The Case/Care Manager in Eating Disorders: the nurse’s role and responsibilities

Abstract

Background and aim of the work: Despite its incidence, the Eating Disorder (ED) is underdiagnosed and, for its complexity, it requires multidisciplinary interventions. The Nurse and Case/Care Manager (CCM) have a central role in taking care of the patients with ED, even if the research concerning their role are lacking. Thus, the aim of the study was to investigate roles, activities and expectations of the nurse and the CCM in taking care of patients with ED. Method: 25 Italian different professionals were interviewed (16 women, average age 43.4; SD = 9.23). The semi-structured interview has investigated: nurses’ roles and activities; perceptions of nurses’ evaluation; expectations on nurses’ and CCM’s roles; the interprofessional collaboration. Results: The nurses analyse patients’ care needs and coordinate the multi-professional care with empathic attitude. Their “professionalism, skills, sensitivity, ability to relate to the patient-family unit” are expectations shared by various professionals. About the interprofessional collaboration, the action of professionals is not always well coordinated, the decisions are often not shared and hospital-territory connection is not always realised. The CCM would be the reference in this process for all interviewees. Conclusions: In the three examined contexts the figure of the CCM was not present, but his/her importance was acknowledged in the management of the patient’s care path and as a point of reference for health professionals. It seems important that CCM is institutionally recognized, because the CCM would ensure an efficient management of the clinical pathway and would guarantee the continuity and appropriateness of care. (www.actabiomedica.it)

Introduction

The Eating Disorders (EDs) represent one of the most common health problems among the youth population, and especially among the female population (1). In particular, among EDs, classified by the DSM-V (2) as Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge-eating Disorder (BED), the incidence of AN is at least of 8 new cases for 100,000 women in one year, while that of BN is at least 12 new cases for 100,000 women in one year. In researches conducted on clinical populations, males represent between 5% and 10% of cases of AN, between 10% and 15% of cases of BN, and between 30% and 40% of BED (3, 4, 5).

Although there is a tendency to chronicize in life-time, the EDs are under diagnosed. People who suffer from it show a delay in access to services and seek medical observation after a long history of disease. These features increase clinical complexity as well as social and relational compromise of patients with EDs.

The Eating Disorders compromise the health of the person on several levels (physical, psychological, social, and relational) with consequences on the patient’s quality of life, from the onset of symptoms until the entire course of the disease. Then they require multidimensional skills, multi-professional interventions (by psychiatrists, psychologists, nutritionists, general practitioners, internists, endocrinologists, paediatricians, child neuropsychiatrists), and multidisciplinary interventions (such as specialist outpatient therapy, intensive outpatient therapy or day-time centre, intensive hospital rehabilitation, ordinary and emergency hospitalisation).

There are several guidelines for the diagnosis and treatment of EDs, such as those of the American Psychiatric Association (APA) (6) and of the National Institute of Clinical Excellence (NICE) (7), which are based on a specialist team approach and on the clinical, psychological and social evaluation of the person. In Italy, patients with EDs are treated following the recommendations of the 2012 National Conference (8), combined with the APA and the NICE guidelines. Each Local Health Service (LHS) has a multidisciplinary specialist service for prevention, therapy and rehabilitation of EDs. The LHSs should guarantee the outpatient activity, plan admissions and day rehabilitation activities in Day Hospital regime and schedule possible residential treatments at specialist health structures. In particular, the care network should guarantee the continuity of the therapeutic path, based on 5 care levels:

1. - First level: general practitioner, free-choice paediatrician;

2. - Second level: hospital specialist clinic;

3. - Third level: day service, day hospital (diagnostic, therapeutic, rehabilitation) and day centre;

4. - Fourth level: intensive residential rehabilitation and rehabilitative therapeutic community;

5. - Fifth level: ordinary and emergency hospital admissions.

From the various guidelines, it emerges that the nurse and the Case/Care Manager (CCM) play a central role in the taking in charge of the patient as they act as a link between the hospital and the territory, even if in daily practice they play a marginal role compared to the medical one.

The CCM is evolving as a response to the evolution of the changes of the health system, with the primary aim of satisfying the bio-psycho-social needs of the person through the management of the entire course of care and through the coordination of the several health and social assistance services.

