SMiLE to Life: Meaning in life in healthcare professionals working in palliative care and rehabilitation medicine SMiLE to Life: Meaning in life in healthcare professionals

Main Article Content

Marina Maffoni
Francesco Zanatta
Ilaria Setti
Ines Giorgi
Laura Velutti
Anna Giardini


Meaning in life, healthcare professionals, wellbeing, palliative care, rehabilitation


Background: In the healthcare landscape, various protective factors are identified, such as meaning in life (MiL), namely what gives sense to life events. However, little is known about this construct in the healthcare population. Objectives: To describe MiL among healthcare professionals employed in palliative care and neuro-rehabilitation medicine, unveiling possible differences related to medical specialty and socio-demographic characteristics. Methods: In this cross-sectional and multicentre study, palliative care and neuro-rehabilitation professionals were recruited. MiL was evaluated with the Schedule for Meaning in Life Evaluation (SMiLE), which provides a list of meaningful areas, as well as related overall indexes of satisfaction (IoS), weighting (IoW), weighted satisfaction (IoWS). Descriptive statistics, t-test, chi-square, linear and binary logistic regressions were performed. Results: Overall, 297healthcare professionals (palliative care=89, neuro-rehabilitation medicine=208, 47% of participants ≤ 40 years old) completed the evaluation. The sample was intra- and inter-groups heterogeneous, in particular concerning age and professional role. Conversely, no significant group differences emerged in MiL indexes comparisons, nor in the number of MiL listed areas. As for MiL areas, the category “family” increased the IoWS index, while terms related to “finances” contributed to decrease it. Comparing specialties, palliative care professionals were more likely to report areas like “partnership”, “social commitment”, and “satisfaction”. Nurses (n=116), nurse aides (n=47), and therapists (n=67) were more likely to mention health-related terms (e.g. health, physical wellbeing) than physicians and psychologists (n=65). Conclusion: This study highlighted MiL areas among professionals employed in palliative care and neurorehabilitation specialties, providing informative suggestions for tailored health prevention programs which should pay particular attention to social and family relationships, socio-economic status, and health.


Download data is not yet available.
Abstract 104 | PDF Downloads 70


1. James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-1858. doi: 10.1016/S0140-6736(18)32279-7
2. Sanso N, Galiana A, Amparo O, et al. Palliative care professionals’ inner life: exploring the relationships among awareness, self-care, and compassion satisfaction and fatigue, burnout, and coping with death. J Pain Symptom Manage. 2015;50(2):200-207. doi: 10.1016/j.jpainsymman.2015.02.013
3. Maffoni M, Argentero P, Giorgi I, Giardini A. Healthcare professionals’ perceptions about the Italian law on advance directives. Nurs Ethics. 2019;27(3):796-808. doi: 10.1177/0969733019878831
4. World Health Organization. (2011). WHO definition of palliative care. Available online at: (last accessed 29-06-2021).
5. Maffoni M, Argentero P, Giorgi I, Hynes J, Giardini A. Healthcare professionals’ moral distress in adult palliative care: a systematic review. BMJ Support Palliat Care. 2019;9(3):1–10. doi: 10.1136/bmjspcare-2018-001674
6. Sliwa JA, Clark GS, Chiodo A, et al. Burnout in Diplomates of the American Board of Physical Medicine and Rehabilitation—Prevalence and Potential Drivers: A Prospective Cross‐Sectional Survey. PM R. 2019;11(1):83-89. doi: 10.1016/j.pmrj.2018.07.013
7. Maffoni M, Argentero P, Giorgi I, Giardini A. Underneath the White Coat: Risk and Protective Factors for Palliative Care Providers in Their Daily Work. J Hosp Palliat Nurs. 2020;22(2):108-114. doi: 10.1097/NJH.0000000000000623
8. Hynes J, Maffoni M, Argentero P, Giorgi I, Giardini A. Palliative medicine physicians: doomed to burn? BMJ Support Palliat Care. 2019;9(1):45-46. doi: 10.1136/bmjspcare-2018-001731
9. Reker GT. Theoretical perspective dimensions, and measurement of existential meaning. In: Reker GT, Chamberlain K, eds. Exploring existential meaning: optimizing human development across the life span. Thousand Oaks, CA: Sage; 2000.39-55.
