
academic world: Italian students, university teaching
staff (including tutors or other figures of guidance to
them during their course of study) and patients.
A recurring opinion among those interviewed is
that the great majority of Italian students adopt detached, distant and reserved behaviours towards them.
-“Concerning the social life, it was very difficult to
socialize in the University with the local students”. (Student of Nursing).
- “I am in Italy from a short time and I find the language really hard. During the lectures I do not understand
exactly everything – even though I follow constantly them
– and I find difficult to take notes. Hence, I am a bit late
with my university’s career. The tutors of the course try to
help me but it is hard anyway” (Student of Nursing).
Many affirm that in spite of their numerous efforts to approach and get to know their fellow Italian
students, 1the latter have never shown any willingness
or desire to form relationships with them. This situation has led many African students to withdraw into
their shell, frequenting above all the group of their fellow countrymen and -women, limiting their relationships with Italians to superficial ones.
- “Italians are very individualistic compared to Africans, who have a group spirit. This way of living of Italians is very unfavourable to integration if we look at my
case, for example: many times I’ve gone up to my fellow
Italian students and none of them offered an outstretched
hand or the support of a friend. I’m not capable of being forceful, and so it’s be better to always seek company
where I’m welcome (that is, among fellow countrymen and
-women)” (Student of Nursing).
- “At a social level I’m not satisfied, because I find all
Italians reserved. I say they’re reserved because from the
first year onwards I have not been able to make friends, or
let’s say the relationships I’ve created here are of a different
type, not like those I always had in Cameroon. Up to now I
haven’t felt accepted by the Italians” (Student of Medicine).
- “Since lot of people daily remind the immigrants
that they are different, the process of integration takes a
long time. Indeed, the immigrants are used to spend time
only with people from their own country and they are not
really open to new relationships” (Student of Nursing).
Some of those interviewed even claim to have met
with discriminatory and racist attitudes towards them
G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
on the part of their Italian counterparts.
- “There are some that don’t want us near them.
When they realise that they have sat down next to us, they
get up straight away and go and look for a place as far
away from us as possible; this is ignorance and hypocrisy.
The situation is like this for the moment, but maybe with
time it’ll change”(Student of Nursing).
- “Some refuse to give you their notes, or they tell you
they don’t have them when they have, they just don’t want
to give them to you. Others have a laugh with you and
then take the mickey out of you behind your back. They are
a bunch of hypocrites” (Student of Medicine).
Some of those interviewed, on the other hand,
adopt a self-critical attitude, maintaining, for example,
that Africans should also put more effort into their relationships with others. Some, again, claim that many
of the prejudices nurtured by the African students towards their Italian peers are transmitted by their fellow countrymen and -women, who often induce those
newly arrived to adopt an initial attitude of fear and
withdrawnness.
- “In my opinion, it’s not the fault of the Italians if we
foreigners are marginalised here in Italy – it’s we ourselves
that are to blame, because we don’t care about anything.
There isn’t any effort on our part”(Student of Nursing).
- “And above all, we have to have our own experience, and not listen to what those who got here before
us say, because that influences the behaviour of others. It
influences relationships, which could be a cause of our difficulties” (Student of Medicine).
Albeit small in number, there also emerge from
our interviews positive experiences of integration.
- “As a student I’m more or less happy, that is, I
haven’t any problems with my fellow students. We relate
well to each other and we have a very good relationship
with some”(Student of Nursing).
Now let us turn to the relationships with the
teaching staff (by teaching staff we mean lecturers, examiners and tutors).
On the whole, the teaching staff are considered by
the majority of those interviewed as being kind, willing to help and above all understanding.
- “In reality, up to now I haven’t felt any form of discrimination or patronising”(Student of Medicine).
- “The teachers are very helpful here in Parma compared to other places in Italy” (Student of Nursing).
Being an overseas student at the Faculty of Medicine and Surgery of the University of Parma
A perception common to all those interviewed is
that of being underestimated during exams. The reasons for this are not clear to most of those interviewed.
Some consider it a manifestation of racism.
- “This happened to a fellow countrywoman, not
to me: she was doing the anatomy exam. She was given
25/30 and the examiner told her that was a high enough
mark for an African” (Student of Nursing).
Others claim that the causes of the underestimation are the language difficulties of the African students, their being less used to taking oral examinations
than Italians, or else their differing cultural conception
of how an oral reply should be delivered during a university exam.
- “I don’t know if it’s a language problem or a cultural
one. Because the Italian students are used to speaking a lot,
that’s how their educational system is. Whereas I have always answered the examiner’s questions directly, that is, I
have always given more concise replies, without wanting
to tell everything I’ve read, and so I feel as if I’m being
underestimated when the same question is put to an Italian and to me and maybe my answer is shorter than that
of the Italian, who speaks continuously without giving
the right answer. But he gets a 30 and I don’t” (Student
of Medicine).
- “It’s obvious that there have been language difficulties, and they still exist, for more or less all of us”(Student
of Nursing).
There are those who account for this underestimation by the prejudice, frequently taken to heart also
by students from Cameroon, that the African “race”
is by nature inferior to the Italian one, also from the
intellectual point of view. This is a prejudice deeply
seated in the collective imagination after centuries of
colonisation.
- “We Africans pretend not to believe in the existence of the inferiority complex. In reality it is a product of
colonisation that has been instilled in us from generation to
generation” (Student of Medicine).
- “Yes, I accept the underestimation, but I find it hard
to accept the fact that we’re considered as being ignorant.
Because whichever way you look at it, even if we start at
the same level as an Italian, whether we’re working or
studying, we have to make 10-15 times the effort to make
ourselves appreciated for what we’re worth. This is a cultural reality that sees all black people as having inferior
217
skills; so I can say that the more ignorant an Italian, the
more superior he thinks he is to blacks and the more he tends
to regard them as incompetent. And consequently, Italians
don’t like blacks who can think, because this makes them
feel inferior” (Student of Medicine).
The opinion is also aired here that Italians see immigrants as being a potential competitor in the process
of allocation of opportunities and social resources who
may take away their future jobs and social position.
And this is the reason, according to these interviewees, why some teachers favour Italian students, giving
them a more thorough academic grounding.
“I would say that the average Italian considers immigrants as invaders, who have come to steal what he
has, hence an unwillingness to educate them. Above all,
Italians are very narrow-minded. In their eyes foreigners
should only do unskilled jobs – they think that if they train
or educate immigrants they will end up governing Italy in
the future. But there are some who take their responsibility as teachers seriously and do a good job of educating us”
(Student of Medicine).
In one interview a student underlines another
aspect: her fear of facing the lecturers because of her
imperfect Italian.
“The teachers are all very nice and willing to help.
The difficulty is the language, because at times you’re afraid
to explain your problem because you don’t know how to
express yourself and so you don’t think it’s worth going up
to them” (Student of Nursing).
Some students from Cameroon also state that
they don’t feel as if they are protected by their tutors
from discriminatory (or racist) behaviour on the part
of some patients.
- ”Anyway, during my two traineeships, I felt really uncomfortable when a patient rejected me. He didn’t
want to be touched by me. Every time I went near him,
he would object. He would say: “I don’t want these people”.
But what really bothered me was that I didn’t feel protected by the doctor who was my tutor despite having told
him about the behaviour of that patient. He kept telling
me not to take any notice of what he was saying“ (Student
of Medicine).
However, apart from these sporadic episodes, relationships with patients are not perceived as being
very problematic. Many claim to have found patients
to be compliant and to have learnt a lot from them.
218
In their dealings with patients, many African students
consider themselves as having advantages to a certain
extent over their Italian counterparts, thanks to presumed cultural peculiarities.
- “... I don’t have any problems with the patients
apart from the surgical wards, where the conditions of the
patients are somewhat critical; in the main I know how
to handle people.“I have a friendly relationship with the
patients, we are really fond of each other, and they ask after
me when I’m not there. This is because in our culture we are
more affectionate than the Italians” (Student of Nursing).
- “I didn’t notice anything untoward, I was happy
with them. In fact, I was more sought after than my Italian colleagues” (Student of Nursing).
- “I encountered some who were less welcoming, ignorant ones who didn’t want to be touched by me, and
others who were curious and asked me stacks of questions”
(Student of Nursing).
