Relational quality and improvement of Life Skills (No technical Skills)

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Submission Date: 2022-01-17
Review Date: 2022-01-31
Pubblication Date: 2022-02-14



The provision of health services implicitly involves an emotional load linked to the specific task / service, which, if extended for long periods of time, falls on the operators, placing them in a burn-out risk.
Various theories and empirical studies (Mayo, 1933; Maslow, 1943; Herzberg, 1959; Vroom, 1964; Alderfer, 1969; Fontana, 1997; McClellant, 1985) reveal how "motivated" work performances generate a sense of personal fulfillment which can be translated into a positive result for performance in general. Therefore, Healthcare Companies must improve the quality of assistance provided by the operators through motivational, wellness and health promotion’s activities for the staff.
In this study we want to demonstrate that psycho-body empowerment © training supported by group psychodynamic proposals with expressive techniques, allows the acquisition of the necessary life skills to support the health worker's perception of well-being.
These activities are aimed at developing a healthy and safe work environment, which also considers the psychological, social and relational implications of the organizational context related to the gender gap.
In the present study, we wanted to explore whether the experiential methodology presented here, aimed at psycho- corporeal awareness in the relationship with the other, could support a path of psychological well-being perceived by the operators, as imagined and measured by Carol Ryff (1989).
In particular, an attempt was made to highlight the difference in the acquisition of skills between male and female health workers, showing that some of them can be more easily acquired by one gender than another.
The action research in this presented study, adapted in web mode in compliance with the safety standards imposed by the COVID-19 pandemic, has been supported by e-learning technologies and the results of this further study will be the subject of subsequent publication.


Background of the study

In the current Italian political-institutional scenario, characterized by continuous changes which impact the provision of services to citizens, the Administrations responsible for health services must enhance the worker’s central role in their organization (Legislative Decree of 27/10/09, n.150 art.14, paragraph 5), in order to improve the efficiency, effectiveness and quality of services.

Furthermore, the Executive Decree of the Campania Region n. 9 of 08/02/12 as well as the PNR (National Research Program) indicate the relational aspects (internal – external communication) among the Training Objectives.

Some health problems require an innovative response that implies important organizational changes in a context of limited resources and increased needs of the assisted population, with a consequent impact on workers’ stress. The management of human resources, particularly in the health field requires the workers’ orientation, along with their placement in specific roles and functions.

It’s vital to understand how to improve the qualitative and relational conditions of work tohave an adequate consideration of the “person” projected into the work environment.

Various theories and empirical studies (Mayo, 1933; Maslow, 1943; Herzberg, Mausner, & Synderman, 1959; Vroom, 1964) (Alderfer, 1969; Fontana, 1997; McLelland, 1985) reveal, on the other hand, how “motivated” work performances generate a sense of personal fulfillment which can be translated into a positive result for performance in general.

Organizational well-being, understood as “the ability of an organization to promote and maintain the highest degree of physical, psychological and social well-being of workers in all types of occupation” (Avallone & Bonaretti, 2003) is the first element related to the effectiveness, efficiency, productivity, and development of a public structure. Therefore, this concept refers to the people’s way of experiencing the relationship with the organization in which they work: the more someone feels they belong to the organization, the more he they find motivation and meaning in their work.

In the italian scenario, well-being has always been an important topic; for instance, the G.U. 5/4/2004 law on work-related stress calls on Public Administrations to act not only to achieve efficiency and productivity, but also to build work environments and relationships that improve the workers’ quality of life. The development and efficiency of the Public Administrations, as issued by the Ministry of Public Function in 2004 (Official Journal – OJ 5/4/2004) must be oriented towards the improvement of the organizational well-being and the emotional conditions of the working environment. To optimize the work and improve the attitude of the staff, it’s also important to enhance the creativity as a resource to better adapt to sudden changes and the problem solving. This part of the agreement is conntected to the Legislative Decree 81/2008 which refers to the European Agreement on work-related stress (89/391 EEC) where employers “have a legal obligation to protect health and worker safety at work”. This must “also applies in the presence of work-related stress issues as they affect a work risk factor relevant for the protection of health and safety”. Legislative Decree 81/2008 also establishes supplementary and corrective provisions on the work safety and establishes that the employer must provide the reduction or abolition of the work-related stress, with the obligation to train his own employees on health risks.

