Health Advocacy and Psycho-body empowerment: An effective Salutogenic Model to fight Burnout syndrome addressed to Health Managers, Health and Social Workers

Introduction

The present study originated from the activation of the ECM Training Course: “Health Advocacy and Psycho-body Empowerment 2020”, addressed to health workers, social workers and health managers and in particular, in this first section, to the staff of the Mental Health Operational Unit of the Health Districts n. 24/73 and 31. This training is based on a health psychology model developed by Dr. Sara Diamare called “Salotti del Benessere©”.

It has been implemented in Campania by the Quality Control Service, currently U.O.C. Qualità & Umanizzazione of ASL Napoli 1 Centro, since 2009, with the aim of encouraging people to adopt healthy lifestyles by redirecting damaging behaviours through the exploration of the “5 Keys to Well-being“: Conscious Breathing, Relaxation, Nourishment, Empowerment and Movement and Emotion.

As such, the model allows the exploration of health promotion issues in a specific progression and, mostly, promotes clear and jovial communication in small groups to encourage users to be active agents of change during a health treatment. Through a narrative medicine approach, communication between operator/operator and between operator/users is facilitated, and the development of resilience is promoted by speeding up the aforementioned communication processes.

The health emergency caused by the Covid-19 pandemic has generated many organisational issues and initially challenged the efficiency of the Italian health system. Our health workers had to face stressful situations and burnout conditions because of the sense of inefficiency originating from the initial failure of pharmacological and instrumental anti-Covid-19 therapies and, of course, from the high mortality rate of patients. Individuals do not always have adequate cognitive and behavioural resources and strategies to cope with such serious and important situations, which require great clarity and good coping skills.

Therefore, it was decided to test the aforementioned method in its online version with health workers involved in hospital care, in order to be supported in this difficult period.

The results obtained from this study are comforting because the efficacy of the method on health workers, even in its online version, could represent a best practice that allows, even through distant workshops, to acquire resilience and the ability to better manage emergency situations.

The new online mode allowed us to support the workers with close tutoring by both computer technicians and young trained psychologists.

The course consisted of 7 meetings, during the first day the topics related to the psycho-body empowerment and the acquisition of communication skills were presented; they were adapted to the online version with the help of specific tools and techniques.

Both the second and third day were dedicated to the Key of the Conscious Breathing, which is easier to share and has a greater impact even online and not in-person. This variation on the “Salotti del Benessere©” programme was chosen to gradually encourage people to get in touch with their bodies through mindfulness, yoga and bioenergetics techniques using pre-recorded audios, and also to consciously manage their own needs and to dissuade them from addiction to tobacco smoke.

The fourth day, dedicated to the Key of Relaxation, aimed to induce self-listening to muscular tension in order to achieve and maintain a state of balance. The exercises, in fact, encourage reflection on stress and, through the technique of Progressive Muscular Relaxation, in the version of Contraction / Agitated Stress (C/DS), we promote the ability to manage stressors and our responses to them.

The fifth day, dedicated to the Key to Movement and Empowerment, provided access to the body and movement awareness in relation to others. The method of “Conscious Creative Embodied Aesthetic Experience©” is used to support a conscious process of embodied simulation, i.e. a mutual mirroring in the movement of the other, using gestural identification to activate creativity and body expressiveness.

The sixth day was dedicated to the Key of Emotions: learning to express emotions in a conscious way also enables a better management of what one is feeling; it consists of a psycho-body workshop with Bioenergetic and Dance Movement Therapy techniques.

The seventh day was dedicated to the follow-up for the return of the data analysis. For the evaluation, Focus Groups were also used to co-construct a Hyperbook, as a report of personal thoughts and considerations about the lessons and the associated workshops.

Methodology

The techniques used in the “Salotti del Benessere©” online workshops were:

Progressive Muscle Relaxation

Conceived by E. Jacobson in 1938, it consists of an anti-stress technique that involves tensing and then relaxing the various muscle areas (hands, arms, feet, legs, buttocks, back, neck, abdomen, shoulders and face) until psychosomatic relaxation and a greater perception of the body is achieved. This technique is currently proposed by the Riza Psychosomatic Institute, as it is easy to administer and learn.