Cultural influence of the host society on the process of
integration
One of the themes explored by the researchers regarded the perceptions and attitudes expressed by the
students from Cameroon towards Italian society and
culture.
Some express indifference to the Italian culture:
for them it is important to go on with their studies,
the rest having nothing to do with their reasons for
emigrating to Italy.
- “I absolutely don’t give two hoots. I stay with people from Cameroon, I only eat African food, I don’t even
want to know how the Italian society works; for me it’s
important that they give me a proper evaluation during
the exams, that’s all” (Student of Medicine).
This attitude on the part of the interviewees could
be supposed to constitute a form of protection against
the exclusionary attitudes shown by the host society, the
disappointment they feel at not having had their premigratory expectations of integration fulfilled representing in itself an obstacle to the process of integration.
- “I don’t feel at all integrated, because they are constantly reminding me of my place as a foreigner” (Student
of Nursing).
Other students, however, state that, because of
the historical experience of colonisation, in the Afri-
G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
can world there exists such a mix of cultures and such a
sense of confusion and disorientation that it is difficult
for an African to understand himself and to be able to
start from a solid cultural base in order to approach
others readily. The opinion also emerges that Africans
are afraid to express their own culture and to get to
know those who are different from themselves.
I think we need to show that we have values, to work
more, and then we have to make so many efforts, we should
not discourage the attitudes of Italian colleagues and try
to work with Italian colleagues, not just with colleagues
Cameroon” (Student of Medicine).
Another interesting reflection concerns the sense
of loss of identity felt by immigrants after years of
contact with a culture different from their culture of
origin.
- “Because at the beginning you are really keen to get
to know how the new ambient works and so you jump in
at the deep end, but in the long run you realise that your
social position isn’t recognised in the society you had been
trying to get to know. In fact, you begin to realise you have
to take a step backwards in order to understand who you
are! It’s something you don’t experience when you first get
here: the search for your identity. It may not seem anything, but the more you stay here and the more you get to
know the people, the more you search for your own identity”
(Student of Medicine).
Considerations on the education system
Most of the students interviewed claimed to have
encountered difficulties linked to their insufficient
knowledge of the Italian language, above all at the beginning, when many of them could not even manage
to understand and follow the lessons. This handicap
significantly influenced the studies of some students:
although some were able to overcome this difficulty
after two or three months, others experienced it for
much longer times.
- “At the beginning, I had lot of difficulties because
of the language: I couldn’t follow the explanations of the
teachers and take notes at the same time. I felt as if I was
in another world. Everything was strange to me, very
difficult to understand. For example, I didn’t know what
“diagnosi” and “accertamento” meant. I seemed to be all at
sea” (Student of Medicine).
Being an overseas student at the Faculty of Medicine and Surgery of the University of Parma
From some interviews it emerges that at this
problematic stage the use of slides on the part of the
lecturers was of great help.
- “But for the first lessons it wasn’t easy for me: it was
very difficult to follow the teacher because I couldn’t understand all he said, although I had a general idea. It’s true:
the slides he showed helped me” (Student of Medicine).
It is above all during their traineeships that the
students from Cameroon feel a sense of inferiority compared to their Italian peers, who seem to be
smarter and brighter than them and to possess greater
quantities of previously acquired knowledge.
- “The only thing I noticed during my traineeship
was that Italians have an academic background that is
more advanced than ours, in the sense that … there are
some things that they take for granted, but that we have
to make an effort to understand. I think it’s a problem of
culture” (Student of Nursing).
Despite the difficulties met by most of these students, there are some who underline, not so much the
difficulties they have encountered but rather the ease
with which, thanks to their ability to adapt, they have
been able to overcome the initial impasse.
- “What I can say about my course of studies at the university is that my experience has been quite positive, because
the difficulties such as the language, the cultural differences
and the new environment that most students experience, I’d
say I’ve got over them” (Student of Nursing).
A fundamental problem emerging from the interviews is linked to the differences between the academic organisation in the territory of provenance of
those interviewed and that which they experience in
Italy. In Cameroon the distance between students and
teachers is greater. It is difficult to speak to or approach
teachers, who are always busy and are placed in a hierarchical position that is much higher than that of
the student. The difference in ways of collaborating
between teacher and student creates some difficulties
for students from Cameroon.
- “Our academic system does not lend itself readily to
this custom of maintaining relationships with teachers,
partly because they are always busy and so it’s difficult to get
hold of them, whereas here the teachers are very willing to
help us (for the language difficulties)” (Student of Medicine)
- “My tutor was very impatient and so I felt stressed.
My first difficulty was the culture, since my own does not
219
permit me to treat with familiarity those I judge to be
higher in status than me” (Student of Nursing).
Some of those interviewed openly criticise the
Italian university system, which would seem to make
for the acquisition of a good theoretical grounding but
not of practical skills.
- “I’m particularly disappointed at the type of situation
that I’ve found here; from the academic viewpoint, I’m satisfied with my theoretical knowledge but not with the practical
side, because we do less in the way of group practice, where
the student learns practically nothing” (Student of Nursing).
Academic achievement does not appear to be influenced to any great degree by financial difficulties.
Almost all students from Cameroon coming to study
in Italy have a study grant and are able to go on without problems, albeit at times finding it necessary to
eke out their grant with temporary employment. Some
found the first few months a little hard, when they
were not yet able to cash in the deposit they had paid
before leaving for Italy.
- “My second difficulty was an economic one, because I
didn’t get back my deposit straight away, which happens to
all of us. I had to wait till the end of October to get mine. It’s
true that I had a bit of money when I arrived here on 31st
August 2010, but I had to pay the admission tax and the first
instalment on my tuition fees, and get my residence permit, so
all the money I had ran out after around a month and I had
nothing left. This situation of having no money affected my
studies because I couldn’t buy the books” (Student of Nursing).
In any case, for varying reasons it is not always
possible for the students to hold onto their study
grants, hence at times they find themselves having to
face the situation of being students and workers at the
same time, which inevitably has a negative influence
on their studies.
Plans for the future
Some students interviewed see Italy as a country
of transit towards another migratory goal.
- “I’m here in Italy temporarily. I’m going to leave
Italy after graduating because, as everyone knows, there
aren’t enough opportunities for specialisation here” (Student of Medicine).
- “Right now I think that after my graduation I’ll
stay in Italy for work, but I would like to do an inter-
220
national working experience, as for instance in England”
(Student of Nursing).
- “I can’t say anything yet, because I’ve still got 3 or 4
years of studies to complete. But I think I’ll go away from
Italy when I graduate, for example to Britain or another
English-speaking country” (Student of Medicine).
For most of those interviewed, the aspiration was
to go back to their country of origin, bringing home
the benefit they gained in emigration.
- “After my graduation, I’d love to go back to Cameroon
to cure my people as I am learning here in Italy. The Italian hospitals are very efficient and it would be great if they
should be the same also in Cameroon” (Student of Nursing).
- “I think that at some time in the future I’ll leave
because I came here with so many goals to achieve, and so
after graduating I won’t be staying here; I’ll have to move
on, and in any case I have my roots, my native land, which
must be able to take advantage of my experiences here in
Italy”(Student of Nursing).
Some students are already planning their return
in some way.
- “I’d like to continue studying, to get a specialist degree, so that I can work for a few years. Now I’m in an
association that gathers charity funds for medical products
together with others from Cameroon, and so my plan is to
go back to Cameroon” (Student of Medicine).
Discussion
This contribution represents the first stage of a
wider study that will involve students of other nationalities; it was conducted with the aim of identifying the
modalities to utilise and the themes to study in-depth
at the subsequent stages of the research. The sample
selected involved exclusively the student population
from Cameroon, since they constitute one of the most
numerous communities among the African student
population at the University of Parma. In Cameroon
there is a good education system and the migration of
its young people is designed to give them a good study
career. This aspect clearly emerged also in the interviews, which revealed that most of these students enrolled in courses at the Faculty of Medicine of Parma
University in order to gain a diploma for use in their
country of origin.
G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
The first salient datum to emerge from the analysis of the interviews is that students from Cameroon
meet with difficulties of integration, perceiving this
difficulty as being due to a great extent to the discriminatory behaviour of their Italian peers. This is not
surprising since the phenomenon of the difficulty of
integration between black African and white students
in the courses of medicine at western universities is
well known and has been widely studied (2, 13-16).
