Development of an organisational model for the preparation of the mRNA-bnt162B2 vaccine: the experience of the Clinical Galenics Laboratory of the Hospital Pharmacy of the Mauriziano Hospital, Turin

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Submission Date: 2022-08-12
Review Date: 2023-01-08
Pubblication Date: 2023-02-15



The centralised preparation of the mRNA-bnt162B2 vaccine at the Clinical Galenics Laboratory of the Hospital Pharmacy of the Mauriziano Hospital in Turin is an organisational model designed to guarantee the quality of the drug to be administered, the safety of both the vaccinee and the vaccinating personnel, and the traceability of all operations performed. The preparation in ready-for-use syringes individually packaged and labelled, according to the Good Manufacturing Practice (GMP) of the Official Pharmacopoeia, was entrusted to the Biomedical Laboratory Technician (BLT) under the responsibility of the Hospital Pharmacist.
In compliance with the GMP, the model was developed through dedicated premises, specific staff training and written procedures concerning the handling of vaccines. The entire production process was guaranteed by: a Hospital Pharmacist and two interchangeable BLTs, one preparer and one assistant. They were necessary to maintain the aseptic technique and the cross-checking of all operations. Labels were prepared showing qualitative-quantitative composition, batch and expiry date, validity of the preparation, pharmacist's signature. The label applied to each syringe, together with the daily work plan, ensured traceability of the process at every stage.
The efficient model proposed has always proved adaptable to the changes that characterised the vaccination campaign. From 27/12/2020 to 31/03/2022 a total of 48.017 doses were prepared. The centralisation of the vaccine preparation in the Clinical Galenics Laboratory of the Hospital Pharmacy also reduced handling errors, as well as the waste from unused residues, which proved to be only 0.08%.


The devastating effects of the SarS-CoV-2 pandemic have led to a pressing demand for the identification of an effective protective vaccination for the largest number of people within a short timeframe.

The promise of the anti-SarS-CoV-2 vaccine became reality on 21st December 2020 with the authorisation of Pfizer-BioNtech’s Comirnaty vaccine by the European Medicines Agency (EMA) and on 22nd December 2020 by the Italian Medicines Agency (AIFA).

The vaccines, even those authorised subsequently, were made available free of charge to the entire population according to an order of priority that took into account the risk of disease, the types of vaccine and their availability. The vaccination campaign started on 27th December 2020 in Italy and Europe with Vaccine-Day. The aim was to get as much involvement as possible from the health facilities.

The Mauriziano Hospital has thus started its vaccination campaign: the Clinical Galenics Laboratory of the Hospital Pharmacy has proposed itself as an active part in tackling it, both as regards the vaccine storage phase and all the preparation phases. We started in the first instance with thevaccination of all the hospital’s health workers followed by the highly fragile patients, for whom due to their immunodeficiency status, the preferential use of messenger RNA vaccines had been confirmed.

Comirnaty (Tozinameran) is a messenger RNA (mRNA) vaccine encoding for the viral spike (S) protein of SarS-CoV-2.

According to the Summary of Product Characteristics (SPC), the concentrate for injectable dispersion must be prepared using aseptic techniques to ensure the sterility of the preparation. To this end, the Hospital Pharmacy has developed an organisational model to guarantee the quality of the drug to be administered. This ensures the safety of both the vaccinee and the vaccinating personnel, as well as the traceability of the entire process. The model envisages the use of the aseptic technique for the preparation of pre-filled syringes ready for use, individually packed inside sterile bags, sealed with an automatic heat-sealing machine and finally labelled.

The vaccine preparation phase is part of a broader and more articulated process: it ranges from receiving the drug in frozen vials (-60/-90 °C) to preparing it in ready-made syringes and finally to administration. In order to run smoothly the whole process, a careful scheduling of daily bookings agreed upon by a multidisciplinary team consisting of the medical management, doctors, pharmacists and administrative staff is therefore necessary. This scheduling takes into account not only the physical stock but also the stock required to complete the vaccination cycle (second dose) and the time required to thaw individual vials.

Methodology and Materials

According to the provisions of the Italian Official Pharmacopoeia XII Edition, the preparation of sterile pre-filled syringes is an operation that can be assimilated to the processing of magistral galenic preparations. Therefore it must be carried out under the responsibility of the hospital pharmacist, in compliance with the Good Manufacturing Practice (GMP). The preparation, according to GMP, has the objective of:

  • ensuring that the sterility of the preparation is maintained;
  • allowing safe preparation for the operator;
  • ensuring that the dosage required for administration is correct;
  • guaranteeing the traceability of all operations.
Fig. 1

In compliance with the GMP and in order to guarantee organisational appropriateness, dedicated rooms, appropriate equipment and qualified personnel, as well as suitable disinfection procedures are also required.

It is for this purpose that the Hospital Pharmacy has set up a special room equipped with:

  • vertical flow hood with HEPA filters;
  • freezer for storage at -80 °C, equipped with a temperature (T) monitoring system;
  • refrigerator for thawing the drug at a controlled T (2-8 °C), equipped with a T-monitoring system;
  • automatic thermosealing machine for syringe packaging.

Vaccine preparation was entrusted to the professional figure of the Biomedical Laboratory Technician (BLT), under the direct and indispensable responsibility of the Hospital Pharmacist.

Taking Art. 16 of its Code of Ethics as a reference, the BLT with specialist skills participates in the production process of clinical galenics guaranteeing quality and safety.

The proposed organisational model envisages the presence of two BLTs: one preparer and one assistant, interchangeable. They were necessary for the maintenance and observance of the aseptic technique as well as for the cross-checking of all operations to be performed.

Fig. 2

The BLTs engaged in the preparation of vaccines were subjected to:

  1. initial training by the multidisciplinary team of the Clinical Galenic Laboratory regarding the modus operandi of the aseptic technique, such as dressing, preparation of the hood, operating modes as preparatory technician and assistant technician;
  2. specific training on the preparation of mRNA vaccines according to the specifications in the SPCs;
  3. ongoing training and refresher courses: acquisition of knowledge and transversal skills regarding vaccine storage, preservation of pre-filled syringes and inoculation.

The quality, safety and effectiveness of a process does not depend only by the individual, but by the careful organisation and constant control of all its stages, as described below.

Preparation Labelling

Each sterile bag containing the single dose of vaccine was labelled with the following specifications:

  • Pharmacy and Hospital references, where the preparation was carried out;
  • first name, surname and date of birth of the vaccinee;
  • quali-quantitative composition of the preparation;
  • batch number and expiry date;
  • date and time of preparation and validity of the preparation;
  • mode of administration;
  • instructions for proper storage;
  • signature of the responsible Hospital Pharmacist.