It has been found, among other things, that most Covid-19 patients experience high levels of anxiety and show a low quality of sleep due to isolation. In this regard, a study carried out on patients with Covid-19 observed that the use of the PMR technique for 30 minutes a day for 5 consecutive days tends to reduce anxiety and improve sleep quality (K. Liu; Y. Chen; D. Wu; R. Lin; Z. Wang; L. Pan; 2020).

According to further studies, the PMR technique combined with music seems to reduce the effects of stress and fatigue among ICU nurses, also bringing improvements in coping style (B. Ozgundondu; Z.Gok Metin; 2019). Therefore, it was deemed useful to use this technique in this pilot study.

Vegetotherapy/Bioenergetics

Vegetotherapy (Reich, 1989), affects the vegetative nervous system. It allows one to work on posture and to reveal to the consciousness the character defences through the associated muscular spasms in order to access the liberating emotional expression.

Bioenergetics (Lowen, 1978), is a body psychotherapy created by A. Lowen, which deepens the postural and energetic aspect of Reich’s approach, identifying those points lacking in energy in order to re-establish an energetic balance. This technique uses postural exercises, in sync with breathing. These techniques, with audio or through the expert’s online guide, are also included in the programme of “Salotti del Benessere©” online to promote awareness of drives, tensions and underlying psychic conflicts in a process of psycho-body empowerment.

Mindfulness

The term Mindfulness (Kabat-Zinn, 2003) identifies the ability to focus one’s attention on awareness and intuition in order to bring to mind a task, a theme or an experience in the present time to achieve the state of well-being. Mindfulness enables one to voluntarily direct attention to what is going on in their mind emotionally or in their body without being judgemental. This approach is effective in Metacognitive skills and in regulating Impulsivity. This meditative practice, developed by Jon Kabat-Zinn at the end of the 70s, teaches how to take care of oneself through the following techniques:

-Body Scan, achieved by bringing attention to the various parts of the body, so as to better focus on oneself.

-Sitting meditation, in which one is taught to focus on the present time with all the internal and external phenomena, accepting the sensations, emotions and thoughts of that precise moment.

-Hatha Yoga, allows one to direct their attention to the body sensations during the exercises.

-Walking meditation, which involves walking while staying focused.

The inclusion of these exercises was necessary in the online version because of breath’s central role in the psycho-body empowerment® practice (Diamare et al., 2010).

Study objectives

General objectives:

To transform places of diagnosis and treatment into places for the promotion of healthy lifestyles even in emergency situations.

To implement a process of individual growth and health advocacy aimed at determining a globalisation that connects the value of the person, the local community, the environment, the products, the experiences and the results obtained from the process of “capacitation” in exercising the natural right of caring for others.

• Empowerment of operators through experiential workshops of psycho-body awareness techniques and art therapy.
• Improving interpersonal relationships and motivation to correct lifestyles.
• Promoting potential, well-being and health of the operator
• To promote operators’ psychosocial skills.
• Sharing common objectives.
• To spread the concept of Salutogenesis and Health advocacy.

Specific objectives:

Analysis of the feasibility of the salutogenesis programme;

Analysis of the effectiveness of the didactic and educational process;

Activation of intra-institutional synergies.

Methods

The Health Advocacy and Psycho-body Empowerment Training course was attended by 30 employees of the A.S.L Napoli 1 Centro belonging to the UOSM 24/73 and 31, including: managers, nurses, paediatric nurses, midwives, laboratory and radiology technicians, physiotherapists, psychiatrists and psychologists.

A battery of tests was administered, both ex-ante and ex-post (as provided for by the Salotti del Benessere© method), in order to assess, monitor and reorient the course and to estimate its effectiveness and benefits.