Most of these studies attribute the phenomenon to
the education system in western countries, which is
decidedly ethnocentric, based on the learning of cultural norms and on expectations of integration typical of western culture (17-20). Students of European
or North American cultures find a correspondence
between their habitual system of learning and the organisation of the study courses, and have an advantage
over students of other cultures, who have to work hard
not only to learn theory and practice but also to assimilate cultural skills often in contrast with their own
personal cultural background (21). African students
need to work harder than their autochthonous counterparts to reach the same levels of education and it is
partly for this reason that they consider their efforts as
being underestimated by the teachers, as emerged from
our interviews. Some lose faith in themselves, coming
to believe that the Italian students are brighter than
they are, or else ending up by despising the atmosphere
around them and starting to plan an early return to
their country of origin. This aspect, clearly emerging
from our analysis, has also been highlighted in other
situations (22,24). The literature also attests to the fact
that the absence of corrective measures in the organisation of study courses is the reason why many students
of ethnic minorities abandon their studies (13, 25).
If this is true for societies such as those of the
United States, Australia or Britain, where the question
of multiculturality in healthcare training courses and
of social integration has been an issue for decades, it
is all the more so for societies such as that of Italy, in
which the phenomenon of multiethnicity and multiculturality is of more recent date. One study by the central office for overseas students in Italy reported that
overseas students in Italian universities in 2001 represented just 1.6% of the student population (compared
to 10% in Great Britain) and that of these only 7.5
Being an overseas student at the Faculty of Medicine and Surgery of the University of Parma
out of 100 came from Africa. The number of African
students is now on the increase, although no precise
recent data are available, those from Cameroon representing around 30% of the African students attending
the faculties of medicine and engineering. This rise is
no doubt linked to the phenomenon of the changes
to society as a consequence of the considerable migratory flows (26,27). Society is changing and, as much of
the recent literature testifies, also in Italy the outcomes
of medical care administered to those with “different”
cultural backgrounds are worse than those of the autochthonous population on account of the linguistic
and cultural barriers, but also because of the lack of
preparedness of the healthcare institutions to tackle the
situation (28,29). It is a widespread opinion that a university training of healthcare staff taking into account
cultural diversities will lead to the overcoming of this
social injustice (3,26,30). As clearly emerged from our
analysis, the educational organisation of our medical
faculties is far from having fully implemented measures moving in this direction. Such experiences can be
found in other situations of the English speaking world
and, although there is controversy over the models to
be utilised (8,29,31-35), some re-examinations of the
literature yield unanimously positive views as to the results obtained by the inclusion of multiculturality and
of ”antiracism” in the study programmes of the medical
faculties (36-38). However, what is tried and tested in
other social contexts is not always adaptable to the Italian situation, and the views expressed by the students
from Cameroon in this study yield some indications
that could be taken up in the organisation of the study
programmes of our medical faculties so as to meet
the needs of a changing society. First and foremost, it
might be useful to take measures to improve the Italian
language competence of all overseas students; we have
seen to what extent language difficulties negatively
influence the integration of the students from Cameroon here interviewed. In addition, university teaching programmes could be organised so as to include
coaching of the awareness of the differing conceptions
of health, sickness and healthcare in the varying cultures. As well as conveying the skills needed for taking
charge of a multiethnic public, this would circulate and
valorise the meaning of cultural diversity. These skills
could be strengthened by increasing the number of
221
teaching hours, a measure already implemented in the
medical faculty of Parma University for demoethnoanthropology and the sociology of interethnic relations.
In particular they should be developed more university
courses that lead to the maturation of a cultural sensitivity as some significant works of Milton Bennet on
Development Models of Cultural Sensitivity (DMSI),
which has been working for years on these issues.
Conclusions
Although this is a preliminary study aimed at the
identification of modalities of research and themes to
be examined in-depth in further studies, the material
gathered and the analysis of the interviews have already provided some indication as to the measures that
could be adopted in the planning of university courses
at Italian medical faculties to encourage the integration of overseas students. Besides raising the quality
of university courses, such an improvement may contribute to creating multiethnic groups of professionals
trained in the enhancement of cultural diversity, which
in its turn would raise the levels of healthcare.
References
1. Binello D. Parola Chiave: integrazione possibile. L’Infermiere
2/2010.
2. Love KL. The Lived Experience of Socialization Among African American Nursing Students in a Predominantly White
University. Journal of Transcultural Nursing 2010; 21(4):
342-50.
3. Allen J. Improving cross-cultural care and antiracism in nursing education:A literature review. Nurse Education Today
2010; 30: 314-20.
4. Bryne M. Uncovering racial bias in nursing fundamentals
textbooks. Nursing Healthcare Perspectives 2001; 22: 299303.
5. Joel L. Impact of DRGs on basic nursing education and curriculum implications. In J. Watson (Ed.), Curriculum revolution: A mandate for change. New York, NY: National
League for Nursing, 1988: 9-26.
6. Ackerman-Barger PW. Embracing Multiculturalism
in Nursing Learning Environments. J Nurs Educ 2010;
49(12): 677-82.
7. Stivano A, Rocco G. Il concetto di etnografia nelle scienze
infermieristiche Ipasvi Roma. L’infermiere 2008; Anno
XVIII - N. 4 - ottobre/dicembre 2008 XVIII.
8. Leininger M, McFarland MR. Transcultural nursing: concepts, theories, research and practice, Mc Graw-Hill Com-
222
pany, New York, ed. it., Ledonne G, Nucchi M. (a cura
di), Infermieristica transculturale: concetti, teorie, ricerca e
pratica, Milano, Cea Editore, 2003.
9. Moro RM. Bambini di qui venuti da altrove, Franco Angeli,
Milano, 2005.
10. Byrne M. Ethnography as a qualitative research method.
AORN Journal 2001; 74(1): 82-4.
11. Pellatt G. Ethnography and Reflexivity: emotions and feelings in fieldwork, Nurse Researcher 2003; 10(3): 28-38.
12. Polit DF, Beck CT. Essentials of Nursing Research –Methods,
Appraisal, and Utilisation. Philadelphia: Lippincott, 2006.
13. Yoder M. Instructional responses to ethnically divers nursing students. J Nurs Educ 1996; 35: 310-15.
14. Allen M, Nunley J. Recruitment and retention of black students in baccalaureate nursing programs.J Nurs Educ 1988;
27: 107-16.
15. Hassouneh-Phillips D, Beckett A. An education in racism.
J Nurs Educ 2003; 42: 258-65.
16. Sullivan LW, Suez Mittman I. The state of diversity in the
health professions a century after Flexner. Acad Med 2010
Feb; 85(2): 246-53.
17. Lynn M. Race, culture, and the education of African-Americans. Educational Theory 2006; 56: 107-19.
18. Ashton P. The concept of activity. In L. Dixon-Krauss (Ed.),
Vygotsky in the classroom. Mediated literacy instruction and
assessment. White Plains, NY: Longman, 1996: 111-24.
19. Lea A. Nursing in today’s multicultural society: A transcultural perspective. Journal of Advanced Nursing 1994; 20:
307-13.
20. Mathews M. Vygotsky and writing: Children using language to learn and learning from children’s language what to
teach. In L. Dixon-Krauss (Ed.), Vygotsky in the classroom.
Mediated literacy instruction and assessment. White Plains,
NY: Longman, 1996: 93-110.
21. P
acquiao D. Educating faculty in the concept of educational
bicultualism: A comparative study of sociocultural influence
in nursing students’ experiences in school. In V.M. Fitzsimons & M.L. Kelley (Eds.), The culture of learning: Access,
retention, and mobility of minority students in nursing. New
York, NY: National League for Nursing, 1996: 129-162.
22. Kosowski M, Grams K. “They took the time... they started
to care”: Stories of African American nursing students in
intercultural caring groups. Advances in Nursing Science
2001; 23(3): 11-27.
23. Sullivan, L. Missing persons: Minorities in health professions. A report of the Sullivan Commission on diversity in
the healthcare workforce, 2004). Retrieved September from
http://www.picosearch.com/cgi-bmts.pl
24. France N, Fields A. “You’re just shoved into the corner”: The
lived experience of Black nursing students being isolated
and discounted: A pilot study. Journal of Rogerian Nursing
G. Masera, C.J. Ngo Bikatal, A. Sarli, L. Sarli
Science 2004; 12: 28-36.