For these aforementioned reasons, the promotion of well-being should be considered a goal for every health organization. This can be done by providing operators with the opportunity to make the most out of their internal resources and the ability to relate on colleagues (Antonovsy, 1993).

According to the World Health Organization, well-being is strongly influenced by the cultural context; for this purpose, nationally calibrated measurement procedures and tools are available. The evaluation design applied to this topic must consider these protocols.

In this perspective, professional and learning development are the keys strategies that health organizations must implement to promote health and well-being in their contexts.

Indeed, studies on organizations have shown that the most efficient structures are those with satisfied employees and a peaceful and participatory “internal climate” (Tavormina, et al., 2014; Grant, Courtaine & Barton, 2009). The improvement of mental and physical health of workers increases the productivity and satisfaction of customers/users, especially in healthcare companies where Health is considered the final gaol.

Consequently, the evaluation of well-being is now a priority for the health organization: “Establishing the current levels of psychological well-being in the organization is a prerequisite, first to decide on interventions.” (The British Psychological Society – Division of Occupational Psychology, 2010) (Warr, 2012; Diamare, Pocetta, & Polito, 2010).

The concept of organizational well-being refers to the way people live the relationship with the organization in which they work; the more a person feels they belong to the organization, because they share its values, practices, languages, the more they find motivation and meaning in their work. It’s for these reasons that it’s necessary to develop skills related to the emotional dimension, the way people live the organization and, above all, the climate in which employees work every day.

Starting from the importance of promoting the psychophysical health of health workers at high risk of stress, we wanted to explore if an in-service training course could have a positive outcome on the psychological well-being, as imagined and measured by Carol Ryff (Ryff, 1989). The empirical evaluation model developed by Carol Ryff remains the most frequent operationalization of the eudaimonic vision of pschological well being (Ryan & Deci, 2001).

This premise justifies the opportunity to evaluate the impact of training carried out with a positive and salutogenic psychology approach aimed at improving individual ability to respond to stressors.  (Antonovsy, 1996) (Suominen & Lindstroem, 2008).

Extending previous research on psychological well-being and claiming that well-being goes beyond happiness and life satisfaction, Ryff (1989) proposed the concept of psychological well-being; while subjective well-being focuses on the pursuit of happiness and a pleasant life, psychological well-being aims to achieve human potential and a meaningful life even in front of challenges and adversity (De Caroli & Sagone, 2016).

Carol Ryff’s contribution to the study of psychological well-being in the workplace has long been recognized (Diamare, Pocetta, & Polito, 2010; Bartels, Peterson, & Reina, 2019). The psychological well-being measurement scale (PWBS) found a great application in different contexts, populations and groups and, although it has been criticized for some statistical weaknesses, it continues to be applied in its different versions validated in different linguistic contexts.


Especially in the workplace, the 24-item version of the PWBS was used to evaluate the relationship between psychological well-being and work performance by comparing different organizational structures (Usman, 2017), to measure the relationship between the psychological well-being of workers in the insurance sector and their self-esteem and resilience (Tripathi, 2011).

A study conducted among workers in the food supply chain in India has highlighted a negative correlation between work stress and psychological well-being measured by the Ryff scale (Gupta & Agarwal, 2017). The Ryff 18-item scale was used to study psychological well-being in working women in India in relation to depression, anxiety, stress and gender discrimination (Madhusudanan & Nalini, 2017).

A validation study of the Swedish 18-item version of the Ryff scale, with a group of white collars, Lindfors and coll found differences in favor of women in the dimensions: “Positive relationships”, “Purpose in life” and “Personal growth ” (Lindfors, Berntsson, & Lundberg, 2006).


In the health care field, the Ryff scale has found application in various studies for many years.

Recently, the Ryff scale (84 items) was used to evaluate the relationship between psychological well-being and other factors such as “spirituality” and “self-esteem” in a group of mental health care workers in the city of Lahore (India) highlighting how “self-esteem and spirituality” in the workplace are predictors of mental well-being (Awan & Sitwat, 2014).