The tests administered are:

• Body Self Awareness Test (BSA; Diamare S., Scafuto F., 2018): to measure the self-perception of the various body districts and body tensions.
• Healthy Lifestyles Interview (National Institute of Health, PASSI Project, 2005): The interview enables the investigation of the subjects’ lifestyles and habits. It consists of 18 questions with different types of structured answers.
• Short Form Health Survey (SF12; Ware, Kosinki & Keller, 1996): This is a self-administered measure of health-related quality of life.

The SF12 is a short version of a larger subjective assessment questionnaire called SF36. The latter version is designed to reconstruct two synthetic indices:

• PCS (Physical Component Summary): Physical Health
  • MCS (Mental Component Summary):  Mental Health.

Specifically, the use of online forms was innovative for the learners; in particular, the sharing of a hypertext on which the thoughts, experiences and emotions about the training course participants were collected was largely appreciated, and was subsequently refined by the psychologist tutors of the Quality and Humanisation Unit. This fostered good teamwork among all the participants, who were constantly coordinated and monitored by the medical and the mental health nurse coordinators participating in the course.

Results and discussion

In the following paragraph, we will show the results obtained from the battery of tests and the general thoughts collected in the hyperbook in terms of the online course effectiveness.

The possibility to take part in the study by completing the battery of tests was completely voluntary; as a consequence, some participants did not submit answers for the follow up. Therefore, in this study we will only examine the data from the completed tests, both in their ex ante and ex post form, and the qualitative analysis of the contents from the hypertext, considered here as narrative evidence of the course.

Bsa test

From the administration and processing of the data in ex-ante and ex-post we can see that there is an overall increase in Self-Perception (Total 245/260) and as often happens in the processes of psycho-body awareness there was also an increase in the perception of body tensions (Total 166/192). The greatest increase in perception concerns the body districts of the pelvis and head (see Graph 1).

Healthy lifestyle interview

For this test, the participants formed pairs via the online platform Microsoft Teams and administered the interview to each other. One asked the questions to their companion, who reported the answers on the online form and vice versa. The administration and processing of the ex-ante and ex-post data showed an increase in the weekly consumption of fruit, vegetables and olive oil, a slight decrease in meat consumption and an increase in the frequency of physical activity, in line with the course teaching; the daily time spent on the computer decreased (see Graph 2), although the time spent on the mobile phone in communication with others increased.

Short form health survey (sf12)

The comparison of ex-ante and ex-post data shows an overall improvement in the perception of the quality of life, whose prevalent incidence is related to the improvement of the physical perception index.

In particular, the slight decrease in the index referring to the perception of one’s own mental health (MCS), which can be explained by the dysphoric experience of an impending health emergency, is associated with an increase in the PCS index referring to physical health, probably connected to the workshop experiences focused on body awareness (see Graph 3).

Conclusions

In conclusion, as shown in the results, despite the pandemic and the difficulties of the remote training, which provided for a quick learning of hard skills (for instance, computer literacy), the course, for the health workers involved in the training, was effective on the quality of life and on the perception of the body.

This makes possible to propose the online version of the method (see  https://sway.office.com/jBFDVmfEWLvaV3Ea)  to a wider target group, also in emergency situations, in order to support the resilience of operators at risk of burnout by improving their perception of the body’s self, but also to activate a process of salutogenesis for those population groups that are more difficult to reach due to environmental conditions or in social isolation due to lockdown.