25. Haigh C, Johnson M. Attitudes and values of nurse educators: An international survey. Berkley Electronic Press 2007;
4: 1-11.
26. Lim J, Downie J, Nathan P. Nursing students’ self-efficacy
in providing transcultural care. Nurse Education Toda 2004;
24 (6); 428-34.
27. Tulman L, Watts R. Development and testing of the Blueprint for integration of cultural competence in the curriculum questionnaire. J Prof Nurs 2008; 24 (3): 161-6.
28. Johnstone M, Kanitsaki O. Ethnic aged discrimination and
disparities in health and social care: a question of social justice. Australasian Journal on Ageing 2008; 27 (3): 110-5.
29. Narayanasamy A, White E. A review of transcultural nursing. Nurse Education Today 2005; 25 (2): 102-11.
30. Hughes K, Hood L. Teaching methods and an outcome tool
for measuring cultural sensitivity in undergraduate nursing
students. Journal of Transcultural Nursing 2007; 18 (1): 57-62.
31. Kanitsaki O.Transcultural nursing and challenging the status quo. Contemporary Nurse 2003; 15 (3): v–ix.
32. Giger J, Davidhizar R. The giger and davidhizar transcultural assessment model. Journal of Transcultural Nursing
2002; 13 (3): 185-8.
33. Campinha-Bacote J. The process of cultural competence in
the delivery of healthcare services: a model of care. Journal
of Transcultural Nursing 2002; 13 (3): 181-4.
34. Campesino M. Beyond transculturalism: critiques of cultural education in nursing. Journal of Nursing Education
2008; 47 (7): 298-304.
35. Culley L. Nursing, culture and competence. In: Culley L,
Dyson S (Eds.), Ethnicity and Nursing Practice. Palgrave,
New York, 2001: 109.27.
36. Beach, M, Price E, Gary T, et al. Cultural competence. A
systematic review of health care providers educational interventions. Medical Care 2005; 43 (4): 356-73.
37. Chipps J, Simpson B, Brysiewicz P. The effectiveness of
cultural competence training for health professionals in
community-based rehabilitation: a systematic review of literature. Worldviews on Evidence Based Nursing 2008; 5
(2): 85-94.
38. Nairn S, Hardy C, Parumal L, Williams G. Multicultural or
anti-racist teaching in nurse education: a critical appraisal.
Nurse Education Today 2004; 24 (3): 188-95.
Accepted: 26 october 2015
Correspondence:
Giuliana Masera
First Level Degree Course in Nursing, section of Piacenza,
University of Parma
E-mail: [email protected]
Acta Biomed for Health Professions 2015; Vol. 86, S. 3: 223-232
© Mattioli 1885
Original article: health care organization
The dynamics of social capital and health
Tiziana Lavalle1, Charles Damimola Omosebi2, Robert H. Desmarteau3
Researcher in General Medical Sciences, Master in Nursing and Obstetric Sciences, Director of Health Operator Training,
Bologna Health Authority; 2 Bc. Of Science in Finance and Bankin, Department of Banking and Finance, Ekiti State University, Nigeria; 3 Researcher in Strategy, Professor of Business Strategy, MBA, University of Quebec at Montreal, Lecturer in
Strategy at the University of Nantes
1
Abstract. In the wake of Robert Putnam’s arrival in Italy to study regionalization, this review of the literature
on social capital aimed to establish whether current knowledge, social or socio-anthropological research have
yielded new findings on how social capital is built and maintained or developed in a community and to what
extent this influences social well-being. This is particularly important for those working in the health sector
to make sure that health-related decision-making and behaviour foster rather than destroy the development
of social capital. Our literature search was based on specific articles published in scientific journals in the
humanist, managerial and medical fields, book titles or subtitles containing references to “social capital or
social cooperation or reciprocity”. Our findings led us to the conclusion that a complex series of coordinated
actions are required for social capital to develop and that, once developed, social capital has a positive impact
on social relations, economic results and social stability. In addition, we understood why it is useful to retain
three stages, conditioning, development and capitalization, in modelling the development of social capital.
Conditioning requires transparency, pragmatism and long-term vision. Development and capitalization require the predominant variables to be chosen. The development of social capital is part of a good strategy for
health promotion and prevention.
Key words: social capital, social stability, social influence on health
The dynamics of social capital and health
Social capital
In recent decades, scholars and policy makers
have expressed convergent views that social capital is
linked to social networks and civic norms (66). However, the different definitions of social capital have
made its meaning ambiguous (13, 14, 56), to the point
of being considered a quasi-concept (2, 5). Bernard
claims that quasi-concepts are hybrid constructs: on the
one hand, they are based on data analysis and thereby
benefit from the aura of legitimacy conferred by the
scientific method; on the other, they are vague enough
to be adapted to myriad situations and political needs.
Some scholars claim that the underlying ambiguity in the concept of social capital makes it difficult
to detach from similar concepts like social cohesion,
sense of community, and competent community. This
raises problems of clarity and consensus with respect
to the operative definition of social capital, its measurement and the identification of causal links (81,
100). Instead, others find the ambiguity is due to the
concomitance of several theoretical approaches whose
choice inevitably weighs on the definition and measurement of social capital (2, 13). In the 1970s, social
capital was frequently associated with intellectual capital (8). Nonetheless, if social capital is construed as
the viewpoint of the organizations concerned with an
analysis of its internal relations with professionals and
224
its external relations first and foremost with the beneficiaries of activities, then many references and links
emerge between the two. In particular, social capital
can be traced in two of the three main categories used
in the literature to represent intellectual capital (32, 33,
72, 88): human capital and relational capital.
The topic of social capital is particularly important in health and social organizations in view of their
special role (3, 16, 35, 42, 43, 47, 55, 61) and the very
nature of the goods produced, defined as “relational
goods” (12).
Theories on economic development have defined
social capital in different ways (trust, civic sense, level
of formal and informal associative behaviour), assigning different contributions to social capital in improving the economy, politics and the state (cause, effect or
both). Robert Putnam, one of the foremost scholars
of social capital and its dynamics, addressed political
institutions among the Italian Regions. In the conclusions to his study (69), he claimed that the differences
in administrative efficiency encountered between Regions in the Centre-North and those in the South were
correlated to different levels of social capital, a decisive
factor also for economic development: “strong society
= strong economy and strong society = strong state”.
Putnam’s thesis also seems to have inspired a recent
article (86) seeking to explain the ongoing differences
in health effects and financial balance of the health and
social services between Italy’s Centre-North and the
South.
Putnam’s study served to spur the interest of
scholars and politicians in the role and impact of social
capital even though the ensuing scientific and political
debate has generated controversial outcomes (91).
Some scientists claim that Putnam’s thesis is not
sufficiently robust, deeming the very concept of social
capital a still under-theorized topic (81). Criticism focuses on the fact that the association among variables
emerging from Putnam’s study (69) does not shed light
on the bonds, and hence the role and impact of social
capital, whereas it would in the case of causality (13,
45, 56, 91).
Generally speaking, Putnam’s work has been
well-received in the political arena as it highlights the
interdependence of economy, society and the state and
hence need an integrated approach in policy-making
T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
(2, 82). However, restricting our analysis to public policies safeguarding public health, social capital serves to
support different views. Polarization is apparent in two
directions. At one end of the spectrum, there are policies fostering social capital to safeguard health by recourse to participation by citizens and the community
in the decision-making process and the importance of
so-called health literacy (20, 21). At the other, there
are policies designed to reduce public liability in safeguarding health, avoiding complaint by recourse to the
responsibility of the individual and civil society (60).
Instead, the core topics of the debate on social
capital’s effects are linked on the one hand to the beneficiaries (individual, community, organization, region,
nation) and on the other to the type of impact (positive
or negative). Social capital is often deemed “good” or
“bad” in line with Putnam’s (70) distinction between
bonding and bridging. Bonding is the type of social
capital generally construed as negative and refers to
groups with strong identities which are cohesive, exclusive and excluding (28): it focuses on local benefits
and survival (15). Bridging is the type of social capital
generally construed as positive and refers to distant
ties among individuals of different ages or social class
(28): it serves for development (15). However, positive or negative judgements on social capital cannot
be formulated a priori on the basis of a definition, but
must address the specific context in which the analysis
is undertaken.