10. Martela, F, Steger MF. The meaning of meaning in life: Coherence, purpose and significance as the three facets of meaning. J Posit Psychol. 2016;11(5):1-15. doi: 10.1080/17439760.2015.1137623
11. Park CL. Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull. 2010;136(2):257-301. doi: 10.1037/a0018301
12. King LA, Hicks JA. The Science of Meaning in Life. Annu Rev Psychol. 2021;72:561–584. doi: 10.1146/annurev-psych-072420-122921
13. Guerrero-Torrelles M, Monforte-Royo C, Rodríguez-Prat A, Porta-Sales J, Balaguer A. Understanding meaning in life interventions in patients with advanced disease: A systematic review and realist synthesis. Palliat Med. 2017;31(9):798–813. doi: 10.1177/0269216316685235
14. Czekierda K, Banik A, Park CL, Luszczynska A. Meaning in life and physical health: systematic review and meta-analysis. Health Psychol Rev. 2017;11(4):387–418. doi: 10.1080/17437199.2017.1327325
15. Saxena S, Orley J. Quality of life assessment: The World Health Organization perspective. Eur Psychiat. 1997;12(Suppl 3):263s–66s. doi: 10.1016/S0924-9338(97)89095-5.
16. Bernard M, Braunschweig G, Fegg MJ, Borasio GD. Meaning in life and perceived quality of life in Switzerland: results of a representative survey in the German, French and Italian regions. Health Qual Life Outcomes. 2015;13:160. doi: 10.1186/s12955-015-0353-y
17. Allan BA, Duffy RD, Douglass R. Meaning in life and work: A developmental perspective. J Posit Psychol. 2015;10(4):323-331. doi: 10.1080/17439760.2014.950180
18. Steger MF, Oishi S, Kashdan TB. Meaning in life across the life span: Levels and correlates of meaning in life from emerging adulthood to older adulthood. J Posit Psychol. 2009;4(1):43-52. doi: 10.1080/17439760802303127
19. Taubman-Ben-Ari O, Weintroub A. Meaning in life and personal growth among pediatric physicians and nurses. Death Stud. 2008;32(7):621-645. doi: 10.1080/07481180802215627
20. Loffler S, Knappe R, Joraschkt P, Pohlmann K. Meaning in life and mental health: personal meaning systems of psychotherapists and psychotherapy patients. Z Psychosom Med Psychother. 2010;56(4):358-372. doi: 10.13109/zptm.2010.56.4.358
21. Hill CE, Kanazawa Y, Knox S, et al. Meaning in life in psychotherapy: the perspective of experiences psychotherapists. Psychother Res. 2017;27(4):381-396. doi: 10.1080/10503307.2015.1110636
22. Tsai FJ, Chen CY, Yeh GL, et al. Nursing students’ relationships among meaning in life, well-being, and positive beliefs: a cross-sectional survey study. Medicine (Baltimore). 2018;97(42):e12914. doi: 10.1097/MD.0000000000012914
23. Barnett MD, Moore JM, Garza CJ. Meaning in life and self-esteem help hospice nurses withstand prolonged exposure to death. J Nurs Manag. 2019;27(4):775-780. doi: 10.1111/jonm.12737
24. Güngör A, Uçman AG. Depression and hopelessness in Turkish healthcare workers: The moderating and mediating roles of meaning in life. Glob Public Health. 2020;15(2):236–246. doi: 10.1080/17441692.2019.1656273
25. Krok D, Zarzycka B, Telka E. Risk of Contracting COVID-19, Personal Resources and Subjective Well-Being among Healthcare Workers: The Mediating Role of Stress and Meaning-Making. J Clin Med. 2021;10(1):132. doi: 10.3390/jcm10010132
26. Carr A, Higginson I. Are quality of life measures patient-centred? In: Carr A, Higginson I, Robinson P, eds. Quality of life. London, England: BMJ Books, 2003:19-30.