The CCM guarantees a global management, promoting a series of integrated interventions so as to achieve a synergistic result. In particular, the CCM guarantees the patient’s support throughout the entire therapeutic course, plans care and ensures its implementation, evaluates achieved results and guarantees a high level of cooperation between the health, socio-assistance and territorial professionals involved (9, 10). The CCM is also part of the multi-disciplinary team and plays both a coordinating role and a clinical, managerial and educational one. Therefore, the CCM works in several care settings: ambulatory, day hospital, hospital, residential and semi-residential care (11).

The CCM also helps to improve: the quality of life of the patient through the common identification of care goals; the acknowledgement of the system of values and beliefs; the encouragement in identifying resources and capabilities of patient and family, helping them to develp realistic expectations compared to assistance results (12).

Unlike the United States of America, where the CCM has been present for many years, in Italy the CCM has been present only in the last decade. Similarly, to France, Germany and the United Kingdom, the role of the CCM in Italy is strictly for nursing purposes.

In addition, literature claims that the most suitable professional to hold this role is the nurse. In fact, research shows that nurses play an essential role in the recovery process of EDs (13, 14). They favour a good therapeutic relationship showing listening and reassuring attitudes towards the patient (15, 16, 17, 18).

As part of the patient’s assistance with EDs, nurse’s behaviour and attitudes are targeted to encouraging dialogue and active listening (19, 20), creating a therapeutic alliance (21), focusing on the patient needs, assisting and supporting the family (22) and ensuring comprehension and empathy (23, 24). The CCM nurse integrates personal/professional and communicative/relational skills to achieve greater effectiveness in achieving objectives and undertaken actions (25).

The CCM therefore represents a figure of mediation of the patient with the family and among the various figures of the team, planning and coordinating the multi-professional implementation of the care pathways and the protection of the rights of the person.

Despite these evidences of the literature, researches concerning the point of view and experiences of nursing care of EDs patients are extremely lacking (26, 27), even if limited scientific material suggests that these professionals find taking care of EDs patients particularly challenging (28, 29, 30).

Aims

The primary aim of the research was to analyse the role and responsibility of the nurse and the CCM in the interdisciplinary management of cases, also in order to prove the importance of the CCM model for the coordination of the EDs assistance.

The secondary aim was to highlight similarities and differences in the diverse treatment contexts analysed, in which these professionals take care of EDs patients.

Method

Study Design

The research included a qualitative study with a descriptive goal in order to elaborate the subjective perceptions of different professionals on regarding nurses and CCMs roles and responsibilities, and in particular on regarding: nurse activities, evaluation compared to the nurse, role expectations regarding the nurse and the CCM.

Instrument

A semi-structured individual interview was conducted with the aim of detecting the perceptions of the nurse and of the other professionals with whom he or she interacts. In particular, the interview has investigated the following 5 areas following the Levati method (31):

1. roles and activities performed by nurses (e.g. What are the activities that the nurse carries out within the Operational Unit (O. U.) compared to EDs patients?);

2. perceptions of nurses’ evaluation (e.g. From whom is a nurse evaluated? To whom must he/she answer for his/her work?);

3. expectations on nurses’ role (e.g. What do you expect from a nurse about EDs patient care?);

4. perceptions and expectations on Case/Care Manager’s role (e.g. Have you ever heard of the Case/Care Manager? What do you think of his/her role?);

5. interprofessional collaboration (e.g. Are there moments of team work? Who participates in them?).

Data Analysis

On the whole textual corpus, a thematic content analysis (32) was performed by three researchers. The inter-judge accordance was calculated by Cohen’s Kappa Coefficient (.087), in order to make a comparison of the narrative themes emerged in reference to the aims of the research.

Healthcare Contexts

Participants were selected through a convenience sampling in three different health contexts: New Children’s Hospital of University Teaching Hospital of Parma; Specialized Medicine / Diabetology Hospitalization and Eating Disorders Unit of Reggio Emilia’s Santa Maria Nuova Hospital; Day Hospital of Diagnosis Prevention Service and Treatment of the Local Health Service 5 of La Spezia.