Madhuchandra et al. (2016) by comparing two professional groups (doctors and nurses) in India and using a variant with 54 items, didn’t find any differences between the doctors regarding the total scale while significant differences were found in the “Autonomy” and “Environmental mastery” dimensions. As for the comparison between the two professional groups, the nurses showed higher scores than the doctors in the “Autonomy” and “Environmental mastery” dimensions (Madhuchandra & Srimathi, 2016).

Many authors have also evaluated the influence of gender in the test results in different social groups and different geographical origins, without however reaching a definitive conclusion.

In a cross-cultural comparison study based on the 18-element scale, no differences emerged between Italian and Swedish teenagers (Garcia, Sagone, & Elvir, 2017) while the males showed a level of higher psychological well-being than girls in the dimensions: “environmental mastery” and “self-acceptance” (De Caroli & Sagone, 2014).

Adolescents and Young Adults

The adolescent population is a particularly significant target for the study of mental health and psychological well-being. However, the results are not consistent between the different studies.

In a study conducted in Ethiopia that included 93 orphans and 93 non- orphans aged between 10 and 18 years, using a 42-item version of the Ryff scale, no statistically significant correlations were identified between the gender of the children and the total scale and individual dimensions. The authors report the results of other research conducted on adolescents in the same condition, underlining that their results are consistent with those produced by studies carried out in China and Ethiopia while gender differences were evident in different studies: for women higher dimensions scores were: “Personal growth and positive relations with others” and “Autonomy” in studies carried out in South Africa and Tanzania. (Hailegiorgis, et al., 2018).

Working with a population of university students in Spain, Garcia- Alandete et al. highlighted that woman achieve a statistically significant higher score than the global scale, and the dimensions: “Environmental mastery”, Personal growth “, Purpose in life” (Garcìa- Alandete, Soucase Lozano, Selles-Nohales, & Martinez, 2013).


Matud a coll. conducted a large study of adult population using the Ryff scale of 38 items validated in Spanish, they highlighted that men achieve a higher score in the “Self-acceptance” and “Autonomy” dimensions, while women prevail in the “Personal growth” and positive relationships with others” dimensions (Matud, López- Curbelo, & Fortes, 2019). Ottolini and coll. report the results of surveys conducted in the United States where the impact of gender difference had affected the dimension of “positive relationships” with a higher score for women (Ottolini, Riuni, Rafanelli, Mangelli, & Fava, 2000). Similarly, Bordbar and Chow report a significant correlation between gender (female) and some aspects of psychological well-being (Bordbar, Nikkar, & Yazdani, 2011; Chow, 2007).

In the aforementioned study by Madhuchandra et al. the influence of gender difference was also assessed in a mixed group of doctors and nurses where males showed a higher score in the “Personal growth” dimension (Madhuchandra & Srimathi, 2016).

In the study involving psychiatrists, psychologists, nurses and other mental health assistants in India, regarding the relationship between psychological well-being and gender, the authors highlight that gender didn’t prove to be a predictive variable for total psychological well- being while it was a significant predictor for the “Autonomy”and “Environmental mastery” (Awan & Sitwat, 2014).


In the Italian context, studies on psychological well-being have been underway for several years, highlighting a significant although not homogeneous influence of the “gender” variable (Steca, Ryff, D’Alessandro, & Delle Fratte, 2020).

In Italy, Visani et al. have studied a population of adolescents, average age 13 years, residing in the most economically developed part of the country (Northern Italy), highlighting that between males and females there are no significant differences in performance compared to the Ryff scale (Visani, et al., 2011).

In the validation study of the Italian version with 84 items, Ruini et al. (2003) found that men achieved higher scores although not statistically significant in the “environmental mastery”, “personal growth”, “purpose in life”and “self-acceptance” dimensions, while women scored higher in the “positive relationships” dimension (Ruini, Ottolini, Rafanelli, Ryff, & Fava, 2003).

In a study involving a group of nursing students (Vitale, Unpublished data), significant differences were identified regarding the “Positive relationships” and “Purpose in life” dimensions, with higher scores in women.

Purpose, hypothesis and main conclusions of the study

In the first part of this research, we assume that participation in a psycho-body empowerment training has a positive effect on the psychological well-being; in the second part, we hypothesize that the gender difference has an influence on the scores achieved before and after participation in this training process and on the pre-post differences of the total scale and sub scale’s means.