From December 2020 to December 2021 it was possible to vaccinate with a good schedule thanks to the close cooperation between the Clinical Galenics Laboratory and the Administrative Department to whom the bookings were entrusted.

Knowing in advance the numbers of daily bookings and their personal details, the Hospital Pharmacy was able to produce customised labels with the specifications of each vaccination.

As of the end of December 2021, the Mauriziano Hospital of Turin, at the behest of the Piedmont Region has become a vaccination HUB thus breaking down the numerical limits of daily vaccinations with which the Hospital used to work. With this new mode, it was no longer possible to work with a daily schedule: both for the mass of users booked, both for the opening of the HUB without reservation (through free access). Consequently, the Hospital Pharmacy readjusted the label structure, removing the individual’s personal details. This was however possible considering that the vaccine is not prepared and administered in customised doses. The specifications of the preparation, indispensable for its recognition, remained unchanged.

Fig. 3
Process Tracking

On each vaccination day, a work plan was drawn up as a record of the preparations carried out by the Clinical Galenics Laboratory. The work plan is a necessary tool for tracking daily activity, especially the dilution time of each vial, the total number of vials prepared, the batch and the expiry date of the vaccine and NaCl 0.9% solution used. Also the responsible Pharmacist, the preparing Technician and the assistant Technician.

During registration on the Regional Information System for Vaccination Management (SIRVa), the presence on the label of the batch of the vaccine used, with its expiry date, allows the Administrative Staff the batch-vaccine association. The aim is to guarantee traceability from a vaccine-vigilance point of view as well as safety.

Validity Of The Preparation

The stability characteristics of this preparation are such that fractionated doses must be administered in a timely manner. The administration should be carried out within a very short period of time and in accordance with the Summary of Product Characteristics, i.e. within 6 hours of dilution of Comirnaty. Fractionated doses of the drug should be stored at 2-30 °C.

With this in mind, the production of ready-for-use syringes by the Clinical Galenics Laboratory takes place in close cooperation with the staff in charge of accepting the users to be vaccinated. With this method, a quantity of vials is diluted to reflect the physical number of people present at the vaccination site.

Quality Controls

To ensure compliance with the Good Manufacturing Practice (Pharmacopoeia XII Edition), in addition to the double check performed by the two Technician, the pharmacist carries out a series of final checks to ensure the validity of the finished product:

  • visual check of the volume taken, appearance and absence of visible particles;
  • checking the integrity and tightness of the primary and secondary packaging;
  • control of residues of unused drugs to check the appropriateness of the volumes taken;
  • checking that the data on the label are correct.

The signature affixed by the pharmacist authorises the dispensing and administration of the final preparation guaranteeing quality, safety and efficacy.

Transport Of Ready-To-Use Vaccine Syringes

The proper transport of the ready-to-use syringes from the Clinical Galenics Laboratory to the premises intended for the administration of the Covid19 vaccine is intended to ensure the safety of the operators involved and the preservation of the quality characteristics of the doses sent.

On request of the Piedmont Region, from 14th May 2021, the Mauriziano Hospital of Turin took part, together with other Turin’s Hospitals, in the vaccination of the ‘Lorusso e Cutugno’ prison and from 1st July 2021 also of the ‘Ferrante Aporti’ Juvenile Penal Institute.

Consequently, the transport of fractionated doses has been structured in such a way that both internal and external transport of the Hospital is guaranteed. In the case of internal transport, the finished products are placed in a rigid container suitable for the transport of drugs. Instead, in the case of external transport the rigid container is in turn placed in a refrigerator inside the vehicle to ensure the maintenance of a controlled temperature (2-8 °C).

The transport must be accompanied by appropriate documentation showing the date, time and content.

Archiving Documentation

The work plan, relating to the activities described and the results of the checks carried out, must be appropriately filed to ensure control and traceability. This is also important in a period after the date of preparation and administration, such as when an adverse drug reaction (ADR) is reported in the context of vaccine-vigilance.

Results and Discussion

The application of this organisational model allowed us to prepare all the doses required to meet the needs of users in real time. The daily schedules and objectives imposed by the Piedmont Region were respected. From 27th December 2020, the so-called Vaccine-Day, to 31st March 2022, the day on which the vaccination campaign closed for the Mauriziano Hospital of Turin, a total of 48.017 doses were prepared, including first, second, third and fourth doses.

The organisational model proved to be successful, as it was flexible and adaptable to the changes that characterised the vaccination campaign. Moreover, having entrusted each professional figure with a very precise phase of the process, the involvement of each actor was widely appreciated and valued in a highly collaborative context.

The centralisation of mRNA vaccine preparations in the Clinical Galenics Laboratory of the Hospital Pharmacy also reduced handling errors, as well as waste from unused residues, which proved to be only 0.08%.


  1. “Farmacopea Ufficiale Italiana”, 12th edition (in force since 31 March 2009).
  2. “Norme di Buona Preparazione” (Good Manufacturing Practice) contained in the “Farmacopea Ufficiale Italiana”, 12th edition (in force since 31 March 2009).
  3. “Codice Deontologico Professionista Tecnico Sanitario di Laboratorio Biomedico”. Federazione nazionale degli Ordini TSRM e PSTRP.
  4. “Raccomandazione n. 14: Raccomandazione per la prevenzione degli errori in terapia con farmaci antineoplastici”. Ministero della Salute, ottobre 2012.
  5. “Linee guida per la sicurezza e la salute dei lavoratori esposti a chemioterapici antiblastici in ambiente sanitario”. Conferenza Permanente per i Rapporti tra lo Stato, le Regioni e le Province Autonome di Trento e Bolzano, agosto 1999. GU 7/10/99, n 236.
  6. D. Lgs. 9 aprile 2008, n.81 “Attuazione dell’articolo 1 della legge 3 agosto 2007, n. 123, in materia di tutela della salute e della sicurezza nei luoghi di lavoro”; recepimento della Direttiva 98/24/CE in materia di protezione della salute e della sicurezza dei lavoratori contro i rischi derivanti da agenti chimici durante il lavoro.