27. Fegg M, Kramer M, L’hoste S, Borasio GD. The schedule for Meaning Meaning in life evaluation (SMiLE): validation of a new instrument for meaning-in-life research. J Pain Symptom Manage. 2008;35(4):356-364. doi: 10.1016/j.jpainsymman.2007.05.007
28. Fegg M, Kramer M, Bausewein C, Borasio GD. Meaning in life in the Federal Republic of Germany: results of a representative survey with the Schedule for Meaning in Life Evaluation (SMiLE). Health Qual Life Outcomes. 2007;5: 59. doi: 10.1186/1477-7525-5-59
29. Bernard M, Braunschweig G, Fegg M. Borasio G. Meaning in life and perceived quality of life in Switzerland: results of a representative survey in the German, French and Italian regions. Health Qual Life Outcomes. 2015;13:160. doi: 10.1186/s12955-015-0353-y
30. Volkert J, Härter M, Dehoust MC, et al. The role of meaning in life in community-dwelling older adults with depression and relationship to other risk factors. Aging Ment Health. 2019;23(1):100-106. doi: 10.1080/13607863.2017.1396576
31. Fegg M, Kögler M, Brandstätter M, et al. Meaning in life in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler. 2010;11(5):469-474. doi: 10.3109/17482961003692604
32. Fegg M, Kögler M, Abright C, Hensler M, Lorenzl S. Meaning in life in patients with progressive supranuclear palsy. Am J Hosp Palliat Care. 2013;31(5):543-547. doi: 10.1177/1049909113492411
33. Mello I, Ashcraft A. The meaning in life for patients recently hospitalized with congestive heart failure. J am Assoc Nurse Pract. 2014;26(2):70-76. doi: 10.1002/2327-6924.12047
34. Fegg M, Brändstatter M, Kramer M, et al. Meaning in life in Palliative Care Patients. J Pain Symptom Manage. 2010;40(4):502-509. doi: 10.1016/j.jpainsymman.2010.02.010
35. Stiefel F, Krenz S, Zdrojewski, et al. Meaning in life of cancer patients assessed with the “Schedule for Meaning in Life Evaluation” (SMiLE). Support Care Cancer. 2008;16(10):1151-1155. doi: 10.1007/s00520-007-0394-9
36. Bernard M, Strasser M, Gamondi C, et al. Relationship between spirituality, meaning in life, psychological distress, wish for hastened death, and their influence on quality of life in palliative care patients. J Pain Symptom Manage. 2017;54(4):514-522. doi: 10.1016/j.jpainsymman.2017.07.019
37. Brandstätter M, Kögler M, Baumann U, et al. Experience of meaning in life in bereaved informal caregiver of palliative care patients. Support Care Cancer. 2014;22(5):1391-1399. doi: 10.1007/s00520-013-2099-6
38. Fegg M, L’hoste S, Brandstätter M, Borasio GD. Does the working environment influence health care professionals’ values, meaning in life and religiousness? Palliative care units compared with maternity wards. J Pain Syptom Manage. 2014;48(5):915-923. doi: 10.1016/j.jpainsymman.2014.01.009
39. Fegg M. The Schedule for Meaning in Life Evaluation (SMiLE) Manual. Accessed December 1, 2019.
40. Casale G, Calvieri A. Le cure palliative in Italia: inquadramento storico. Medic. 2014;22(1):21-26.
41. Szabo S, Nove A, Matthews Z, et al. Health workforce demography: a framework to improve understanding of the health workforce and support achievement of the Sustainable Development Goals. Hum Resour Health. 2020;18(1):1-10.
42. Kagan SH, Melendez‐Torres GJ. Ageism in nursing. J Nurs Manage. 2015;23(5), 644-650.
43. Schluter PJ, Turner C, Huntington AD, Bain CJ, McClure RJ. Work/life balance and health: the Nurses and Midwives e‐cohort study. Int Nurs Rev. 2011;58(1):28-36. doi: 10.1111/j.1466-7657.2010.00849.x
44. Dousin O, Collins N, Kler BK. The experience of work‐life balance for women doctors and nurses in Malaysia. Asia Pac J Hum Resour. 2021. doi: 10.1111/1744-7941.12282
45. Delle Fave A, Brdar I, Wissing M, Vella-Brodrick D. Sources and motives for personal meaning in adulthood. J Posit Psychol. 2013;6(8):517-529. doi: 10.1080/17439760.2013.830761
46. Lambert NM, Stillman TF, Baumeister RF, et al. Family as a salient source of meaning in young adulthood. J Posit Psychol. 2010;5(5):367-376. doi: 10.1080/17439760.2010.516616
47. Schnell T. Existential indifference: Another quality of meaning in life. J Human Psychol. 2910;50:351–373.
48. Erikson EH. The life cycle completed. Extended version with new chapters on the ninth stage by Joan M. Erikson. New York: Norton, 1998.