Putnam and other authors have been criticized for
having simplified the explanation of differences in the
functioning and outcomes of institutions and in the
development of the Italian Regions towards a sort of
cultural determinism leaving no room for change (14,
91). Critics accuse Putnam of assuming the existence
of a primitive endowment of social capital to be put
to good use and failing to address the problem of how
to implement building and development processes and
how to preserve this community resource (13).
An in-depth study on the dynamics and hence
the modality of social capital growth in a community
was undertaken by Robert H. Desmarteau (29) who
proposed three stages: conditioning, development and
capitalization. Each of these stages can be construed
as steps in a process of social engineering and each comprises distinct but recursive components in the sense
225
Social capital and health
that the products (the effects) are also the producers
(i.e. the causes) of effects. This circularity represents the
functional reciprocity found in Lévy-Leblond’s teachings of the complexity theory1 that Putnam (ibid.) and
Fukuyama (37) associate with the virtuous circle of social capital dynamics.
The conditioning stage
Desmarteau uses the term “conditioning” to mean
the factors acting as precursors for the development
of social capital. In other words, these factors prepare
the terrain, supplying the growth process with essential raw materials such as, for example, transparency,
pragmatism, horizontal bonds and long-term vision.
As the first precursor of social capital, transparency has three instrumental features. The first recalls
Voslensky’s (96) association of transparency and “freedom of speech”. In other words, a transparent setting
is a setting allowing both disagreement and agreement
to be voiced. The second feature is transparency is as
an information trampoline catalyzing action, a trampoline as described by Coleman (19) starting from the
information potential inherent in all social relations.
The third feature of transparency generates the last of
the desirable things, the capacity of individuals to understand what they experience stemming from what
Sztompka2 describes as transparency allowing a clear
understanding of one’s actions and also control over
one’s own destiny. In other words, it is an environment
in which individuals understand their destiny having
deliberately influenced the same. Mohan and Mohan3
add that transparency is seeing clearly and a society
transpiring transparency builds the unity or social stability from which it will benefit during “capitalization”.
Pragmatism represents the propensity to put action first, propensity being construed as a component
of the conditioning of social capital for two reasons.
1
Lévy-Leblond JM. The Unbegun Big Bang. Nature 1989, 342,
p. 23.
2
Sztompka P. Trust, Distrust, and the Paradox of Democracy.
Paper presented at 27 XVIIth IPSA World Congress, Seoul,
1997
3
Mohan G, Mohan J. Placing Social Capital. Progress in Human
Geography 26.2, 2002, 191-210. University of Cincinnati. Web. 7
Nov. 2010 http://phg.sagepub.com/content/26/2/191
The first stems from the meaning attributed to altruism
in the definition of generalized reciprocity proposed
by Taylor (92), previously associated with the expression “I help you now” in a setting of social capital. This
form of altruism requires a minimum dose of pragmatism, thereby generating the claim that to be reciprocal
means being a little pragmatic. Here lies the second
reason, rooted in the cultural differences towards pragmatism. In an imaginary way, Gannon (38) explores
these differences by devising national metaphors, including “opera” for Italy. The libretto represents the
Italians of the North – recognised for their propensity to engage in communal activity and develop social
capital (70) – as individuals with a direct and sophisticated business behaviour, whereas Southern Italians
show a propensity for contextualisation, subtlety and
putting things off to the next day. It is no coincidence
that Gannon uses Verdi to depict the North and Melodrama for the South. The semantic potential of pragmatism is thereby built culturally as a component of
conditioning to foster the practice of generalized reciprocity and ultimately develop social capital.
Long-term vision follows the two sources of legitimacy presented for pragmatism. In the final analysis, long-term vision is the consequence of pragmatism.
Hence the long-term meaning of generalized reciprocity linked to Taylor’s4 (et al.) “long-term self-interest”
previously enshrined in the “if I need your help tomorrow” bestows semantic legitimacy. Probably, only
faith in the future allows an expected payback from
today’s gesture, leading to the claim that reciprocity
entails at least some confidence in the future. Cultural legitimacy is widely documented in many studies,
including the classic discoveries of Kluckhoohn5 and
Strodbeck6 presented in “Variations in value orientations” highlighting significant changes in the temporal
orientations of different societies. These orientations
include a re-emergence of the emphasis on the present
for Latin Americans, the ineffable past for the Chinese
Taylor M, Kent ML, White WJ. How activist organizations
are using the Internet to build relationships. Public Relations
Review 2001, 27(3), 263–84
5
Kluckhoohn C, Murray HA. Personality in Nature, Society and
Culture. Alfred A. Knopf, NY, 1949, 35
6
Kluckholn C, Strodtbeck F. Variations in value orientations.
Evanston, IL: Row, Peterson, 1961
4
226
and the United States’ inclination towards the future
when everything will be better. Briefly, time is explicitly acknowledged as a cultural vector. This conclusion
was also reached by Hofstede’s (48) study on “Culture’s
consequences” analysing organizations in 72 countries.
His research is built on the development and measurement of four indices: power distance, individualism,
masculinity and uncertainty avoidance. Of these, the
fourth specifically attracts our attention scrutinizing
the propensity to avoid uncertainty. The results show
that different societies present different ways of relating to uncertainty. The lower the uncertainty avoidance index is, the closer countries relate to uncertainty.
The index in the United States, a land characterized
by numerous mutual trust associations as described by
Alexis de Tocqueville (30) and Robert Putnam (69)
is low (46) whereas in France it is high (86). For Italy the uncertainty avoidance index is 75. Given the
framework of the study there is no distinction between
North and South. However, starting from the work of
Putnam (ibid.) and Gannon (ibid.), a lower index for
Northern Italy becomes highly likely. A positive longterm vision predisposes to the practice of reciprocity
in addition to relating to uncertainty and ultimately
to the development of social capital. As for pragmatism, cultural legitimacy confirms a semantic potential,
but this time with the long-term outlook individuals
express through their confidence in the future. Hence
the long-term vision can be claimed to be an outlook
of confidence.
The development stage
The main reference is to the capacity to build
cooperation and social awareness (41) that support
the evolution of individuals’ capacity for socialisation,
nowadays construed as the empowerment of the community. Commitment, capacity and control are influenced by eleven different factors.
1. Understanding community development.
This refers to the knowledge system, understanding
the nature of the community development process and
the effects of programme strategies and tactics. It also
includes how the participants understand their own
interests, roles and responsibilities and those of other
participants of the community.
T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
2. Credibility and commitment. The success factors of credibility can be summarized as “cultivating
and maintaining strong relations among community
members”, i.e. how to take a stand on a “hot” topic;
recruiting local people; the capacity to encounter and
focalise local culture. The key to credibility is through
commitment and in the long term focusing actions on
targets, promoting-supporting-building the development process in the experience of dealing with the
common good.
3. Confidence in goals, objectives and in others. Trust is strongly correlated to credibility. In turn,
credibility has a strong reputational component and
is directly linked to the perception of hard results.
Confidence has strong personal psychological elements and is highly relevant for the target population.
The confidence of citizens is substantially increased
by the attention they receive and by early successes.
Many activities that enhance credibility also help
to boost confidence, but the risk of focusing all efforts and attention on only one milestone or objective must be managed. In addition to reinforcing the
importance and value of achievements, citizens need
to be reminded of the importance of their objectives
and commitment, expressing confidence that they will
reach the next milestone and reassure them they will
get the help they need.
4. Competence comprises the technical, financial and organizational aspects of working. The ability to pinpoint local sources of technical support and
its capacity to gain degrees of skills and experience in
the organizational field are central issues in creating a
community’s capacity for development. Whether it is
a question of political or productive activity, cooperation or volunteering, a well-designed and implemented
programme must ensure that distinctive competence is
developed for the core and for roles that will have a
major impact on outcomes.
5. Comfort as shared experiences. Viewed in
terms of social capital, experience are vehicles through
which participants identify and confirm their mutual
interests and build relationships based on trust. Comfort (and trust) are the foundations on which citizens
can solve problems and disagreements together and
facilitate many types of transactions, especially when
they must address issues like race, class and power.