In Parma actually a specific DTAP (Diagnostical-Therapic Assistential Pathways) of the EDs patient does not exist. The patient is taken in charge by the internal paediatrician of the Operative Unit of reference, to which the patient arrives after direct access to the Paediatric Acceptance Desk. For EDs patients there is not a unique treatment only but, rather, an ensemble of clinical and psychiatric/psychological treatments. The Eating Disorder treatment is divided into two phases. The first one consists in the re-establishment of body weight in a short time and saving of life, also through hospitalization; during hospitalization, parenteral or enteral therapy is practiced.

The second one consists in the psychology individual sessions. In the Paediatric Unit the hospitalization occurs for patients between 14-17 of age for whom the best accommodation is identified according to the unit’s situation and to the patient’s features.

Reggio Emilia provides an interdisciplinary approach for both outpatient and intensive partial or total hospitalization treatments. The hospitalization in Specialized Medicine /Diabetology Department and Eating Disorders Unit is necessary in case of serious physical problems or acute psychiatric comorbidities; these are treatments limited in time and aimed to achieving a resolution of the specific acute condition. Specialized psychotherapeutic and nutritional support for Eating Disorders is provided as well as network paths with the territory that allow rehabilitative care and therapeutic continuity. This continuity has the advantage of being able to create a privileged path for the patient who can benefit of the most suitable therapy compared to his state of health and to physical and psychological needs, without interrupting the diagnostic-therapeutic path.

Regarding La Spezia, the Eating Disorders Unit is present at the Mental Health Centre (for patients over 18) and it includes a psychiatrist and a psychologist. Nurses are also always present as well as dieticians. The entire staff has undergone specific training for the treatment of EDs.

Access takes place directly upon request of the patient and/or his/her family members, upon request of the general practitioner or by other services, such as the Counselling Service, the Emergency Department, the Psychiatric Service of Diagnosis and Treatment or other hospital wards. Family counselling and group psycho-educational interventions are planned. Should a taking in charge of family members be necessary, collaboration with psychologists of the multidisciplinary service is provided. Based on the assessments carried out an individualized path is provided which may include the outpatient taking in charge, admission in Day Hospital, hospitalization in medical ward and in the Psychiatric Service of Diagnosis and Treatment or in a specialized department for EDs.

The choice of professionals to be involved was based on the study of the organization chart of the three-healthcare setting, from which the following professionals were identified: Medical Nutritionist, Psychiatrist, Psychologist, Nutritionist Biologist, Nurse, Social-Health Worker, Dietician and Nursing Coordinator.

Participants

Twenty-five participants joined the research (16 women, average age 43.4; SD = 9.23), of which: 10 Nurses, 3 Medical Directors, 4 Nutritionist Biologists, 2 Nursing Coordinators, 3 Social-Health Workes, 1 Psychologist, 1 Dietician and 1 Departmental Director.

In Reggio Emilia and in La Spezia the professionals were balanced for gender (4 men and 4 women in both contexts), while in Parma 8 women and 1 man were interviewed. The professionals average age in Reggio Emilia was 39.62 years old (SD = 8.52), in Parma was 43.33 years old (SD = 9.75) and in La Spezia was 47.25 years old (SD = 8.81).

Table 1 shows the professional roles of the participants of the three selected healthcare contexts.

Table 1.

Professional roles of respondents

Professional role	Santa Maria Nuova Hospital of Reggio Emilia	University Teaching Hospital of Parma	Local Health Service 5 of La Spezia	Total
Nurse	4	3	3	10
Medical Director	1	1	1	3
Nutritionist Biologist	2	1	1	4
Nursing Coordinator	/	1	1	2
Social-Health Worker	2	1	/	3
Psychologist	/	1	/	1
Dietician	/	1	/	1
Departmental Director	/	1	/	1
Total	9	10	6	25

Ethical considerations

The study has been conducted in agreement with the Ethical Principles for Medical Research Involving Human Subjects of the Helsinki Declaration and it has been approved by the International Research Board of the University of Parma. All the healthcare setting where the study took place was contacted and was asked for their availability to participate in the research. An explanatory document of the study was sent to the Coordinators of the Operating Units in order to inform them, and to agree on the access times in the structures. All eligible participants were informed of the purpose and characteristics of the study and received a clear informative written document, explaining the design, aims, procedure and ethical considerations of the research. Informed consent was obtained before the professionals’ participation. Those who signed the consent have been informed that participation in the study was voluntary and that they could withdraw their consent to participate at any time.