49. Hicks JA, Trent J, Davis WE, King LA. Positive affect, meaning in life, and future time perspective: An application of socioemotional selectivity theory. Psychol Aging. 2012;27(1):181–189. doi: 10.1037/a0023965
50. Bressi C, Manenti S, Porcellana M, et al. Haemato-oncology and burnout: an Italian survey. Br J Cancer. 2008;98(6):1046-1052. doi: 10.1038/sj.bjc.6604270
51. Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health Syst Pharm. 2018;75(3):147-152. doi: 10.2146/ajhp170460
52. Dinç L, Gastmans C. Trust in nurse–patient relationships: A literature review. Nurs ethics. 2013;20(5):501-516. doi: 10.1177/0969733012468463
53. Grouden ME, Jose PE. How do sources of meaning in life vary according to demographic factors? New Zeal J Psychol. 2014;43(3):29-38.
54. Schnell T. The Sources of Meaning and Meaning in Life Questionnaire (SoMe): Relations to demographics and well-being. J Posit Psychol. 2009;4(6):483–499. doi: 10.1080/17439760903271074
55. Ma H, Qiao H, Qu H, et al. Role stress, social support and occupational burnout among physicians in China: a path analysis approach. Int Health. 2020;12(3):157-163. doi: 10.1093/inthealth/ihz054
56. Sansoni J, De Caro W, Marucci AR, et al. Nurses’ Job satisfaction: an Italian study. Ann Ig. 2016;28(1):58-69. doi: 10.7416/ai.2016.2085
57. Gallagher M, Muldoon OT, Pettigrew J. An integrative review of social and occupational factors influencing health and wellbeing. Front Psychol. 2015; 6:1281. doi: 10.3389/fpsyg.2015.01281
58. Petmesidou M, Pavolini E, Guillén AM. South European healthcare systems under harsh austerity: a progress–regression mix? S Eur Soc Polit. 2014;19(3):331-352. doi: 10.1080/13608746.2014.949994
59. Correia T, Dussault G, Pontes C. The impact of the financial crisis on human resources for health policies in three southern-Europe countries. Health Policy. 2015;119(12):1600-1605. Doi: 10.1016/j.healthpol.2015.08.009
60. Maffoni M, Torlaschi V, Pierobon A. It's all a matter of time. Ann Ig. 2020;32(6):689-690. doi: 10.7416/ai.2020.2389.
61. Fillion L, Duval S, Dumont S, et al. Impact of a meaning-centered intervention on job satisfaction and on quality of life among palliative care nurses. Psychooncology. 2009;18(12):1300–1310. doi: 10.1002/pon.1513
62. Frankl VE. Man's search for meaning: An introduction to logotherapy. Am J Orthopsychiat. 1963;33(2):390-390.
63. Maffoni M, Sommovigo V, Giardini A, Paolucci S, Setti I. Dealing with ethical issues in rehabilitation medicine: The relationship between managerial support and emotional exhaustion is mediated by moral distress and enhanced by positive affectivity and resilience. J Nurs Manag. 2020; 28(5): 1114–1125. doi:10.1111/jonm.13059.
64. Maffoni M, Sommovigo V, Giardini A, Velutti L, Setti I. Well-Being and Professional Efficacy Among Health Care Professionals: The Role of Resilience Through the Mediation of Ethical Vision of Patient Care and the Moderation of Managerial Support. Eval Health Prof. in press.
65. Bernuzzi C, Setti I, Maffoni M, Sommovigo V. From moral distress to burnout through work-family conflict: the protective role of resilience and positive refocusing. Ethics & Behavior. 2021; 1-23. doi: 10.1080/10508422.2021.1955682.
66. Zanatta F, Maffoni M, Giardini A. Resilience in palliative healthcare professionals: a systematic review. Support Care Cancer. 2020; 28: 971–978. doi:10.1007/s00520-019-05194-1.