227
Social capital and health
6. Constructive criticism. Criticism allows people to reflect on their experience. In a complex dynamic effort with multiple stakeholders, criticism can make
a major contribution to long-term success. Criticism
is particularly valuable in bolstering the community’s
development capacity and ought to be encouraged to
produce openness and trust.
7. Communication among actors is the prerequisite for understanding and trust. Communication
seems to inspire commitment and the flow of information intensifies the community’s development capacity: special efforts are needs to stimulate constructive communication on important difficult issues and
strong relations must be cultivated, training people to
be coaches without becoming intermediaries.
8. Consistency of vision and aims. To achieve
objectives and cooperate, people must share the same
vision and the same priorities. This condition comes
about when the previous requirements are present.
9. Congruence has a strong influence on credibility. Congruence is the way in which the activities, tactics, actions and words key actors develop throughout
the programme strategy and objectives: doing what is
needed, doing what is said, saying what is done and
what will be done. In organizational or institutional
relations, it is necessary to be sensitive to how actions,
management style, personality are perceived and how
participants’ perceptions can influence their viewpoint
or their reactions.
10. Counterbalancing is the central challenge of
building local capacity and inspiring local responsibility:
1. The tension between the need to set and maintain general guidelines for participation and
build confidence and the importance of being
flexible and adaptable to local settings to foster
comfort and nurture local capacity.
2. The tension between process and product. The
goal is to produce visible rapidly achieved intermediate value, outcomes or outputs to solicit
commitment and gain credibility, moving slowly enough to build competence and confidence
among different participants.
3. The tension between providing strong leadership and guidance by assistance staff and the
community support volunteers need to assume
greater control and enhance their learning capacity, making many choices and sometimes
delaying a programme or making mistakes.
11. Mutual adjustment. Adapting relationships
or actions to the local setting is important: political
climate, culture, history of community development,
degree of social and political openness and ideas produce awareness and sensitivity to results. Ideally mutual adjustment should modulate the local perception
and reaction of citizens.
Gittel and Vidal suggest some general lessons:
1. Facilitating the participation of citizens intensifies the development of capacities and commitment as an approach to creating institutional infrastructure;
2. The advantages are not always perceived: they
must be highlighted and made understandable
because they are aggregating elements;
3. Representativeness is attractive as a value but an
organization has greater difficulties functioning
if participants do not communicate and/or have
divergent views;
4. It is important to organize meetings or joint
activities in which people experience trust.
Capitalization
Reflecting on the relations between social capital
and health, Thompson (93, 94) claims that when patients play an integral part in the treatment strategy
they exert an effect on treatment producers in the same
way as clinical and organizational audits are currently
starting to affect the actions of professionals. For this
to happen, patients must be accorded peer status as
stakeholders. Thompson maintains that a more liberal
relationship model would place patients in the role of
health producers, considering that on several occasions
they satisfy their needs by cooperating and co-acting
with health operators in what has been defined as a
model of “co-production or collaborative autonomy”.
This vision has deep implications on how health system resources will be conceptualised in the future. The stages of capitalization are specified below
confining examples to the specific health setting.
1. Maintaining favourable environments. To
create a healthy society, health systems must take
228
measures to enact a broader change in the development of institutions and healthy institutional relations and make sure that organizations (or social systems) participate. Interventions to achieve this goal
require health personnel to be competent in organizational development strategies and community intervention to support commitment and improve ‘health
governance’. Health governance must be promoted as
a key social responsibility in the management of all
social systems, and refers to the cooperative integration of health promotion goals or daily processes of
social and organizational systems which have an impact on individuals and communities. Development
consists in doing differently what has already been
done. Like progress, health is seen as an investment
and not a cost for society, an “added value”, social
products stemming from the implementation of the
right of citizenship and not as additional goods that
can be obtained by purchasing something, but gained
through the participation of people interested in the
process of implementation and change. Participation
is fundamental and a prerequisite for fairness and the
democratization of the parties involved. Social systems must allow people from all areas and all levels
of an organization to be involved, to express their
concerns, to assess the value and their own capacity
to participate actively in each stage of the evolutive
process of transformation.
2. Creation/maintenance of a healthy work-life
environment. Healthy work-life environments promote participation, fairness, concern for the earth’s
resources and for people and topics of social commitment.
3. Integrating health promotion into community culture. The values and daily activities of health
promotion aim to integrate understanding and commitment among the activities, and the ways of producing or influencing health must enter every system in
planning, human resources management and in other
organizational functions. One way is to create partnerships among different people and social systems
in health promotion and institutions must work in a
network through actions designed to support, promote
and request an intervention of interdisciplinary, interdepartmental and interagency cooperation exploiting
the imagination, innovation and mutual support that
T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
can come from working beyond professional and organizational confines.
4. Advocacy of collective interests in a broader
community. Acknowledging that organizations and
society as a whole are characterized by conflicting interests, the use and development of advocacy and mediation capacity are necessary to increase participation,
cooperation and social consensus. This contributes to
the development of informal social networks and support systems essential to build social capital and can be
implemented through initiatives designed to enhance
knowledge, abilities and individual social skills able to
support and positively orientate social behaviour.
5. Attention to quality, social audit and the assessment of health responsibilities. The routine development of policies on quality, implementation or consolidation of social audits and the procedures for assessing the social responsibilities of health organizations
allow the target populations to be properly informed
and notified of the role played and the results and to
select the relevant results to meet the needs of the different stakeholders. The first outcome of this structured
intervention if the creation of trust between citizens
and institutions. Secondly, it allows communities to
increase the “sense” of interaction in institutional relations and in the principal-agent treatment relationship.
The World Health Organization’s Ottawa Charter identifies three basic strategies for health promotion:
1) Create the conditions essential for health, allowing all people top achieve their fullest health
potential and mediate between the differing
interests of society in the pursuit of health.
2) Build a healthy public policy.
3) Strengthen community actions.
In its Jakarta declaration on promoting health in
the 21st century, the World Health Organization confirmed that these action strategies are important for
everyone: organizations, institutions and communities, recalling the relations of mutual influence already
highlighted by Putnam among the strength of the state
(institutions), the strength of organizations and the
strength of communities in building social capital. In
the current work it should be emphasized that in the
case of reduction, the same relations influence the loss
of social capital.
Social capital and health
229
Figure 1. Rizzi P. Local Development and Social Capital: the case of the Italian regions. Laboratory of Economics, Catholic University,
Piacenza, 2003, p. 28
Implementation of social capital measures
Starting from Smith and Weber, increasingly
frequent references have been made to social attitudes to account for social evolution. Authors like
Fukuyama explain the differences in political and
economic growth in terms of trust in social relations and the market, construed as the willingness
of people to cooperate rooted in a shared culture.
Mutti (64) set out to measure cultural aspects supporting social virtues like trust that he identifies as
a tool to reduce transaction costs between social and
economic actors.
Barro’s model7 was used to test the contribution of
different social capital indicators in econometric terms,
as already assessed in Italy by Cosci et al8 and Paci et
al.9:
Barro R J. Economic growth in a cross section of countries.
Quarterly Journal of Economics 1991, n.106
8
Cosci S, Mattesini F. Convergenza e crescita in Italia: un’analisi
su dati provinciali. Rivista di Politica Economica 1995, 4
9
Paci R, Pigliaru E. Differenziali di crescita tra le regioni italiane: un’analisi cross-section. Rivista di politica economica 1995,
Vol. 85, n°10
7
log(GDP99/GDP) = a + b1 log(GDP) +b2 log
(INVEST) + b3 log(INN) + b4 log(NET) + b5 log(TS)
The single variables of the estimation:
- GDP99/GDP: regional per capita GDP of the
year of reference.
- INVEST: fixed gross investments of GDP, average regional value of the period.
- INN: indicator of regional innovative capacity
- NET: indicator of regional networking.
- TS: indicator of trust syndrome (values of social
commitment and solidarity).
The equation was graphically depicted by Rizzi
(71) as seen in Figure 1.
The results were tested several times and Rizzi
demonstrates that:
−S
ocial capital values are positively correlated to
productive innovation and an increase in per
capital GDP.
−S
ocial capital values are positively correlated to
social networking.
−S
ocial capital values are directly correlated to
the social and cultural attitudes of the society/
reference group.