Results

1. Roles and activities performed by nurses

For the various professionals, nurses play an essential role in the recovery process, thanks to a therapeutic program, carried out with criteria of adequacy and appropriateness of care, high professionalism and excellent relational skills. In fact, the nurses take into consideration the protocols and the procedures designated, but also and above all the individuality of each patient. The nurses themselves declared:

“Usually we carry out patient care, data collection trying to establish a relationship of trust. We talk to the family explaining the activities of the department. Blood tests are performed, vital signs are checked, electrocardiogram is carried out” (Nurse, Reggio Emilia).

“The activities that a nurse does are multiple, they can be divided into direct assistance activities, such as, for example, withdrawals, positioning of the gastric nose tube, drip and more personal activities, more intimate as trying to understand the patient, listening to him/her in order to build a relationship of trust, which in nursing care is fundamental” (Nurse, Parma).

“The activities I carry out with respect to patients with EDs are: reception, filling out of the nursing record, detection of vital signs, weight control, assisted meal and administration of therapy. Then I participate in interviews with the team, generally composed of nurse, doctor, patient and dietician” (Nurse, La Spezia).

The other professionals also agreed with what was stated by the nurses themselves.

“Nurses not only have a high quality of communication and interpersonal skills, but are able to build a relationship and trust with the patients themselves. The fundamental values are: commitment, trust, empathy, sincerity, honesty, support, confidence, ability to not judge, responsibility and consistency” (Social-Health Worker, Parma).

“In addition to a high level of professionalism and competence, I believe it is essential to have a good dose of empathy, that is very useful with these patients” (Medical Director, La Spezia).

2. Perceptions of nurses’ evaluation

In the three healthcare contexts, the common thought which emerged was that nurses are evaluated primarily by the patient and family, as well as by the Nursing Coordinator and all the professionals with whom they work.

“First of all, I am evaluated by the patient and his family” (Nurse, Reggio Emilia).

“I am evaluated by the patient, by the doctor, by the Nurse Coordinator and by the family members” (Nurse, Reggio Emilia).

“By everyone: patients, parents, relatives, coordinator, colleagues, and doctors. I must respond above all to myself, secondarily to my colleagues, to the doctors and above all to the Departmental Director” (Nurse, Reggio Emilia).

“By the Nursing Coordinator, by the doctors of the department and by the primary doctor …. Whereas from an ethical point of view, by the patient or from who takes his place” (Nurse, Parma).

“From a legal point of view, I am evaluated by the Nursing Coordinator, but, from an ethical point of view, I am evaluated by the patient” (Nurse, Parma).

Several professional figures focused on the importance that the nurse is evaluated based on his/her ability to relate to the team.

“I think that the nurse must guarantee a correct application of the planning and diagnostic therapeutic prescriptions and must act individually and in collaboration with all the professional figures he/she meets every day” (Departmental Director, Parma).

“The nurse […] must respond to the professional rules, to the ability to adhere to the care protocols and to work in groups” (Medical Director, La Spezia).

“I think they should answer to the Coordinator. Surely to all the figures of the multidisciplinary group with whom he/she interacts” (Nursing Coordinator, La Spezia).

Finally, the professionals underlined some indispensable criteria in the evaluation of nurses such as: professional skill, reliability, responsibility and professional training.

“I am evaluated according to the criteria of productivity, professionalism and appropriateness of behaviour during the working hours” (Nurse, La Spezia).

“When you enter a specific department such as Paediatrics, there must be the sense of responsibility, the great propulsion to learning, the desire to learn, to get involved, to continue studying. In short, the willingness to change adopting a not rigid attitude” (Departmental Director, Parma).

3. Expectations on nurses’ role

The participants showed the expectation that the nurse’s responsibility is to take care of the person, respecting his life, health and dignity.

“Professionalism, empathy, moral support and above all non-judgment, which are not always easy to implement. I do not set myself goals to reach because the hospital stay is the smallest thing compared to the whole therapeutic path to achieve the remission of the disease” (Nurse, Reggio Emilia).