The setting of the study consists of a training course in “Relational quality and improvement of Life Skills (No technical Skills)” carried out at the ASL Napoli 1 Center and repeated in various editions between 2012 and 2018 with the same tutors, structure, methodology and training objectives.

The teaching method provided practical workshops with the use of Non-verbal / Expressive Communication Techniques and Arts Therapies for 90% of the course.

During the Training course, the results of which we present ex ante and ex post, we explored the six dimensions of well-being: self-acceptance, positive interpersonal relationships, autonomy, environmental control, personal growth and purpose in life.

In addition, Carol Ryff’s self-evaluation Psychological Well-Being questionnaire was administered for the evaluation of the training course; the questionnaire was made in ex

ante and ex post in the Italian version validated by Ruini and coll.

The PWB test consists of 6 sub-scales, which measures the Psychological Wellness dimensions:

  1. Purpose in life: perceived measure of the meaning, purpose and direction of one’s life;
  2. Autonomy: perceived measure of living according to one’s personal beliefs;
  3. Personal growth: measure of the use of one’s talents and personal potential;
  4. Environmental mastery: how well you manage the environmental situation;
  5. Positive Relationships: profound and meaningful relationships;
  6. Self-acceptance: self-knowledge, acceptance, awareness of personal limits3.

The answers are coded on a Likert scale; therefore, for each category, a high score indicated that the interviewee was comfortable with that particular concept; conversely, a low score proved otherwise. The inverted scales were directly re-coded in the database.

Inclusion Criteria

The ex ante data were collected on the first day of the course

before introducing the concept of life skills; the ex post data, however, were collected after the presentation of the last skill on the

penultimate day of the course. All learners completed the tests voluntarily, although some subjects were excluded due to missing data. Furthermore, all participants were guaranteed anonymity and were informed of the possibility of using the data to investigate the effectiveness of the course. The subjects took about 30 minutes to complete the questionnaires.

Statistic Analysis

The test results are presented as the mean and standard deviation (SD) of the total scores and the scores of the individual sub scales for the whole sample and by gender. The difference between the ex ante and ex post averages was evaluated with the Student’s t test for the paired samples and at a level of statistical significance <0.05.

Following the indications of different authors, a further analysis was conducted using a nonparametric test (Wilcoxon); in the case of differences, the result of the non-parametric test was deemed acceptable. Data processing and statistical analyzes were conducted with the SSPS XXX ed. (IBM Inc., Chicago, IL).


All the participants (112), mainly women (62.5%), were aged between 45 and 65, graduates and with long professional experience.

The differences between the scores (mean and SD) before and after training (table 1) were positive for the whole scale (9,634; IC95% 4,207, 15,061) and considering the sub scales: Autonomy (1,598.

IC95% 0.016, 3,180), Environmental Mastery (2,205; IC95% 0.981, 3,430), Personal   Growth (0.723;   IC95%   0.6,   2,047),   Positive Relationships (0.491; IC95% 0.902, 1,884), Purpose in life (1,946. IC95% 0.685, 3,208), Self-acceptance (2,670; IC95% 1,412, 3,928).

A moderate level of statistical significance was obtained for the Autonomy sub-scale but not confirmed in the nonparametric test, while a more evident result was found for the sub-scales Environmental Mastery, Purpose in life and Self-acceptance, all confirmed with the non-parametric measurement; on the contrary, a level of insignificance has been reached for Personal Growth and Positive Relationships with the other (also confirmed by the nonparametric test).

 AntePost  Post-Pre Mean Diff95% Confidence Interval of the DifferencePaired Samples t Test     (2- tailed) (df 111) (p <   .05)Paired Samples Wilcoxon Signed Ranks Test (2-tailed) (p <   .05)
 MeanS.D.MeanS.D. LowerUpper  
Environmentally Mastery  61,72  8,933  63,93  8,367  2,205  ,981  3,430  ,001    .000
Personal Growth  67,01  9,024  67,73  7,721  ,723  -,600  2,047  ,281  .308
Positive relationship  66,94  10,470  67,43  9,655  ,491  -,902  1,884  ,486  .468
Purpose in life  62,47  7,986  64,42  7,082  1,946  ,685  3,208  ,003.007
Self-acceptance    60,39    8,805    63,06    8,032    2,670    1,412    3,928    ,000.000
Tab. 1Comparison of ex ante and ex post psychological well-being scores (No. 112)