Training: implementation of laboratory tests for molecular, antigenic and serological diagnostics of SARS CoV2 and reorganization of work activities

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Submission Date: 2022-07-06
Review Date: 2023-01-09
Pubblication Date: 2023-02-14



The U.O.C. of Microbiology and Virology experienced a disruption of work activity in the year 2020 due to the COVID 19 emergency ..
On 3 April 2020 the U.O.C. of Microbiology and Virology of the San Camillo-Forlanini Company is included in the network of CORONET laboratories for molecular, antigenic and serological diagnostics of SARS CoV2.
To cope with this emergency it was necessary to reorganize the entire laboratory activity, so as to be able to carry out both the routine activities and those concerning the diagnosis of SARS CoV2, coming not only from the San Camillo-Forlanini company, but also from the territorial ASL, Case di Cira, RSA, Drive in and Walk in.
The complex and unexpected scenario brought out the need to quickly create an organizational model that could guarantee the execution of routine exams, but also provide a diagnostic priority for SARS-Cov2.
The initial phases were difficult on various fronts: in a very short time the laboratory technicians had to learn the most sophisticated molecular techniques indispensable for the diagnosis of SARS CoV2, moreover, it was necessary to face the serious shortage of reagents difficult to find on the market. Europe.
However, the biggest challenge was managing the hundreds of daily samples.
Thanks to the reorganization implemented, the U.O.C. of Microbiology and Virology is able to carry out surveys on increasingly large population samples, in compliance with regional and national guidelines.


On 11 March 2020, WHO Director-General Tedros Adhanom Ghebreyesus defined the spread of Covid-19 no longer an epidemic confined to certain geographical areas, but a pandemic spread throughout the planet.

The Lazio Region on January 26, 2020 issues the indications for the management and surveillance of suspected cases for SARS CoV2

In the indications of the Region are defined:

• the arrangements for handling suspicious cases,

• specific laboratory tests for the identification of SARS CoV2,

• the reference laboratories,

• the flow of notification to the competent authorities necessary for the rapid identification of subjects affected by COVID 19

On 3 April 2020 the U.O.C. of Microbiology and Virology of the San Camillo-Forlanini Company is included in the network of CORONET laboratories for molecular, antigenic and serological diagnostics of SARS CoV2.

The complex and unexpected scenario has led to the need to rapidly implement an organizational model that could, on the one hand, guarantee routine examinations, and on the other provide a diagnostic priority for SARS-Cov2.

The organizational change involved the implementation of laboratory tests for the molecular, antigenic and serological diagnostics of SARS CoV2, the training of personnel in new methods, the adequate management of Human Resources, the reorganization of spaces with dedicated paths for SARS CoV2, staff recruitment.

The biggest challenge faced was the management of hundreds of daily samples for the identification of SARS Cov2 coming not only from the company Operating Units, but from local ASLs, Nursing Homes, RSAs, Drive in and Walk in territorial

The initial phases were difficult on various fronts as in a very short time the technicians had to learn the most sophisticated molecular techniques indispensable for the diagnosis of SARS Cov2, it was necessary to face the serious shortage of reagents difficult to find on the market throughout Europe.

During the Pandemic, SARS-CoV2 molecular diagnostics has been constantly evolving, leading to the need to review most of the protocols in use and workflows, introducing new methods, mostly of molecular biology, to provide the clinician with a report more and more accurate, complete and rapid. The evolution of technology in SARS-CoV2 diagnostics and organizational well-being have made a training course necessary.


The training project was created to improve the performance of professionals, aimed at developing new skills, necessary to standardize shared procedures and protocols.

At the end of the course all participants will be able to use specific procedures and protocols, acquire theoretical and practical manual skills on the new molecular, antigenic and serological biology diagnostics for SARS-CoV2 research.

Meterials And Methods

The location of the course was the “San Camillo-Forlanini” Hospital, Malpighi Pavilion – U.O.C. Microbiology and Virology.

The course is intended for number 18 TSLB of the U.O.C. Microbiology and Virology of the San Camillo-Forlanini Hospital

The training course took place in a single edition lasting three months, every Monday of the week for a duration of two hours, starting on April 6, 2020 and ending June 22, 2020. two in number. The teaching methodology used was training in the field with technical demonstrations and the direct execution of the participants in the practical and technical activities. The didactic material provided was the specific protocols and procedures on molecular, antigenic and serological diagnostics Participants’ performance will be evaluated according to a predefined grid.

Results And Conclusions

The personnel involved actively participated by preparing themselves proactively. The results obtained resulted in greater motivation and involvement of staff during work, greater autonomy in the work organization, in addition, there was an improvement in interpersonal skills and an improvement in skills. Furthermore, within one month of the end of the course, 100% of the participating TSLBs were able to perform all the techniques of molecular, serological and antigenic diagnostics for the detection of SARS-CoV2.

The methods implemented were:

  • molecular for research of the Spike, N, RdPr and Orf1 genes
  • antigenic in chemiluminescence for antigenic research N (nucleus capsid)
  • serological chemiluminescence for the detection of anti Spike and anti N IgG

The pandemic experience has imposed the use of good practices and innovations that will certainly be a wealth of experience useful for the future

The occurrence of all these events related to a SAR CoV2 pandemic, an etiological agent unknown until then, has taught us that it is essential not to be taken by surprise by this type of situation, for these reasons, we must implement dedicated organizational plans. to emerging healthcare systems such as these, which allow us to face new pandemics with greater pandemie.


  1. Corporate Determination “A.O. San Camillo Forlanini “ Roma
  2. Corporate determination A.O. San Camillo Forlanini – Rome
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  4. Hirotsu Y, Meajima M, Shibusawa M, et al. s.l. :Comparison of automated SARSCoV-2 antigen test for COVID-19 infection with quantitative RT-PCR using 313 nasopharyngeal swabs, including from seven serially followed patients. Int J Infect Dis. 2020;99:397-402.
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  8. Gili A, Paggi R, Russo C, et al. s.l. : Evaluation of Lumipulse® G SARS-CoV-2 antigen assay automated test for detecting SARS-CoV-2 nucleocapsid protein (NP) in nasopharyngeal swabs for community and population screening. Int J Infect

Electrostimulation: Therapeutic Support In Contemporary Aesthetic Speech Therapy


Submission Date: 2022-12-06
Review Date: 2022-12-08
Pubblication Date: 2022-12-09


Electrostimulation can be considered a technological innovation of great help in improving muscle conditions in several areas or specialties such as Neurology, Orthopedics, Physiotherapy, Dermatology and also in Speech Therapy. Facial Aesthetics is one of the areas of activity of speech therapists specialized in Orofacial Motricity, an area of activity that introduced the electrostimulation technique in the therapeutic program, a contemporary proposal as a therapeutic support to accelerate and optimize results. With the aim of softening wrinkles, this technique can prevent and/or treat the stigmas of aging (Lepri, 2020)

Through aesthetic speech therapy, we speech therapists expand our professional area, maintaining the same field of action, that is, a therapeutic process that develops in all its fullness based on the area of Orofacial Motricity. Thus, the speech therapist is able to modify, restore and promote orofacial harmonization, as it acts directly on the functional and muscular aspects of orofacial structures, acting directly on some of the causes and consequences of facial changes resulting from the aging process (Lepri, 2020).