“I expect them to provide an adequate welcome, that they can establish a cordial and above all empathetic relationship. And that they can, from the first moments, put patients at ease” (Nursing Coordinator, La Spezia).

There was also the common expectation that the nurse take care of the reception of the person and also of the family through dialogue, therapeutic alliance and support.

“Professionalism, skills, sensitivity and optimal ability to relate to the patient-family unit are all expectations felt and shared by the various health professionals” (Psychologist, Parma).

“First of all we have to evaluate their way of approaching parents, because we have been able to observe that the problem of feeding the adolescent is more of a family problem […] so the nurse must know how to address parents without making them feel guilty” (Nursing Coordinator, Reggio Emilia).

“In reality we relate mainly with parents and family members who revolve around children, more than with children” (Nurse, Parma).

The participants also have show the expectation that the nurse involved in the care of EDs mediates between patient and family and among the other professionals of the team.

“The expectation is that the nurse who meets the needs of care, assistance and is able to plan and collaborate in the implementation of appropriate care pathways for the patient’s well-being. Moreover, he/she is able to interact with the patient’s relatives and with the various multidisciplinary figures of the team” (Social-Health Worker, Reggio Emilia).

“I would say an empathic attitude in the treatment phases from the acceptance to the management of the pathology in its clinical aspects and in the educational aspects of nutrition. I also expect the ability to work in groups and according to protocols” (Medical Director, La Spezia).

On the part of nurses, there was the desire to be supported by specific training courses on the problems of patients with eating disorders to ensure the best care and care of these patients.

“My expectations are a suitable insertion in team to be able to reach the objectives, but above all an improvement of the empathic contact with the patient. I am expecting to be able to improve my knowledge through professional practice and through refresher courses” (Nurse, La Spezia).

“To have training on this pathology as targeted as possible and to be surrounded by professionals who are able to collaborate with my work and direct me to targeted interventions. I hope in the future that there will be more training courses for us nurses and for health or social assistants because we are in contact with these patients 24 hours a day. Our training has been always in the field, in the department dealing with the situations proposed day after day” (Nurse, Reggio Emilia).

In addition to the importance of training, the active participation of the nurse in the decisions of the multi-professional team was also highlighted.

“Eating disorders are a group of psychiatric disorders that require a multidisciplinary approach and a care and therapy plan that involves not only the hospital but also all territorial assistance. All the professional figures involved should therefore be coordinated and trained to work as a team. The nurse and the various figures involved should carry out their professional skills by cooperating and coordinating according to a common therapeutic plan (Medical Director, Parma).

“To actively participate in the care pathway by carefully monitoring the patient with regards to compliance with the treatment in progress and to attends specific professional refresher courses in order to help the doctor in optimizing the treatment in progress. He/She must be able to better understand and interpret the needs of the patient, this is very important as the nurse is the professional figure who has the greatest daily contact with the patient” (Medical Director, Reggio Emilia).

In Reggio Emilia, however, nurses did not always feel adequately involved in the decision-making process.

“I would expect more involvement in the team that follows the cases. I believe that the opinion of both nurses and social-health workers can be useful in the decision-making process. Currently, only doctors and psychologists are involved. Empathy, professionalism, knowledge and a good communication among various professionals” (Nurse, Reggio Emilia).

4. Perceptions and expectations on Case/Care Manager’s role

In the three contexts the figure of the CCM was not present, but the importance of the CCM was acknowledged in the management of the patient’s care path and as a point of reference for the family and health professionals.

“Yes, I have heard about the CCM. I think the CCM can be very useful” (Dietician, Parma).

The presence of a professional CCM trained in taking care of the patient can improve the management of the patient’s path with EDs.

“Then, the CCM allows the flow of information between the various professionals, manages the urgency and addresses the most suitable professional to manage it, collects the instances of the family and directs them towards solutions in general can also reassure patients on the management of their problem in a complete and careful way. As part of a multidisciplinary service dedicated to EDs, a CCM is indispensable to accompany the patient in the ongoing communication between the various professionals involved “(Medical Director, La Spezia).