230
−S
ocial capital values are positively correlated to
the density of institutional networks.
Rizzi’s research shows yet again that the North of
Italy is richer in social capital than the South.
There have been widespread warnings not to waste
the social capital present in the Regions of Northern
Italy, but the growing individualism threatens to undermine the capital built over the centuries and the
speed up its depletion. As health operators, it is our
task to revive and create the system of trust and reciprocity with citizens in order to reduce this risk.
Conclusions
Building social capital is a complex task that
brings together several interwoven variables. Social
capital has a positive impact on social relations, the
economy and social stability and to understand how
to model the development of social capital, it is useful
to retain three stages: conditioning, development and
capitalization. Conditioning requires transparency,
pragmatism and long-term vision. Development and
capitalization require the predominant variables to be
chosen. The development of social capital is part of a
good strategy for health promotion and prevention.
Key Messages:
Ø
Social capital is particularly important in important in health and social organizations in view of
their special role and the type of goods they produce, defined as “relational goods”.
Ø
Three stages are required to understand and maintain the growth of social capital in a community:
conditioning, development and capitalization. These
stages can be construed as different steps in a social engineering process and each comprises distinct but recursive components in the sense that
the products (the effects) are also the producers (i.e.
the causes). This circularity represents the functional
reciprocity associated with virtuous circles in social
capital dynamics.
Ø
Since Smith and Weber, reference has increasingly
been made to social attitudes to explain social evolution. Some authors explain the differences in political and economic growth in terms of the level of
T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
trust present in social and market relations, construed as the willingness to cooperate entrenched
in a given culture, while others measure the cultural
aspects underpinning social virtues like trust seen
as a means to cut the costs of transaction between
social and economic players.
Acknowledgements
The authors thank Anne Prudence Collins for linguistic
assistance.
References
1. Baum F. Social capital: is it good for your health? Issues for a
public health agenda. J Epidemiol Community Health 1999;
53: 195-96.
2. Beauvais C, Jenson J. Social cohesion: updating the state of
the research. Discussion paper F/22, Ottawa, Canadian policy
research networks. 2002
3. Becker SW, Neuhauser D. The efficient organization. New
York, Elsevier Inc., 1975
4. Begum H. Social capital in action: adding up local connections
and networks. London, Center for Civil Society, 2003
5. Bernard P. (1999) La cohesion sociale: critique dialectique d’un
quasi-concept. Liason social et Politiques 1999; 41: 47-49.
6. Bonani GP. La sfida del capitale intellettuale. Principi e strumenti di Knowledge Management per le organizzazioni intelligenti. Milano, Franco Angeli, 2002.
7. Bonazzi PL et al. Capitale sociale e sistema sanitaria: l’arte
sottile di creare circoli virtuosi. In Casi di gestione. 3 e 4 anno,
materiali didattici del Master in amministrazione gestione dei
servizi sanitari, Bologna, CLUEB e Regione Emilia-Romagna,
1999.
8. Bourdieu P. Outline of a theory of practice. Cambridge: Cambridge University Press, 1977.
9. Bueno E, Salmador MP, Rodriguez O. The role of social capital
in today’s economy. Journal of Intellectual Capital 2004; 5(4):
556-574.
10. Bueno E. El Capital Social en el Nuevo enfoque del Capital Intelectual de las organizaciones. Revista de psicologia del trabajo
y de las organizaciones 2002; 18(2-3):157-76.
11. Borgonovi E. Fiducia, parola magica (editoriale). Mecosan
2010; 74: 3-7.
12. Bruni L, Zamagni S. Economia civile. Efficienza, equità, felicità pubblica. Bologna, Il Mulino, 2004.
13. Cartocci R. Mappe del tesoro. Atlante del capitale sociale in
Italia. Bologna, Il Mulino, 2007.
14. Cartocci R. Diventare grandi in tempi di cinismo. Bologna, Il
Mulino, 2002.
15. Catanzaro R (a cura di) Nodi, reti, ponti. La Romagna e il capitale sociale. Bologna, Il Mulino, 2004
16. Charns W, Schaefer J. Health care organization: a model for
Social capital and health
management. NJ, Prentice-Hall, Englewood Cliffs, 1983
17. Cheragi-Sohi S et al. What are the key attributes of primary
care for patients? Building a conceptual map of patient preferences. Health Expect 2006, 9:275−84.
18. Cicchetti A, Mascia D. Organizzare le reti in sanità: teoria, metodi e strumenti di social network analysis, in Biocca M, Grilli
R, Riboldi B (a cura di), La governance nelle organizzazioni
sanitarie, Milano, Franco Angeli, 2008.
19. Coleman, J. S. Social Capital in the Creation of Human Capital. The American Journal of Sociology 1988; 94: S95-S12.
20. Commissione delle Comunità Europee People in Emerging
Markets Catch Up to Advanced Economies in Life Satisfaction, 2014, http://www.pewglobal.org/2014/10/30/people-inemerging-markets-catch-up-to-advanced-economies-in-lifesatisfaction/
21. Commission of the European Communities (2007), White paper. Together for health: a strategic approach for the EU 20082013, 630 final.
22. Commission of the European Communities (2005), Green Paper. Improving the mental health of the population. Towards a
strategy on mental health for the EU Bruxelles, 484 final 23.
23. Consiglio nazionale dell’economia e del lavoro (2010), Istituto
nazionale di statistica, Cnel e Istat misurano il benessere: entro
il 2011 sarà individuato il set di indicatori, comunicato stampa.
24. Daniels N. Accountability for reasonableness. Establishing a
fair process for priority setting is easier than agreeing on principles. BMJ 2000; 321: 1300-01.
25. Davies H. Falling public trust in health services: Implications
for accountability. Journal of Health Services Research and
Policy 1999; 4: 193-194.
26. Delbono F. Presentazione, in Barbagli M, Colombo AD, Partecipazione civica, società e cultura in Emilia-Romagna. Milano,
Franco Angeli 2004.
27. Delegazioni dei Ministeri della Salute degli Stati Membri
dell’Unione Europea. La salute in tutte le politiche, dichiarazione del 18 dicembre 2007.
28. De Sario B, Sabbatini A, Mirabile ML. Il capitale sociale degli
anziani, supplemento Rassegna Sindacale 2010, n.38.
29. Desmarteau HR. Pensare e modellizzare il capitale sociale
in armonia strategica con il capitale economico per tessere la
democrazia, synopsis per le attività didattiche del MBA, Université du Québec (Montréal, Canada) 1999.
30. De Tocqueville A. La democrazia in America. Torino, Utet
1968.
31. Dever GEA. An Epidemiological Model for Health Policy
Analysis Soc Ind Res 1976, vol. 2.
32. Edvinsson L. Developing Intellectual Capital at Skandia. Long
Range Planning 1997; 30 (3): 366-373.
33. Edvinsson L, Malone M. Intellectual Capital. London, Piatckus 1997.
34. Flournoy R, Yen I. The influence of community factors on
health: an annoted bibliography. PolicyLink and California
Endowment 2004.
35. Freddi G. Medici e Stato nel mondo occidentale. Bologna, Il
Mulino 1990.
36. Frey B. A constitution for knaves crowds out civic virtues. Economic Journal 1997; 107: 1043-53.
37. Fukuyama F. The Great Disruption: Human Nature and the
Reconstitution of Social Order. New York: Free Press 1999.
231
38. Gannon M, Pillai R. Understanding global cultures: Metaphorical journeys through 17 Nations (5ed.). Thousand Oaks,
CA: Sage Publications 2011.
39. Giddens A. The third way and its critics. Cambridge, Polity
Press 2000.
40. Gilson L. Trust and the development of health care as a social
institution. Social Science & Medicine 2003; 56: 1453-68.
41. Gittel R, Vidal A. Community Organizing. London, Sage
Publication 1998.
42. Goss M. Administration and the physician. American Journal
of Public Health 1963; 52: 183-91.
43. Grilli R, Taroni F. (a cura di) Governo clinico. Governo delle
organizzazioni sanitarie e qualità dell’assistenza. Roma, Il Pensiero Scientifico Editore 2004.