The electrostimulation technique in Aesthetic Speech Therapy is considered an innovation that offers the therapist new intervention possibilities to promote orofacial harmonization, restoring the characteristics of rejuvenation in a direct and effective way. Considered as a therapeutic support technique, it favors prevention and aesthetic balance whenever associated with functional balance. This technique works from the inside out in a controlled manner, generating deep muscle contractions, promoting a “lifting” effect, stimulates metabolism, increases vascularization, oxygenation and soft tissue trophism, in addition to enabling the restoration of volume and also muscle tone, and considerable improvement in the texture and vitality of the skin (Souza 2007).      

Electrotherapeutic currents indicated in Aesthetic Speech Therapy

FES (Functional Electrical Stimulation), a pulsed electrical current and its modulations capable of stimulating the motor nerve and obtaining functional muscle contraction as a result ( Bohórquez , 2013) which aims to generate a functional movement from the artificial muscle contraction whether in intraoral or extraoral modalities. The FES stimulation mode, in addition to improving the metabolic and functional condition of the muscles, also favors muscle strength and endurance, especially in the lower middle third of the face, SMAS and facial retaining ligaments. When applied for aesthetic purposes, it can combat facial flaccidity, a result of multiple factors, including muscle atrophy. The electrostimulation technique must be associated with orofacial exercises and functional reprogramming (chewing, swallowing, breathing), an important condition to optimize and maintain the results obtained (Lepri, 2020).

KOTZ, current developed in Russia in the 1970s, introduced in Canada and the United States by the Russian scientist Yadou M. Kotz. Indicated mainly for cases of flaccidity and circulatory disorders, its correct use can improve tissue and muscle condition, effect lymphatic drainage and increase cellular oxygenation (Pereira, 1999). The discomfort factor, the perception of electric current, is sometimes a limiting factor for using the technique. The Kotz current has in its characteristics a carrier of medium frequency, this condition favors the delivery of the electric charge that causes less sensorial discomfort and makes possible the applicability of the intensity parameter with high dose in an efficient way allowing vigorous muscular contractions ( Ward et al, 2006 ).Kotz current would therefore be an effective alternative to replacing the FES mode of electrical stimulation, especially in cases of those patients with muscle and tissue flaccidity (gravitational wrinkles) with a lowered sensory threshold.

TENS, Trasncutaneous Electrical Nerve Stimulation, it is a low-frequency electrostimulation modality that selectively stimulates large-diameter tactile fibers without activating smaller-diameter nociceptive fibers, promoting pain relief and thus generating functional gains (Chiarello et al., 2005). The explanation for the analgesic effect is that this current promotes the release of endorphins, which are endogenous analgesics released whenever the body feels pain. The applicability of the TENS mode in speech therapy may be related to the analgesia effect, which is why this current is used with excellent results, for example, in the control of painful symptoms in temporomandibular joint disorders (Fernandes et al., 2006). However, TENS can also be used in Aesthetic Speech Therapy in order to enhance the effect of muscle relaxation and the release of tension in soft tissues, a condition that favors the smoothing of expression wrinkles.

MESN, ( Microcurrente Electrical Neuromuscular Stimulation), they act directly on the stimulation at the cellular level of micro structures producing micro stimulation and neuro stimulation. It is a general bioelectric current in the range of microamperes, as it is able to allow a more efficient transport of ions, which in turn increases cellular metabolism and energy of muscle fibers (Jyothis, 2005). According to Soriano et. al 2002, some physiological effects favor an improvement in the aesthetic condition of the face such as; optimization of metabolism, increase in adenosine triphosphate and collagen production, increase in the lymphatic drainage effect of intracellular ionic exchanges and mobilization of liquids from the lymphatic and blood circulations.


There is no single procedure capable of reversing all the changes resulting from the facial aging process. In a therapeutic process, it is necessary to combine techniques for the different structural planes of the face. Speech therapy with a focus on facial aesthetics supported by the technique of intra and extra oral electrostimulation has been shown to be effective in redefining facial contours and smoothing expression wrinkles.


  1. Bohórquez, I.J.R.; Souza, M.N.; Pino, A.V. (2013) Influência de parâmetrosda estimulação elétrica funcional na contração concêntrica do quadrícepes. Revista Brasileira de Engenharia Biomédica, vol. 29, n.2, p. 153 – 165.
  2. Fernandes, G. Ferreira,A., Gonçalves, D. et al., (2006) TENS uma modalidade de tratamento para a dormuculo esqueléticocrônico da face. Revista de odontologia da UNESP, v. 35, n.especial.
  3. Jyothis, A.B.R. ( 2005) Arndt- Schutz Law: a scientific evidence. Homeopathy Times, v.2, n. 11.
  4. Lepri, Juliana R. (2020). Eletroestimulação na Fonoaudiologia Estética.Ed. Pró-Fono, ISBN: impresso 978-65-87564-00-5; SP/Brasil.
  5. Pereira, F. N. (1999) Eletroterapia sem mistérios. Rio de Janeiro ed. Robson Achimé.
  6. Souza, S.L.G.; BraganholoL. P.; Avila A.C.M. et al. (2007) Recursos fisioterapêuticos utilizados no tratamento do envelhecimento facial. São Paulo: Revista Fafibeon line, n.3.
  7. Soriano, M.C.D.; Perez, S.C.; Bakués, M.I.C. (2002) Eletroestética profissional aplicada: teoria e prática para autilizaçãode correntes na estética. Saint Quirze dell Valles: sorisa.
  8. Ward, A.; Oliver, W. G.; Buccella, D. (2006) Wrist rxtensor torque production and discomfort asociated whith low frequency and burst- modulated kolohertz-frequency currents. Physical Theraphy, v.86, n.10, p.1360-1367.

Evaluating the quality of the relationship between health workers and patients/caregivers during the Covid-19 pandemic: a review

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Submission Date: 2022-10-31
Review Date: 2022-11-15
Pubblication Date: 2022-11-17



The SARS-Covid 19 pandemic has produced a change in the relationship between health professional and patient and between doctors and family members. Restrictions to avoid the spread of the virus encouraged the use of electronic communication in interactions and the use of face masks in hand-to-hand contact, reducing the possibility of communication.
Communication has changed, losing important non-verbal components and partly body language. This change risked impoverishing the relationship between doctor/nurse and patient/family, as the role of non-verbal communication is vital in healthcare (Diamare et al., 2021). Indeed, facial expressions, gestures, eye contact, posture and tone of voice 'speak' with great intensity, becoming an important tool for healthcare professionals in understanding symptoms.
To this end, it was decided to implement a health and business psychology survey to analyze any emerging needs and to improve the quality of the relationship in the healthcare facilities participating in the survey. Therefore, questionnaires were administered to healthcare professionals and patients/caregivers in order to investigate how they interact and their different points of view on similar issues.


