Rivista per le Medical Humanities

Mattia Lepori
rMH 43, 2019, 11

Living with violence in the emergency room

In a place like a first aid service, where emotional tensions are often intense, you sometimes have the feeling of living in a violent environment. Sometimes, violence is present to the extent that you have to deal with patients who are victims of violent acts; some other times, because health professionals themselves are subject to verbal or physical attacks by users or their relatives. The evolution of the situation over recent years has required – and still requires – the implementation of protection measures (security agents, surveillance cameras) that – ideally speaking – are hardly compatible with the vocation of a place intended for taking care of people. More frequent, not to say constant, however, is the presence, at times insidious, of that climate of permanent tension generated by work overload, reciprocal misunderstandings between colleagues, or inadequate logistic and technical situations. These are situations characterised by a form of subliminal violence that risks, if ignored, to lead the operators involved to frustration and exhaustion. It is the duty of the institution to take any such measures upon themselves that are likely to limit these phenomena as much as possible, especially those of manifest violence. Only a serene atmosphere in which to operate allows taking the necessary step to move on from “curing diseases” to “taking care of individuals”.

Duilio F. Manara
rMH 43, 2019, 12-22

Aggression and non-recognition in care institutions

The increasing number of reports relating to violent episodes taking place at care institutions is just striking: it is indeed a phenomenon that cannot just be explained by appealing to the recent greater sensitivity and attention in reporting such episodes. After a brief presentation of the data available in the literature and on institutional websites, the paper proposes an analysis carried out with a phenomenological approach. Starting from Paul Ricoeur’s reflections on recognition paths, and ruling out any pathological or criminal situations, the argument proposed is that in contemporary society the increase in acts of violence can be partly assumed as a sign of the crisis of the “principle of giving”, which ended up by clashing with the extroversion of values and behaviours related to individualism. The patient or his/her family members who feel injured by an alleged wrong committed to the detriment of their rights – first and foremost to their right to be heard by their own carers – and the care professionals themselves, who are often trained for an apathetic kind of caregiving, or have become over time (due to fatigue, disorganisation or neglect) unable to grasp the “right degree” of involvement in the care relationship (with increasing levels of carelessness and insensitivity towards their care recipients), would be an expression of the same phenomenon: that is, the fatigue of giving and receiving a mutual recognition of one’s needs and limits.

Luisa Lomazzi
rMH 43, 2019, 23-26

Preventing maltraitance, promoting bientraitance

The exploration of the phenomena of ill-treatment in the nursing homes for the elderly in the Canton of Ticino, carried out through a long research process, of which this paper provides a partial account, takes as a reference the concept of “maltraitance ordinaire”, which allows catching in a sensitive and refined way the many-sided facets and nuances of human behaviours towards old age and frailty. At the same time, the model of bientraitance, a bearer of a vision and a culture strongly focused on the value of the person, generator of attentions and motivation, is identified as a virtuous approach to be promoted in residential facilities. In the logic of abuse prevention, along with a rigorous policy to fight ill-treatment, it is therefore crucial to focus on the phenomena of maltraitance ordinaire, thus forcing the institutions to dwell upon those attitudes – the “ordinary” ones, precisely – that, if not identified and dealt with decisively in everyday life, can lead to the normalisation of ambiguous practices (such as, for example, the standardisation of pet names). A strategy capable at the same time of preventing maltraitance ordinaire while promoting a bientraitant approach is characterised by: a participative managerial style, updated gerontological-geriatric knowledge, work in interprofessional teams, an open cultural climate focused on the recognition of the other and his self-determination. The promotion of bientraitance is a dynamic process, a horizon to strive for, in an ethical dimension that implies situating the person, his expectations   and his conception of well-being at the centre of reflection.