“There is no real path of connection between the hospital and the territory that allows a gradual transition between the two health areas. It would be useful a professional to ensure compliance with the established path. A professional figure with specific skills in the field of health care management of EDs would be essential to ensure the efficiency and effectiveness of the care pathway; in particular as a point of reference for the patient’s family in resolving the critical issues that occurred, both in exposing the difficulties to the territorial healthcare structure, with the aim of proposing in a rational manner possible solutions in agreement with the two actors. Certainly a CCM would be fundamental in the management part of the care path in order to guarantee that the continuity of the care path is respected. Moreover the CCM would be a point of reference for the family in order to help in solving any intercurrent problems and a point of reference for health professionals in organizing the path, adapting it to the individual patient” (Medical Director, Reggio Emilia).

The CCM could manage the exchange of information within the team and guarantee a connection between hospital to territorial structures.

“He/She is a professional who should know the possibility of intervening especially in all these difficult cases and it is perhaps the one that should act as a link between the hospital and the territory, with the possibility of creating more networks than just about at EDs, but also on other difficulties on the management of hospital discharge and helping families on the territory” (Departmental Director, Parma).

“In my opinion, the CCM would be useful if there were a figure that could act as a bridge between the multidisciplinary professionals and the patient. It would guarantee continuity of care and the passage of important information. At the moment I do not know if this CCM exists in the territory, but, in any case, I believe it is important to have a connection between family and assistance, both outside and inside the hospital. I believe it is important and fundamental that there is a figure dedicated exclusively to covering this role that is able to interact with all the professionals in order to be able to create a 360° assistance” (Social-Health Worker, Reggio Emilia).

The introduction of the CCM could entail an advantage for controlling the duration of admissions, the services performed and the related costs, crucial elements for the budget of health facilities.

“Sometimes we have had cases that have been hospitalized, that have been prolonged precisely because the figure that acted as a link was missing, that really took care of the case, and therefore not only that he founding an accommodation but founding it adequate to the situation. Even here we had long, perhaps even improper, hospitalization, but we could not leave them on a street” (Nursing Coordinator, Parma).

5. Interprofessional collaboration

We have already emphasized how taking charge of subjects with EDs is long, poly-structured and multidimensional, based on a bio-psychosocial model that adopts a global approach of the person. Thus the inter-professional collaboration becomes fundamental.

In this case, some differences emerge between the contexts investigated. In La Spezia, the knowledge of the connections between hospital and territory is well known by all the team members. The latter is encountered during the weekly meetings for the management of new cases and the planning of cases already taken into account and whenever the need emerges.

“During the meetings and the meetings with the users I relate with the psychiatrist the psychologist and the nurse who is a constant and fundamental “presence” (Nutritionist, La Spezia).

“I relate to the department team: nurses, psychologists, psychiatrists. Food, medical and psychological information are shared” (Nurse, La Spezia).

In Parma and Reggio Emilia, the moments of inter-professional sharing were more infrequent and were missed moments dedicated to briefings, collegial decisions. Also was scarce the knowledge of the structures and the tasks of the territorial context that can guarantee therapeutic continuity and adequate family support at the time of discharge.

“Information is shared in a piecemeal way, if there is no conductor, that is, if there is no definite time to possibly share all together to be able to make the point…. Understanding what is good and what is not. Understanding in what sense we are proceeding. The optimum would be to have a meeting to discuss the case. If there is not a CCM who allows all this often the way to exchange information becomes fragmented” (Psychologist, Parma).

“I do not participate in moments of teamwork: they are managed above all by the care team I am not a member” (Nurse, Reggio Emilia).

“I deal with the ward team, the doctors, the nurses, the nutritionist and the psychologist, but currently there are no moments of team work” (Nurse, Parma).

“With the nursing colleagues and with the department doctors, but there are no team moments, at least not with the nurses. Only the doctors, the nutritionist and the psychologist participate” (Nurse, Reggio Emilia)

“I relate mainly with users, the relationship with users is fundamental… in fact having a certain empathy, sympathy, esteem helps the user to feel good and improve his conditions” (Social-Health Worker, Parma).

Another critical aspect was found in the poor communication between the structures and in the scarce knowledge of the healthcare path on the territory, penalizing the continuity between hospital and territory.