In healthcare, quality in the care field was first discussed immediately after the end of the Second World War with W. E. Deming, an expert in business organization, who began to spread the criteria of organizational quality aimed at the continuous improvement of resources based on his experiences during the reconstruction of the American military and technological potential (Colucci A., F. Ferretti, R. Cioffi, 2009).

Avedis Donabedian, a founding physician of the study of healthcare quality, defines Quality as: “doing only what’s useful (theoretical effectiveness), in the best way (practical effectiveness) with the least cost (efficiency), to those (accessibility), and only to those, who really need it (appropriateness), having the care done by those who are competent to do it (competence), obtaining the results deemed best (satisfaction)” (Donabedian A., 1988).

In 1997, healthcare satisfaction was considered the most important predictor of the overall satisfaction in hospitals and is still one of the outcome indicators of the quality and efficiency in healthcare systems (Merkouris A, Papathanassoglou EDE, Lemonidou C., 2004).

In the study and evaluation of quality of care, it’s fundamental to include the relationship and bonding with the patients which is, according to the literature, the most perceived aspect in the care process.

However, the safety regulations imposed by the Covid-19 pandemic, especially with the use of the face masks, have taken away mimic elements of non-verbal communication from the relationship between health workers and patients/caregivers. These aforementioned elements are fundamental to establish a good doctor-patient alliance from the very beginning. Because of these changes, the relationship has inevitably changed, leading to the need of developing new skills regarding the quality of verbal and non-verbal communication in the care process: for instance, the ability to create patient trust, the ability to treat the patient with care, empathy and sensitivity (Egman S.,et al. 2011), which can guarantee an experience similar to that in the pre-pandemic condition.

Customer Satisfaction questionnaires, a tool used in almost all companies and not only the ones related to healthcare, allow one to have real feedback on the service offered, to identify problems and to show the quality of the services offered (Perucca R, 2001). Because of that, surveys on perceived quality are increasingly common in organizations that pay attention to the individual. (Tanese A., Negro G., Gramigna A, 2003).

Regarding the technical quality of care, the fundamental requirements are the appropriateness of the service provided and the skills with which the appropriate care is delivered, without neglecting the necessary balance between the risk/benefit assessment and ethical issues. While doctors and nurses would like to achieve technical excellence, patients seem to be more involved in accessibility and performance.

Then, Customer Satisfaction can represent a strategic lever to improve the service offered starting from the relationship between the health professional and the user, especially because healthcare personnel’s competence is expressed through the quality of the care. The focus must be on the patient as a whole, identifying their needs through a holistic approach (Egman S.,et al.,2011).

The SARS-Covid 19 pandemic has produced a change in the relationship between health professional and patient and between doctors and family members. Restrictions to avoid the spread of the virus encouraged the use of electronic communication in interactions and the use of face masks in hand-to-hand contact, reducing the possibility of communication.

Communication has changed, losing important non-verbal components and partly body language. This change risked impoverishing the relationship between doctor/nurse and patient/family, as the role of non-verbal communication is vital in healthcare (Diamare et al., 2021). Indeed, facial expressions, gestures, eye contact, posture and tone of voice ‘speak’ with great intensity, becoming an important tool for healthcare professionals in understanding symptoms.

To this end, it was decided to implement a health and business psychology survey to analyze any emerging needs and to improve the quality of the relationship in the healthcare facilities participating in the survey. Therefore, questionnaires were administered to healthcare professionals and patients/caregivers in order to investigate how they interact and their different points of view on similar issues.

Service objectives

In Public Local Health Service ‘A.S.L. Napoli 1 Centro’ a team of psychologists from the ‘U.O.C. Quality and Humanization’  (;jsessionid=D6A7778E6626841DFBE355BF817C5C6A?, in partnership with the Primary Care Department, implemented a pathway to assess the quality of the relationship between health workers and patients/caregivers, and to research the services provided by the healthcare facilities during the period of the Covid-19 pandemic, in order to structure interventions aimed at reducing the discomforts expressed by internal/external users.

In addition, the questionnaires were administered exclusively online, exploring the still-very-young area of healthcare digitalization.


The aim of this study is to explore the different views of operators and patients/caregivers on the care provided and especially the operator/patient relationship during the period of the COVID-19 pandemic.

In particular, the aim was to develop a method for more in-depth future research into possible changes in non-verbal communication during pandemic emergencies following the use of personal protective equipment (PPE).

Target group

The questionnaires were addressed to operators in districts and hospital wards involved in the COVID-19 emergency, reaching a total of 62 operators in 30 days.

The mirror interview was previously addressed to caregivers and patients from the same catchment area.

Methods And Materials

The study was carried out through an online interview aimed at exploring, from the point of view of the healthcare operators, the perceived quality of healthcare and the relationship with patients/caregivers, especially regarding the degree of attention and participation in care, the quality of information and empathy.

In line with the current aims of healthcare digitization, the questionnaires administration was proposed exclusively online through a QR CODE, considering that questionnaires could not be handed on paper due to the ongoing pandemic.

This online protocol, illustrated by the posters displayed in the healthcare facilities, was supported by moments of unstructured sharing spaces, making the respondents participate in quality improvement processes through the evaluation of their degree of satisfaction. Despite the lack of digital literacy, there have been some responses and participation regardless.

The questionnaire was created and developed using the Microsoft Forms platform, which allows the creation and sharing of surveys. Thanks to this platform, it has been possible to create a QR code to fill in the questionnaire directly from smartphones. Health workers and users/caregivers accessed the questionnaire by framing the QR code inside the posters placed in the local healthcare facilities. This allowed the user to fill in the questionnaire faster and with certainty of data registration while respecting their privacy, since it was completely anonymous.


The qualitative analysis presented here is based on data emerged from a thematic comparison between the answers of the questionnaire addressed to users (reported in the previously published study “Humanisation of the health worker-user relationship and improvement of the quality of services” (Diamare et al. 2021)), with those of the questionnaire presented in this paper, adapted to be administered to health workers.