References

1. Caporale, C., Pirni, A. (2020). Pandemia e resilienza. Persona, continuità e modelli di sviluppo dopo il Covid-19. CNR Edizioni, Roma.
2. Diamare S. (2010), «Empowerment psicocorporeo come strategia di BenEssere e prevenzione del burn out nei servizi di cura», in Rivista Educazione Sanitaria e Promozione della Salute n. 4/2010 pag. 390 a 404.
3. Diamare, S. (2015). I salotti del Benessere. Poligrafia-F.lli Ariello Editori s.a.s., Napoli.
4. Diamare S. (2017), «I “Salotti del Ben Essere”: spazio di promozione della salute per caregivers di pazienti con problemi di salute mentale» in La Salute Umana, Editore Perugia.
5. Diamare, S. (2017). «I “Salotti del Ben Essere”: spazio di promozione della salute per caregivers di pazienti con problemi di salute mentale».in La Salute umana,  n. 265, Editore Perugia.
6. Diamare S. (2018). «I Salotti del Benessere. Embodied education per la relazione d’aiuto», in Sistema Salute. La rivista italiana di educazione sanitaria e promozione della salute, Vol. 62 N. 3.
7. Diamare S. (2019), «Un metodo di Embodied Education in Riabilitazione: approcci di valutazione partecipata e di empowerment psicocorporeo», in Journal of Advanced Health Care. (https://doi.org/10.36017/jahc1909-002)
8. Diamare S., Goretti M., Furia R., Mantice M., Salerno M., D’Ambrosio M. (2020), «Peer Education e salutogenesis with the method of “I Salotti del Benessere®”», in Journal of Advanced Health Care. (https://doi.org/10.36017/jahc2003-006)
9. Di Trapani G. (2019). «Cultura ed Innovazione: una proposta per lúniformità dei prodotti della Ricerca dei TSRM e delle PSTRP», in Journal of Advanced Health Care Volume 1, 4–7. (https://doi.org/10.36017/jahc1909-005)
10. Di Trapani G. (2020). «New models and the major challenges for the academic research of the orderś experts TSRM PSTRP». in Journal of Advanced Health Care. (https://jahc.eu/editoriale/jahc2003-001/)
11. Di Trapani G. (2020). «Healthcare System Innovation: the vital systemic approach for new healthcare professionals», in Journal of Advanced Health Care (https://doi.org/10.36017/jahc2012-004)
12. Jacobson, E. (1938). Progressive Relaxation. University of Chicago Press, Chicago.
13. Kabat-Zinn, J. (2003). «Mindfulness-based interventions in context: Past, present, and future». Clinical Psychology: Science and Practice, 10(2), 144-156
14. Liu, K., Chen, Y., Wu, D., Lin, R, Wang, Z., Pan, L. (2020). «Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19», in Complementary Therapies in Clinical Practice, 54, 54-63.
15. Lowen, A. (1978), Il linguaggio del corpo. Feltrinelli, Milano.
16. Margarito A., Guaitoli E., Di Trapani G., Petrucci L. (2020). «Between perception and reality: BMI in adolescence», in Journal of Advanced Health Care. https://doi.org/10.36017/jahc2011-003
17. Meekums, B., Karkou, V., & Nelson, E. A. (2015). «Dance movement therapy for depression», in The Cochrane database of systematic reviews, (2), CD009895. (https://doi.org/10.1002/14651858.CD009895.pub2)
18. Ozgundondu, B., Gok Metin, Z. (2019). «Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping styles among intensive care nurses», in Intensive & critical care nursing, 54, 54–63.
19. Peirone, L. (2020). Nuovo coronavirus e resilienza. Strategie contro un nemico invisibile. Anthropos, salute-cultura-psicologia, Torino.
20. Petrucci L., Margarito A., Di Trapani G. (2020). «Colon-rectal Cancer and Lars Management». in Journal of Advanced Health Care, Volume 2,. (https://doi.org/10.36017/jahc2009-002)
21. Reich, W. (1989), Analisi del carattere. SugarCo Edizioni, Milano.
22. Tosello M.F., Diamare S., Sabelli M., Verrengia A., Annunziata R., Esposito L., Maglia F., Tomberli A., Gambardella L.,  I “Salotti del Ben Essere” nella Salute Mentale. Uno Spazio di promozione di sani stili di vita per caregivers https://drive.google.com/file/d/137dnWDTlAulpZoR7-U5RqZNM8t0CWu-J/view?usp=sharing
23. Ware, J., Jr, Kosinski, M., & Keller, S. D. (1996). «A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity», in Medical care, 34(3), 220–233