Ivo Calvi
rMH 43, 2019, 26-29

The team's strength in facing the dark paths

The paper gives an insight of the path that characterised Casa Mistral, a facility managed by the Sirio Foundation, established in the Canton of Ticino in November 2013 as an experimental project, at the behest of the Disability Insurance Department (ai): it highlights both the difficulties represented by the work with a very complex user base – composed of individuals with serious psychiatric illnesses – and the solutions that the team has gradually experimented and found during its difficult path. Particular attention is paid to the peculiarities that characterise the action put in place by this team: a multidisciplinary team, well integrated, where individual talents are valued, which – thanks to this – succeeds to meet the demands imposed by their task. The article examines, in a particular way, one of the ingredients that characterise the modus operandi of the centre, which gradually became its very mainstay: wellcoming. This is a practice that is not merely confined to the initial or project phase, but rather accompanies the user throughout his path. Reception, along with networking, sharing, supervision, elasticity and creativity, allows operators to live inside an organisation that is ever evolving rather than being monolithic and static, which is continually shaped and transformed in an attempt to always meet adequately the demands by which it is prompted. Such capacity – i.e. being able to change shape while remaining itself – is essential when it comes to facing the challenges that an institution is called to deal with day by day.

Paolo Ferrara
rMH 43, 2019, 30-32

The necessary stop

Stopping is perhaps the first act required for a leader and for a team in the daily and intensive path of caretaking. Stopping to give quality to the meeting with the patient and his family members, with one’s own collaborators and colleagues, with one’s superiors. And stopping with oneself, to give quality to one’s own intra- and interpersonal skills. We give to others what we are, our way of being. Conversely, as individuals and as a team, each dimension feeds on the other. Nevertheless, all this requires commitment. The Cantonal Hospital Authority of the Canton of Ticino (Ente ospedaliero cantonale) has chosen to invest in that individual and team commitment to have environments that are suitable for caregiving. This goal is achieved through: a strategic plan aimed at supporting teamwork; an infrastructure based on interdependence, on the culture of feedback, on the ability to raise questions and start communication; the commitment of the Human Resources Service to promote the development of everyone’s emotional and social skills, recognised as essential as well as the technical-clinical ones; the help of an internal business counsellor. This is how dedicated and interdisciplinary training programmes were born along with individual and team tutorship, moments of sharing between carers, managers of departments/services around episodes of relationship difficulty. All these were as many opportunities to stop doing, with a view to listening to each other and discussing one’s own respective experiences and behaviours, so as to ultimately shade light on the dark paths. Stopping becomes culture.

Antonella Keller
Federica Merlo
rMH 43, 2019, 33-37

Taking care of educators

The paper focuses on the specificity of the “obscure paths” in the care of people with disabilities, raising in the first place the issue of the peculiar – or not – character of the care relationship that involves these subjects. One wonders if there are differences between taking care of a patient in an emergency room or in a hospital ward and that of mental suffering and disability in an institution such as the otaf Foundation (Opera ticinese per l’assistenza alla fanciullezza – Ticino childhood care organisation). Further on, the authors try to understand where the “darkness” that sometimes arises marking the course of care is ge- nerated: whether it is linked to a situation of discomfort in the educator-user relationship, whether expressed by a widespread uneasiness that involves the whole team. To address these “dark paths”, the otaf institution has chosen to offer, as a privileged pathway, the tutorship of professionals through supervision: with the help of a specialist, each group member has the opportunity to express their uneasiness, translating their discomfort into words, even legitimising all their censored feelings, such as anger, grudge, embarrassment and shame. Despite this, it can be still difficult to succeed in thoroughly dissecting the complex causes of the “dark paths” in order to get to understand them completely: they can certainly be lit a little, but never completely.  