“Eating disorders are a group of psychiatric disorders that require a multidisciplinary approach and a care and therapy plan that involves not only the hospital but also …. and above all… territorial assistance. All the professional figures involved should therefore be coordinated and trained to work as a team…. The nurse and the various professionals involved should carry out their professional skills by cooperating and coordinating according to a common therapeutic plan” (Psychologist, Parma).

Discussion

On the basis of the three healthcare contexts analysed, results can be summarized as follows.

In Reggio Emilia the perception about the roles and activities performed by nurses was uniform among the various participants, which highlighting the tendency of nurses towards relationships with patient and family and emphasizing their empathic and professional attitude.

As for Parma, the professionals’ perception was the nurses have an essential role in the process of the patient’s recovery through their daily involvement. They have to analyse patients’ care needs and coordinate the most suitable personalised multi-professional care. The importance of having interpersonal skills, such as: hospitality, predisposition to dialogue, observation and empathic listening was also declared.

In La Spezia what emerged was that the nurses have the task of welcoming, analysing the person’s healthcare needs, coordinating the implementation of multi-professional care programs and protecting the person’s rights.

As for the perceptions of nurses’ evaluation, In Reggio Emilia different opinions were manifested. In brief, what emerged was that the nurses should be evaluated by all the healthcare members with whom they interact, and particularly by the Coordinator, by Medical Director, but also by patients and family members. In the same way, the professionals of La Spezia believed that the nurses should be evaluated by the Coordinator and by the Medical Director, according to the hierarchy of the organisation, but also by patients and family members. Alike In Parma, the nurses claimed to be evaluated by the patient and family as well as by colleagues and the Coordinator. The latter reinforced the importance of the nurses’ responsibility to respond to the patient and the ability to know how to relate even with other nurses. The Medical Director and the Departmental Director emphasised the importance of some criteria in the nurses’ evaluation, such as: professional skills, reliability and the ability to work in a team.

Regarding the expectations on nurses’ role, in Reggio Emilia, the nurses did not felt sufficiently involved in the decision-making process of patient care, even if the Medical Director and the nutritionist deemed essential that nurses’ actively participate in the care process. There were therefore conflicting opinions on the professional relationships and on the team work, while there was uniformity of opinion about the importance of having specific training on EDs.

In Parma, the nurses’ “professionalism, skills, sensitivity, optimal ability to relate to the patient-family unit” were the expectations shared by the healthcare professionals. The Medical Director, in particular, reported the importance of a multidisciplinary approach emphasising the role of nursing. Even the psychologist attributed high value to the nursing role in the care process, as nursed are the “spokesman” of valuable observations in moments of team discussion. As in Reggio Emilia, nurses of Parma reported the need to participate in specific training courses on patients with EDs.

In the same way in La Spezia emerged that the nurses must be prepared both from a clinical point of view and from a relational point of view, in order to work as a team.

Regarding the perceptions and expectations on Case/Care Manager’s role all participants of Reggio Emilia recognised their role in managing personalised care and they were perceived ad reference point for families and health professionals. This highlights a need for CCMs’ training, as they take on a “fundamental” role in the organization of each person’s personalised care.

Also in Parma the need for a hospital-territory connection was felt by all the professionals, even if this was not always realised. The CCM would be the professional reference in this process for all interviewees. The interviewees of La Spezia declared equally that the CCM could be the interface between the patient, the family and the multidisciplinary team. To do this the CCM must have technical and professional skills, as well as clinical and relationship ones.

In Reggio Emilia, the need for greater interprofessional collaboration and shared actions emerged. Particularly, nurses and social-health workers felt the lack of a moment to share information among teams and they reported the need for greater interaction between professionals. In Parma, at the same way, was emerges that the action of different professionals is not well coordinated, the decisions is often not shared, and the context of care of the territory is not adequately known.

In La Spezia the model of care considered most suitable is the multidisciplinary one and this is one practiced most: the professionals who work in teams must know how to collaborate. The interprofessional collaboration is considered essential as it leads not only to a greater healing result, but also to a reduction in treatment times.

Conclusions

Based on the results, the three examined healthcare contexts differed for two reasons.

The first was the age at which patients are taken into care: in Reggio Emilia and in La Spezia, patients are taken into care in adulthood, while in Parma patients are treated at a paediatric age.