“The extent to which respondents felt their lives had meaning, purpose, and direction (purpose in life); whether they viewed themselves to be living in accord with their own personal convictions (autonomy); the extent to which they were making use of their personal talents and potential (personal growth); how well they were managing their life situations (environmental mastery); the depth of connection they had in ties with significant others (positive relationships); and the knowledge and acceptance they had of themselves, including awareness of personal limitations (self- acceptance)”. (Ryff, 2014)

The set of these data is useful because it makes us understand that the variation of the scores across the formation took place in the same direction for everyone both regarding the scale in total and the individual dimensions that make up the Ryff model.

Table 1 Comparison of ex ante and ex post psychological well-being scores (No. 112)

Gender Analysis

Tables 2 and 3 show the same data collected separately in the two genders. In both genders the differences between the scores recorded before and after the course are positive. However, in men the differences are not significant for any of the sub scales nor for the

total scale, except for a modest significance

for the “Self-acceptance” sub-scale to the parametric t test. On the contrary, among women, the differences are overall significant apart from “personal growth” and “positive relationships with others” in both tests except the sub-scale “autonomy” significant only in the parametric test.

 AntePost  Post-Ante Mean Diff95% Confidence Interval of the DifferencePaired Samples Test *Wilcoxon
 MeanS.D.MeanS.D. LowerUpper  
Environmental Mastery63,4510,55364,529.1341,071-1,0393,182,311.290
Personal Growth67,1910,83267,268,076,071-2,5212,664,956.905
Positive relationships65,3311,64765,4810,707,143-1,7862,072,882.520
Purpose in Life63,938,26864,627,660,690-1,1662,547,457.464
Tab. 2 – Comparison of ex ante and ex post MEN’s psychological well- being scores (n. 42)
* (2-tailed) (df 41) (p < .05)
 AntePost  Post-Ante Mean Diff95% Confidence Interval of the DifferencePaired Samples Test*Wilcoxon
 MeanS.D.MeanS.D. LowerUpper  
Environmental Mastery60,690,92063,577,9192,8861,3724,399,000.000
Personal Groth66,900,93568,017,5461,114-,3712,600,139.241
Positive relationships67,901,15468,608,839,700-1,2392,639,474.572
Purpose in life61,600,92564,306,7662,7001,0074,393,002.006
Tab. 3 – Comparison of ex ante and ex post WOMEN’s psychological well- being scores (n. 70)
* (2-tailed) (df 41) (p < .05)

Association Between Differences In Pre And Post Scores And Gender

A non-parametric Wilcoxon test was used to test the null hypothesis according to which the gender difference has no influence on the differences in the scores before and after the course expressed by the participants (p <.05).

Table 1 summarizes the average values of the differences between the means for the total scale and the sub scales. The difference between the averages recorded before and after participation is positive and this indicates that for all the dimensions examined there has been an improvement in the average scores (see also the number of positive

and negative pairs).

Gender difference between pre post averages 
 MeanNStd. DeviationStd. Error MeanZAsymp. Sig. (2-tailed)
PWB Diff p/a9,6311228,9852,739-2,519b,012
Autonomy Diff p/a1,59821128,44853,79831-,334c,738
Environmental mastery Diff p/a2,20541126,53906,61788-,689b,491
Personal Growth. Diff p/a,72321127,06751,66782-1,519c,129
Positive Relations. Diff p/a,49111127,43863,70288-1,787c,074
Purpose in life Diff p/a1,94641126,73680,63657-,380b,704
Self-Acceptance Diff p/a2,66961126,71879,63487-1,273b,203
a.       Wilcoxon Signed Ranks Test
b.       Based on negative ranks.
c.       Based on positive ranks.


Some studies have highlighted a relation between a high cultural background and higher scores on the scale, particularly in the “Purpose in life” and “Personal growth” dimensions.

The heterogeneity of the empirical results is not surprising if we consider the influence of the cultural and socio-economic context on gender difference. In addition to this, we must ask whether the result achieved is linked to the greater number of women Burns (Burns & Machin, 2009) also states that coherent differences between different items on different scales may support a difference between genders not attributable to the composition of the sample.