  1. On the first item “How carefully and effectively do you think you participated in the care of your patients?” 57% of the respondents report that they participated very carefully and 15% “not at all”. Only 28% report having “moderately” participated. The majority is therefore satisfied with the job done with their patients, despite the difficulties and limitations due to the SARS-Covid 19 pandemic.
Tab. 1
  • In response to the question: “Do you believe that you provided clear and adequate information about the patient’s state of health and treatment during the period of hospitalization?” a large proportion of healthcare professionals claim to have provided the patient with clear and adequate information about the patient’s state of health and treatment in all facilities: 44% felt that they were very satisfied, 10% “not at all” satisfied with the clarity and 41% “moderately” satisfied.
Tab. 2
  • Concerning the question “Do you think that being “empathetic” is important for a doctor/health worker in relation to his patients?” all respondents considered empathy to be a pivotal factor in their profession. Specifically to the question “If yes, what level of empathy (from 1 “not at all” to 5 “plenty”) do you feel has been achieved in the relationship with your patients with whom you have had contact during the pandemic?” the practitioners find a good level of empathy with their patients. In fact, the majority of healthcare workers consider that a high level of empathy was achieved in their relationship with their patients, as can be seen from the graph in Tab. 3.
Tab. 3

At the same time, patients/caregivers in the majority of cases perceive this relationship as positive, even though a small percentage (10% “extremely” and 3.3% “moderately”) report a low level of empathy with caregivers (Diamare S. et al., 2021)

  • The question “Do you consider eye contact to be important in patient care during the pandemic period?” shows that almost all of the practitioners interviewed considered eye contact with patients to be important.
Tab. 4

Only a small percentage does not attach the same importance (7% “moderately”, 3% “a little”) to eye contact.

Also for 86.6% of patients/caregivers the eyes are an important means of communication.

  • Concerning the question “During the treatment period, how much were you able to emotionally support your patients/caregivers despite the limitations imposed by COVID-19?” more than half of the caregivers believe that they “moderately” (54%), “very much” (30%) or “extremely” (5%) offered their emotional closeness. However, there is a small percentage (11%) who feel that they have not been able to give their support, as can be seen from the percentages in the following graph (Tab. 5).
Tab. 5

At the same time, as shown in the previous Pilot Study, most of the patients/caregivers interviewed felt supported by the caregivers (“very much” 26.7% and “extremely” 53.3%).

  • When asked “How much do you think that your state of mind influences your relationship with patients?” there is a certain heterogeneity in the thinking of the health workers (Tab. 6): 7% of the interviewed health workers state that their state of mind does not influence their relationship with the patient at all and 25% that it influences it “a little”; whereas 26% think that their state of mind is “moderately” influential on the patient, 31% that it influences them “very much” and 11% “extremely”.
Tab. 6
  • From the question “How well did you feel understood by your patients/caregivers with regard to the difficulties you faced in dealing with the Covid-19 pandemic?
Tab. 7

As the percentages below and the graph (Tab. 7) show, only 17% felt “very much” and 8% “extremely” understood by their patients/caregivers.

44% of the respondents felt “moderately” understood by their patients.

But the 31% who felt “a little” understood gives us an indication of an emerging critical issue, on which corrective actions need to be articulated.


Analyzing the results relating to the Health Care Workers’ perception of the quality of their communication and relationship with their patients, it is possible to note that, despite the difficulties and restrictions imposed by the pandemic emergency, the workers believe that they managed to take care of their patients carefully and effectively, and that they provided clear and exhaustive information, both on their state of health and on the methods of care. Bearing in mind the impact of the pandemic and the difficult situation that many patients faced, emotional support from healthcare professionals is of paramount importance in dealing with this difficult time. In fact, one must not only consider the physical damage, but also the emotional impact that an illness has on the subject’s inner world; therefore, good communication between health workers and patients/caregivers offers a containment of suffering and emotional distress.

In line with what has been said so far, from the analysis of the answers it emerges that the healthcare personnel considers empathy as an essential tool of the work, strongly supported by the gaze that represents a vehicle of immediate understanding of the other. In this regard, an interesting point to be adequately investigated with further scientific studies is to understand whether the gaze assumes a greater weight in interpersonal relationships.

All health professions assume the role of ‘communicator and translator’ not only of information but also of feelings. But it is interesting to note that some practitioners believe that their state of mind does not have too much relevance on the relationship with the patient/caregiver.

An even minimal measure of the interviewed users would have wished for more empathy in the relationship. Therefore, what needs to be further investigated is the patient’s and caregiver’s view of the degree of understanding, closeness and empathy they feel they have received from the healthcare personnel, in order to have more elements available on the importance of the caregivers’ state of mind  in the relationship.

Not all workers, on the other hand, perceived understanding from patients and their caregivers with regard to the practical and emotional difficulties caused by the emergency, despite the fact that they, on the other hand, felt they had offered support and understanding to them. During the pandemic period, healthcare workers carried out their work in exceptionally difficult conditions, and understanding the emotional state of those working in healthcare facilities became a fundamental step in dealing with states of emergency while avoiding the risk of unwarranted aggression.

However, it is possible to infer from both of the assessments examined the strong spirit of adaptation that health workers and patients/caregivers demonstrated during the health emergency. There’s a certain congruence of the opinions of patients/caregivers and carers concerning the quality of the relationship, which represented perhaps one of the most important resources in the difficulties management.

These results were fundamental for the implementation of online communities of salutogenesis addressed both to practitioners and patients/caregivers such as the “Virtual Wellness Lounges” and of contents developed in the training courses “Health Advocacy and Psycho-body Empowerment” and in programmes aimed at conscious digitalisation such as “Enterprise 2.0 for Quality Improvement“.

In emergency situations, communicative exchange is essential because the feeling of participation increases resilience. Therefore, paths of humanisation and improved communication are also a priority in order to improve the quality of care in times of crisis in order to get closer to each other and to respond appropriately also to the submerged needs of the users.

The way of communicating with the patient/caregiver does not only depend on the scientific and technical level, but also on his/her ability to empathically ‘enter’ into contact with the patient and his/her body expressions. Mimicry is undoubtedly a useful tool, since it arouses in the interlocutor a feeling of “similarity”, and this opens up good communication channels.

An important aspect, in the social context in which the questionnaire was administered, is to allow a reflection on perceived sadness and distress, as a “natural” reaction to an extraordinary event that has affected both patients/caregivers and operators and that, therefore, needs to be welcomed by specialized personnel trained in humanisation processes. That is to say, we are not only emphasizing the importance of ‘clinically treating’ people affected by overt reactive syndromes, but of taking care of a silent distress that runs through us, makes us unhappy and harms the wellbeing of the individual and of the community.


Analyzing the results it was found that, despite the important communication restrictions and the lack of contact, the quality of the caregiver-patient relationship is perceived positively in most cases. An interesting understanding was also established on the caregivers’ side regarding the difficulties encountered by healthcare workers during the COVID-19 pandemic in the management of patients and their families.

It can be said, in the end, that the health emergency, while amplifying negative emotions, generated deep trust in health personnel.

Regarding the aspects that could be further investigated by means of Customer Satisfaction surveys in healthcare, it’s interesting to introduce elements to assess the effectiveness of communication and relations: indicators of empathy, non-verbal communication, attention to the patients and caregivers’ state of mind, and to increase the resources allocated to such projects.