The second related to the context of care: in Parma and Reggio Emilia treatment settings are treated at the 4th-5th stage (intensive residential rehabilitation and rehabilitative therapeutic community; ordinary and emergency hospital admissions), while in La Spezia they are treated at 2 th-3th stage (specialist hospital outpatient, day service, diagnostic, therapeutic, rehabilitative and day care centre).

Similarities can instead be found in the way patients are treated with EDs, since all the healthcare contexts follow the APA guidelines, as foreseen in the document drawn up in the “National Consensus Conference for Eating Behaviour Disorders in adolescents and young people adults” (33).

Based on these results, was appears that taking charge of people with EDs considers all levels of patient functioning: biological, psychological and socio-relational. In all the three examined contexts, it seems that nurses play an essential role in the recovery process through the involvement with the patient, implemented with criteria of adequacy and appropriateness of care, ensuring a good therapeutic relationship.

The results have also shown that nurses have high technical-specialist professionalism and excellent interpersonal skills that would make them the principal candidates for the role of CCM.

In the examined contexts, the nurse’s responsibility in treating a person with respect for life, health and dignity was also clear. A nurse must be professionally prepared and able to treat the user both clinically and on a relational scale; nurses must know how to collaborate and stay in close contact with the multidisciplinary team and must encourage a strong professional understanding to guarantee the performance of the various activities.

The importance of teamwork was also highlighted, where the transfer of information about the patient and the active participation of the nurse in the care process are both fundamental. According to the multidisciplinary model (34) to ensure a benefit to patients and reduce treatment time, it is necessary to make the different professional positions interact while working in teams. This means that the individual actions of the various professionals are coordinated and that the decisions taken on different competence levels can be shared. This occurred above all in La Spezia, unlike Parma and Reggio Emilia, where difficulties in sharing information on the patient’s conditions with EDs emerged. The moments of participation and inter-professional collaboration were therefore a bit lacking.

A final consideration regards the perceptions and expectations from the CCM. Located at the centre of a multidisciplinary team (in which we find a nutritionist doctor, a psychiatrist, a psychologist, a nutritionist biologist, a dietician, an healthcare assistance, a nurse, and a social worker), he/she accompanies the patient along the entire personalised care (territory-hospital), he/she takes part in decisions to be made and ensures cooperation between the professions, being aware of all the patient’s clinical, welfare and social problems.

He/she is called to perform or coordinate in a multidisciplinary team, to govern and monitor the process of planning the services requested in a prompt and efficient manner, while preserving the person’s interest and the sustainability of the system.

The activity of the CCM therefore includes the communication, the setting of goals and all the psychological, guidance, training, social and educational interventions. The CCM evaluates the results achieved, proposing innovative solutions starting from one’s own experience and questioning, if necessary, established methods that can represent obstacles. In fact, the CCM is required to carry out evaluations, to make decisions, as well as cooperate in coordinating work within the multi-professional team, assessing the requirements for access to services and needs that require their activation. Thanks to the activation of a network of interventions, he/she leads to the resolution of user problems and to the relative satisfaction of their requests. To do this, the CCM must be able to actively listen to all the interlocutors, to value their requests, to express personal opinions and to resolve differences. Requirements and abilities therefore outline a medium-high professional profile, capable of operating in a wide variety of contexts and fit a considerable degree of autonomy and responsibility.

In the three different care contexts it appeared therefore that the CCM is the most suitable figure in sustaining and supporting the patient and their family for all their requests of information relevant to the times, and to the modalities of the personalised clinical healthcare.

Especially in Parma, the professionals declared that the CCM could lighten the work of other professionals in both a bureaucratic and clinical way.

However, in all the healthcare considered contexts the absence of an institutionalised CCM position was evident. Such position, carried out informally by professional nurses, does not therefore appear to be adequately recognized.

The results of the study therefore have shown the need for professionals to include this position within the EDs team supporting the importance that the CCM is also institutionally recognized, in order to ensure continuity of assistance from the hospital to the territory, to improve hospital care and improve the quality of life of patients with EDs, becoming a point of reference for patients and healthcare professionals. This organizational example could be an important step forward for the coordination and assistance of patients with EDs, as it would ensure a more effective and more efficient management of the healthcare.

Conflict of interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article