The first objective of the research was to verify whether participation in a long and complex training process based on life skills and addressed to a group of health professionals of an ASL in Italy, was able to improve the psychological well-being of the participants measured through the questionnaire developed by Carol Ryff.

The level of psychological well-being increased among the participants in the training in all sub-scales: Autonomy, Environmental Mastery, Personal Growth, Positive Relationships with others, Purpose in life and Self-acceptance. Was confirmed the

significance of the difference of the means for the dimensions: “Environmental Mastery”, “Purpose in life” and “Self-acceptance”.

After the training course for the whole sample, there was a significant increasing in the ability to manage daily dynamics with confidence compared to the working context, knowing how to catch the opportunities that come up. In addition, it increases the personal ability to set goals by giving meaning to one’s working and personal life.

The last dimension that significantly increases is “self-acceptance”, which improves the positive attitude towards oneself and the awareness of one’s qualities.

About the gender difference. From the results of the statistical analysis, it emerges that gender had a weak positive relations, that affected some dimensions such as: “environmental mastery”, “life purpose”, “positive relationship with others” and “self-acceptance”; while it had a weak negative relationship in the following dimensions: “autonomy”, “personal growth” and total psychological well-being.


This training model appears to have a positive short-term impact. More extensive and long-term studies are needed to confirm short-

term results and evaluate what happens compared to     

psychological well-being.


The critical issues are related to the use of the PWB test itself, as the scale used by Carol Ryff in the version of 84 items and the related translation into Italian, presents a subjective self-reported judgment.

Another limitation consists in the fact that the pilot study presented here concerned a small number of operators in the public health services of the Naples area and therefore the results cannot, at the present time, be generalized.

However, this research opened a window on the connection between the development of individual well-being and organizational development in the public health field and in the care professions, through professional updating.

This study warrants further investigation on long-term results on a larger sample.


At the end of this paper, we can consider in-service training as a possible contribution to improving the ability to stressors respond, as it would seem to favor a peaceful and participatory working environment. To this end, the training process of psycho-corporal empowerment4© has proven effective as the individual perception of well-being has improved overall in the sample analyzed. We also found differences in the results between the two genders.

The statistical survey showed that the level of psychological well- being of the entire sample increased significantly; this data leads us to consider that the participants tend to improve in those dimensions considered functional to the operator’s well-being.

In particular, three were the dimensions that more than the others reported a better result confirmed by the statistical analysis: “environmental mastery”, “self-acceptance” and “purpose in life”. The personal skills of knowing how to manage daily life in the working context with confidence, with a positive attitude towards oneself and with awareness of one’s qualities, having clear objectives, in fact, are dimensions that contribute to maintaining a more efficient and goal- oriented working climate.

A significant difference emerged

in the dimensions examined ex-ante and ex-post between the two genders.

In the health services, the feminization process is evident, which is particularly relevant in the professions with the most direct contact with users (Saporito, Sartirana, & Tozzi, 2019). This inserts a further interest in research on gender difference in healthcare where are more evident the characteristics and differences between genders and potential relapses in terms of stress.

From the results on the gender difference, in fact, it has been shown that in men the differences are not significant for any of the sub scales or for the total scale. On the contrary, among women, the differences are overall significant except for the items “personal growth” and “positive relationships with others” in both tests; the “autonomy” sub-scale is significant, however, only in the parametric test.

This leads us to consider that, for statistical purposes, the statistical weight of the women’s group is greater than the men’s group; so the positive results found at the end of the training course are attributable to skills acquired by women.

In particular, the positive changes found in the women’s group concern the area of work context management, the personal ability to set specific goals and objectives and awareness of one’s qualities in the present.

In conclusion, the sample considered recorded a global improvement through experiential laboratories related to the development of Life Skills, even if the men sample didn’t record significant changes.

The female population seems to be the driving force in mixed groups towards the creation of trans-formative environments, while the male popolutation seems to be more self-confident but also more resistant to change.

Therefore, joint work on groups made up of both male and female operators can articulate useful experiences to create a positive climate and the possibility of positive changes.

The action research in this presented study, adapted in web mode in compliance with the safety standards imposed by the COVID-19 pandemic, has been supported by e-learning technologies and the results of this further study will be the subject of subsequent publication.


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