44. Halman L et al. Changing values and beliefs in 85 countries.
Trends from the values surveys from 1981 to 2004. Leiden and
Boston, Brill 2008
45. Helliwell J. Do borders matter for social capital? Economic
growth and civic culture in United States and Canadian Provinces. working paper n.5863, NY, National bureau of economic
research 2001.
46. Hendryx MS et al. Access to health care and community social
capital. Health Services Research 2002; 7: 87-103.
47. Heydebrand WV. Hospital bureaucracy: a comparative study of
organizations. New York, Dennell 1973.
48. Hofstede GH. Cultures and Organizations. NY McGraw-Hill
1995.
49. Kemm J, Parry J, Palmer S (eds). Health impact assesment:
concepts, theory, techniques and applications. Oxford University Press 2004.
50. Kliksberg B. Capital social y cutura claves olvidadas del desarrollo. Instituto interamericano para el desarrollo social 2000,
doc. 7: 1-37.
51. Inglehart R, Welzel C. Modernization, cultural change and
democracy: the human development sequence. Cambridge,
Cambridge University Press 2005.
52. La Porta R, Lopez De Silanes F, Shleifer A, Wishny R. Trust
in large organizations. American Economic Review 1997; 87
(2): 333-38.
53. Levy-Leblond JM. The importance of being (a) constant.
Problems in the foundations of physics. Enrico Fermi School
LXXII, G. Torraldi ed. (North Holland) 1979: 237.
54. Lindstrom M et al. Socioeconomic differences in leisure-time
physical activity: the role of social participation and social capital in shaping health related behavior. Social Science and Medicine 2001; 52: 441-51.
55. Longo F. Governance dei network di pubblico interesse: strumenti operativi aziendali. Milano, Egea 2005.
56. Marradi A. Metodologia delle scienze sociali. Bologna, Il
Mulino, 2007.
57. Materia E. Perchè le società più egualitarie stanno meglio, at url
http://saluteinternazionale.info/2009/05/perche-le-societapiu-egualitarie-stanno-meglio. 2009
58. McKee M, Figueras J. Setting priorities: can Britain learn from
Sweden? British Medical Journal 1996; 312: 691-94.
59. Millenson ML. How the US news media made patient safety a
priority. BMJ 2002; 324: 1044.
60. Ministero del Lavoro, della salute e delle politiche sociali della
Repubblica Italiana. La vita buona nella società attiva: Libro
232
Bianco sul futuro del modello sociale. Roma, 2009
61. Mintzberg H. Structure in fives: designing effective organizations. NJ, Prentice-Hall, Englewood Cliffs, 1983.
62. Morrow V. Conceptualising social capital in relation to the
well-being of children and young people: a critical riview. Sociological review 1999; 47: 744-65.
63. Muntaner C, Lynch J, Smith GD. Social capital and the third
way in public health. Critical Public Health 2000; 10: 107-24.
64. Mutti A. Social capital and development. Trust as a resource.
Bologna, Il Mulino 1998,
65. OECD The Well-being of Nations. The role of human an social capital. Paris 2001.
66. Office of national statistics. Social Capital: a review of the literature. London 2002.
67. Perrow C. Hospitals: technology, structure and goals, in March
J, Handbook of organizations, Chicago, Rand McNally 1965.
68. Portes A. The two meanings of social capital. Sociological forum 2000; 15: 1-12.
69. Putnam R. The civic tradition in the Italian regions. Milan,
Mondadori, 1993.
70. Putnam R. Social capital and individualism. Bologna, Mulino,
2004.
71. Rizzi P. Local Development and Social Capital: the case of the
Italian regions. Laboratory of Economics, Catholic University,
Piacenza, 2003, p.28
72. Roos J. et al. Intellectual Capital. Navigating the New Business
Landscape. London, MacMillan Business Press 1997.
73. Rosenheck R et al. Service delivery and community: social capital, service systems integration and outcomes among homeless
persons with severe mental illness. Health Services Research
2001; 36: 691-710.
74. Rumelt RP. Strategy in a “structural break”. The McKinsey
Quarterly 2009; 1: 35-42.
75. Sabatini F. Un atlante del capitale sociale italiano. Roma, Dipartimento di economia pubblica, 2005.
76. Scheffler RM, Brown TT. Social capital, economics, and
health: new evidence. Health Economics, Policy and Law
2008; 3: 321-31.
77. Scheffler RM, Paringer L. The Economic Evidence on Prevention. Healthy People: The Surgeon General’s Report on Health
Promotion and Disease Prevention, publication No.7955071A,
Washington DC, Government Printing Office 1979.
78. Scheffler RM, Brown T, Rice J. The role of social capital in
reducing nonspecific psychological distress: the importance of
controlling for omitted variable bias. Social Science and Medicine 2007; 65(4): 842-54.
79. Sheppard B. Reshaping business education in a new era. McKinsey Quarterly 2010, January.
80. Shore DA. The trust crisis in health care. Causes, consequences,
and cures. New York, Oxford University Press, 2007.
81. Shortt S. Making sense of social capital, health and policy.
Health Policy 2004; 70: 11-22.
82. Silver H. Policies to Reinforce Social Cohesion in Europe, in
de Haan A, Burle FJ. Social Exclusion: An ILO Perspective.
Geneva, International Labour Organization, 1998.
83. Smith A, Nicholson JS. An inquiry into the nature and causes
of the Wealth of Nations. T. Nelson and Sons, 1987.
84. Sobel J. Can we trust social capital? Journal of Economic Lit-
T. Lavalle, C. Damimola Omosebi, R.H. Desmarteau
erature 2002; XL: 139-54.
85. Spataro P. Crisi economica. Quant’è infelice il vecchio capitalismo. L’Unità 2010, 8 novembre.
86. Sterpi S. Salute, capitale sociale, egualitarismo. Politiche sanitarie 2010; 11(3): 147-61.
87. Ståhl T et al. Health in All Policies. Prospects and potentials.
Finland, Ministry of Social Affairs and Health, 2006.
88. Sveiby KE. The New Organizational Wealth: Managing and
Measuring Knowledge based Assets. San Francisco, BerrettKoehler, 1997.
89. Szreter S. A new political economy for new labour: the importance of social capital. Renewal 1999; 7: 30-44.
90. Taroni F. L’evoluzione delle politiche sanitarie in Italia, tra crisi
finanziarie e problemi di fiducia. Autonomie locali e servizi
sociali 2007; 1: 29-42.
91. Tarrow S. Making social science work across space and time:
a critical reflexion on Robert Putnam’s making democracy
work. American political science review 1996, XC: 389-97.
92. Taylor C. Sources of the Self: The Making of Modern Identity. Harvard University Press 1989 (trad. it. Radici dell’io,
Feltrinelli, Milano 1993)
93. Thompson CJ. Caring Consumers: Gendered Consumption
Meanings and the Juggling Lifestyle. Journal of Consumer
Research 1996; 22: 388-407
94. Thompson CJ, Locander WB, Pollio HR. Putting Consumer
Experience Back into Consumer Research: The Philosophy
and Method of Existential Phenomenology. Journal of Consumer Research 1989; 16: 133-46.
95. Thompson, Craig J, Troester M. Consumer Value Systems
in the Age of Postmodern Fragmentation: The Case of the
Natural Health Microculture. Journal of Consumer Research
2002; 28: 550-71.
96. Voslensky M. Les Maîtres De La Nomenklatura. Pierre Belfond ed. 1989, Paris.
97. Weber M. Politics as a Vocation (p. 2). Philadelphia: Fortress
Press, 1965.
98. Wilkinson RG, Pickett K. The spirit level: why equality is better for everyone. Penguin, 2010.
99. Wilkinson RG, Pickett K, De Vogli R. Equality, sustainability
and quality of life, British Medical Journal 2010; 341: c5816.
100. Woolcock M. Social capital and economic development: toward a theoretical synthesis and policy framework. Theory
and Society 1998; 27: 151-208.
101. World Health Organization, European Center for Health
Policy. Health Impact Assessment: main concepts and suggested approach. Gothenburg Consensus paper, 1999.
102. World Heath Organization Closing the gap in a generation.
Health equity through action on the social determinants of
health. 2008, Geneva.
Accepted: 7 october 2015
Correspondence:
Dr Tiziana Lavalle
Via Delle Fonti 66, 40128 Bologna (Italia)
Tel. +393384828141
E-mail: [email protected]; [email protected]