Bellocchio Olimpia (P.O. Ospedale del Mare), Scognamiglio Mariarca (P.O. Loreto Nuovo), Mario Sabatino (D.S. 25), Alberta Mariniello (P.O. Pellegrini) for the dissemination of questionnaires.


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Geopolitical Security Of University Staff In Teaching / Research Activities Abroad



Vanacore Giuseppe1, Niola Giovanni2, Ruotolo Fabrizio3

1Head of the Prevention and Protection Office at the Federico II University of Naples
2Prevention and Protection Service Officer at the First Prevention and Protection Office - Federico II University of Naples
3Prevention Technician Prevention Technician c / o ASL Napoli 1 Centro - Supervisory Inspector


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


This report aims to address the problem of occupational safety for people, whether structured or not, belonging to universities, engaged in scientific, research or study activities in the context of scenarios exposed to possible geopolitical risks.

The term geopolitics refers to the science that analyzes the relationships between geographical factors and political choices, which are constantly evolving due to new world structures, emerging problems affecting different areas of the world, dynamics capable of redesigning geopolitical realities by creating imbalances and instability.

Globalization, although it has reduced physical distances, has not been able to neutralize the cultural, ethnic, religious and political divisions that require a continuous process of assessment and monitoring of the risks to which travelers may be exposed so: plan activities; schedule an immediate return; identify trusted people of reference and support once you reach the foreign location; communicating in advance one’s movements and having a knowledge of the cultural and anthropological factors of the social fabric of the host country become factors that, inevitably, must be taken into account in order to avoid unexpected consequences,

At the same time, international scientific research, which represents one of the key factors for the growth and development of society in the medium-long term, by virtue of its potential ability to provide innovation through technological application, has now assumed a leading role for the activity of researchers; the frequent exchanges of scholars of different nationalities make it possible to pursue collaborative projects that determine growth in the scientific and technological fields. More generally, international exchanges are an opportunity for intercultural, social and linguistic learning that determine, for our country, a more competitive and attractive presence at the international level of all Italian research and higher education institutions as a qualified contribution to construction. of the EU and non-EU scientific and technological space

In light of the news reports of the disappearance of Erasmus students and researchers engaged in research activities abroad, the need has emerged to combine the growth of international exchanges with that of preparing suitable security measures for personnel who carry out research or studies. in foreign locations

Therefore, knowledge of geopolitical risks is essential for the purposes of the correct assessment of the factors that may influence the “safety” of researchers whether they belong to employees or students, doctoral students, etc. .. The preventive analysis of these factors allows, with a sufficient degree of approximation, to give an assessment of the different levels of risk.

Methodology And Materials

The topic is addressed in the light of the obligation provided for by art. 28 of Legislative Decree 81/08 which requires the employer to assess all risks to the health and safety of workers. If the assessment of the risks ordinarily attributable to one’s activities is taken for granted, the assessment of those dependent on the danger deriving from socio-political, health and economic scenarios is not taken for granted, although they can cause accidents, even lethal ones, and the onset of serious professional diseases

Therefore, a procedure has been drawn up which, starting from the elaboration of a regulation governing the management of the safety of workers engaged in research activities in contexts where the incidence of specific geopolitical factors is found, leads to a methodology that allows first identify the factors that can affect the psycho-physical integrity of staff abroad. The procedure, in addition to focusing on the owners and with delegated functions, defines the steps from the preliminary monitoring phase of these factors to the administration of a specific questionnaire upon return from abroad. In the preliminary phase of risk assessment, all the information and training tools offered by new technologies and by governmental, international and non-governmental institutions will be used

To this end, the Italian Government offers travelers numerous travel support and assistance tools in relation to the health situation, the presence of embassies and consulates, information on public order, crime, terrorism and mobility. This information is integrated with that from international and non-governmental organizations that provide information of various kinds, from health and humanitarian to those on political and financial stability. In addition, the Farnesina offers a specific collaboration service dedicated to Universities and Research Centers, which have a greater vocation for internationalization, with the support of the skills and experience gained by the Crisis Unit.

Therefore, taking into account the importance of the preliminary monitoring of geopolitical risks and the variability of cognitive sources, the preparation of a correct procedural procedure will allow for an assessment of the risks that can capture the actual and concrete criticalities of the host country.

The idea of ​​adopting a regulation also goes to remedy a gap found in the monitoring process of geopolitical risks that concerns the subject “responsible for the purposes of Legislative Decree 81/08”, since, for this problem there is no exact discipline starting from the identification of the subject, in the university system, required to supervise the assessment of the related risks and the possible adoption of corrective and precautionary measures. This criticality is largely dependent on the freedom of research and teaching recognized to teachers, which allows for ample autonomy and independence in planning activities abroad.

Therefore, following an analysis of the current administrative-accounting authorization processes adopted in the Fridericiano University for missions abroad, which generally end with an authorization for expenditure, a geopolitical risk monitoring procedure was added.

The procedure requires that the teacher promoting the activity abroad or the university tutor, who supports the student in the related activity, in producing the request for a foreign mission / trip to obtain the authorization for expenditure, completes the preliminary risk monitoring form in which in addition to their personal and career data indicates:

  • Place of the mission / trip
  • The type of accommodation of the stay
  • Length of stay
  • Purpose of the activity
  • Possible frequency with which the same location is chosen
  • Level of cultural linguistic knowledge of the country / locality

Subsequently, the Employer, or his / her delegate, with the support of the RSPP together with the Tutor / supervisor will evaluate this form by making a preliminary estimate of the risks including contextual factors (social / economic crises, conflicts, crime, sanitary conditions, etc. ) and subjective factors (knowledge of the country, traveler’s health suitability, estimate of the risks at the host facility, degree of linguistic-cultural knowledge of the country of destination, etc.) reporting in form B the preliminary indications on the estimated risk level

This first monitoring of potential geopolitical risks will end with a final opinion from the Director of the Department in which he can indicate any precautions that the applicant for the mission will have to take before and / or during the mission abroad (form C).

Considering that the preferred countries for the aforementioned missions / trips are often identified as they are already recipients of other missions due to the presence of cultural and scientific collaboration agreements with European and non-European universities, in order to allow the establishment of a database containing the ” feed back ”of travelers upon their return, a specific questionnaire was drawn up to be administered upon return from the mission with a request for information on the main risk factors found in the country visited (form D). These elements will constitute a database that will allow both to validate the results of the preliminary risk monitoring and to integrate the information already acquired from institutional and non-institutional sources with that coming from the direct experience of the researchers concerned. The procedure thus set up will allow, when fully operational, to obtain an updated mapping of the risks present in a specific area.