Zefiro Mellacqua
rMH 43, 2019, 38-41

The home-within-us

Compared to other national and international institutions, the Home Treatment of Bellinzona and the Tre Valli district – a pilot project of the cantonal Socio-psychiatric Organisation of the Canton of Ticino – stands out for the uniqueness of the approach with which it was implemented, as it represents one of the rare cases of a psychiatric hospital (namely the Cantonal Psychiatric Clinic of Mendrisio), which in turn arose from an ex-asylum facility, that transfers the already existing resources of a single ward directly for the benefit of the territory, so as to allow a multidisciplinary psychiatric home caretaking at the domicile of patients in conditions of acute psychopathology. From the carers’ perspective, the Home Treatment is not just a treatment project, but essentially a collective process of de-institutionalisation and further humanisation of clinical psychiatry in Ticino. By crossing the patients’ doorstep with all humility, the “homewithin- us” provocatively means to be a non-place where the operators can, with human warmth, make room in themselves, courageously, for the fear and responsibility that such an activity entails and for the questions it raises. What level of complexity and risk is the Home Treatment operator called to face? What about psychiatric care at home from a socio-anthropological and ethical point of view? Maybe we are institutionalising the home or trivialising the psychiatric intervention by distorting the institutional setting? What transformations are health professionals engaged in a work of human and socio-family proximity to mental distress required to make? What kind of political and economic choices does the exercise of a psychiatric care hopefully integrating and integrated at the patients’ domicile with their families require?

Mattia Mengoni
rMH 43, 2019, 42-45

Istitutional inertia

In the universe of care, it may happen that the institutions themselves promote the existence of dark paths made of boredom, violence, frustration, and inertia. In the frenzy of rhythms, times and organisational constraints, we come across actions, thoughts, and situations that are located in the large grey area between good treatment and mistreatment. When the institutional dimension gets the upper hand over the dimension of care and accompaniment, dictating times, limits, rules and boundaries, there is a risk of inevitably forgetting the person, participation, and reception. This is why it is necessary to acknowledge individual stories and include them within the institutional context with the awareness that the two dimensions condition one another in a continuous and important way. It is not the sole task of the operator to remain vigilant with respect to this dimension; the facility itself, through the definition of its own culture, mission, and values, must promote a continuous questioning of its own actions and of being. In other words, it must build trust and hope, encourage participation by expressing responsibility and exercising resistance and indignation towards any form of violence and exclusion, without ever forgetting, however, the recognition for those who, like care operators, constitute the institution itself thanks to their daily acts. Drawing into itself, with self-referentiality and fear of change, is the beginning of the dark paths for any institution.

Franco Zambelloni
rMH 43, 2019, 46-49

Light and darkness

The classical tradition associates the genesis of medical therapy with Asclepius, the Greek god of medicine. From those distant origins to the modern age, and even beyond, throughout the historical course of the Western world, medicine has been constantly intertwined with the sacred: medical action means defence of life and conflict against death, which puts it in relation to religious and metaphysical archetypes. That is why the carer’s dark hour brings to mind the dark night experienced by the mystics, when they suddenly felt the anguish of God’s silence. Thus the good doctor, who does not only entertain a therapeutic relationship with the patient, but also an empathic link that makes him share the former’s drama and suffering, probably feels the discouragement of the dark hour when his therapeutic efforts prove useless and when he must accept and admit his impotence. But today, as the technique is becoming more and more dominant even in the medical practice, there is a risk for the doctor – converted into a technician – to be sheltered from such discouragement, which is definitely not desirable, either for doctors or, above all, for patients.

Marco Aschwanden
rMH 43, 2019, 81-100

Healthcare data between protection and sharing

In the era of e-health and big data, the relentless diffusion of digital literacy requires us to rethink of the management of healthcare data. Politics, medicine, nursing staff, patients, all the main players in the complex and fascinating world of healthcare are asking for it. As a consequence, the dilemma between data protection and sharing is amplified. The original concept of data protection is tottering, it does not look like being up to date any longer. Regula tory – as we ll as organiza tional and train ing corrections – must be found, without forgetting that the patient’s wellbeing must always be placed at the centre of the whole process. The paper presents a sort of photograph of the current historical moment, referring to the healthcare context necessarily confronted to this evolution. It does this through some terminological considerations, followed by a regulatory overview (both at national and cantonal level), highlighting the centrality of the medical record as a Sammelsurium of sensitive information, and therefore worthy of being protected. The article lingers over the sharing of these data, diversified in forms – either voluntary o r involuntary – and degrees, in an attempt to draw as a final step a decalogue project that calls for a comparison of opinions and solutions shared between health professionals, authorities and users/patients. This is to prevent the fear of complications from leading to not proactively addressing the unsolved aspects of the dilemma.