Everything is accompanied by a short “traveler’s manual” in which information is provided on the common behaviors to observe for those who intend to spend a period of study abroad. It was divided into three chapters (territorial and logistical risk, cultural and language differences, crime and social order) and a final part.

Results And Discussion

In the wake of the protest movements born in 2016 following the murder of Giulio Regeni, an Italian doctoral student, some universities have promoted information and training initiatives to identify the most suitable measures for the protection of students / doctoral students / postdocs / researchers / professors who have to go to work in areas at geopolitical risk. Risk communication and the fight against disinformation were the objectives of our working group. Therefore, starting from an analysis of the data of the missions carried out in the last 5 years by staff belonging to a Department of Humanities of the Federico II, we have found that over the years there has been a progressive increase in international exchanges by the staff of the ‘University which also involved the non-employed, precarious and fixed-term one. However, this trend had a turnaround in 2020 due to the Covid19 pandemic. We also found that the share of missions carried out outside the EU was significant, which, in relation to the geopolitical and health context, were indicated as places with greater geopolitical risk. Therefore, we simulated a geopolitical risk assessment by adopting the designed procedure, finding the effectiveness of the proposed methodology in identifying potential risk areas.

Tab. 1

These data will allow us to protect workers abroad by providing them with information on the most suitable preventive measures and to the limit to advise against the mission. The results of the geopolitical risk assessment procedure, collected in this way, will integrate the DVR pursuant to art. 28 of Legislative Decree 81/08.


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Effectiveness Of Workplace Health Promotion In Protecting Against COVID Risk



Tobia Loreta1, Provvidenti Luca1, Mancinelli Vittorio1, Guerrini Luca1, Fiasca Fabiana1, Fabiani Leila1

1Dept. of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


The emergence of the COVID-19 pandemic has had health, social and psychological impacts on workers worldwide (1, 2,3). The Italian National Institute for Insurance against Labour Accidents (INAIL) has developed a classification system for companies (4) at high, medium and low Covid risk based on exposure probability, proximity index and aggregation factor.  Exposure measures the probability to be in contact with potential sources of infection during work activities (e.g., health sector, hazardous waste management, research laboratories). Proximity measures the intrinsic features of work activity that cannot guarantee an adequate social distancing (e.g., specific tasks such as in assembly lines) for part or for most of the working time. Aggregation measures work activities that may determine contacts with people other than workmates (e.g., restaurants, retail, entertainment, hospitality, education).

Educational activities have been classified as medium-low risk of transmitting Sars-CoV-2.

Every company had to implement a safety and prevention protocol against Covid-19 in the workplace. The document is based on the shared protocol of April 2020, as amended and supplemented on 6 April 2021, agreed by the employers’ associations and the trade unions for the regulation of measures to contrast and contain the spread of the Covid-19 virus in workplaces (5). In line with such enhanced measures, the University of L’Aquila established a COVID Committee composed of the Employer, the Health and Safety Officer, the Workers’ Health and Safety Representatives, and the occupational health physicians. Various countermeasures were implemented to mitigate the risk of spreading the virus, such as transitioning to virtual instruction, remote working, reduced capacity within the offices and the laboratories at any one time, social distancing, use of face masks, hygienic measures, access controls, contact tracing of possible contacts of confirmed cases of COVID, and monitoring of the mandatory quarantine requirements set forth by the health authority.

In relation to the University’s health promotion programme that has been in place for 5 years, this study aimed at investigating the relationship between the COVID-19 preventive measures and the occupational risk perception and the adoption of more protective health behaviours to mitigate the spread of SARS-COV-2.

Methods and materials

The University Health Care System managed health surveillance with proactive attitude serving as a reference point (also through a helpline) for the identification of persons at risk (contact-tracing), for the recommendation of molecular swab tests, for monitoring the mandatory quarantine and/or isolation requirements, for advising the arrangement of occupational health appointments before returning to work from sick leave, and for the management of vulnerable subjects through a remote work or remote education order.

The survey was conducted from July 2020 to January 2021, as part of the University’s worksite Health Promotion programme, called “Ateneo in salute” (i.e., good health and well-being in the University) that has been in place for five years. The voluntary based programme aims at raising awareness among workers on health promotion measures to prevent the risk of metabolic, cardiovascular diseases (Cuore project – Italian National Health Institute), and of other chronic conditions.

The programme involved the collection of data related to the medical history and lifestyle practices of the respondents, a medical examination along with health counselling and follow-up visits, free access to blood and urine tests to detect any metabolic and blood lipids diseases, electrocardiogram, and promotion of adherence to screening and vaccination campaigns. The collected data were added to a database that was subsequently complemented with the survey questionnaire on COVID-19 risk perception.

The survey used an online questionnaire (Microsoft Form) that was sent through email by the University Health Care System to all the domain users.

The questionnaire was designed to collect data on specific medical conditions in relation to Covid-19: symptoms, any history of previous positive molecular nasopharyngeal test or antigen test, any mandatory quarantine or isolation measures. It assessed the pandemic-related risk perception with responses based on a 1-10 scale, with 10 being the highest perceived risk, the individual preventive measures such as hand hygiene, the use of PPE, and of social distancing behaviours. Moreover, the questionnaire aimed to assess the willingness to accept a COVID-19 vaccine if made available.

The merging of the database of Ateneo in Salute with the responses to the questionnaire has generated a complete dataset of 314 records concerning the university employees, including lecturers and technical/administrative staff (137 M and 177 F) divided by age group and role, as reported in Tables 1 and 2.

Age groupNumber of employeesEmployees in %
<=30 years227
30 > x <= 40 years4714,9
40 > x <= 50 years6320
50 > x <= 60 years11536,6
>60 years4915,7
Tab 1 – division by age group of the employees who took part in the study

Indirectly employed personnel (Residents, PhD Students, Interns)59
Technical/administrative staff131
Tab 2 – division by role of the employees who took part in the study

The statistical analysis examined the frequency measures, the measures of central tendency and the measures of association between the variables. The multivariate logistic regression model was used to determine the association between the variables. The significance associated to the measures was assessed using the Student’s t-test, the Chi-square test, the Fisher exact test, and the Wilcoxon test.

Based on the mean score (7.11±2.26) assigned to the perceived risk for COVID-19 infection, the sample was stratified in two groups: medium low score (1-7) vs high score (8-10). The discrete and nominal variables were expressed as absolute and percentage frequencies, and the difference between the two groups was assessed using the Chi-square test or the Fisher exact test, as appropriate. The continuous variables were reported as mean values to determine the standard deviation, the difference between the two groups was assessed using the independent samples t-test. Where statistical significance was reported, the variables were included into a multivariate logistic regression model to detect the independent factors associated to a higher COVID-19 risk perception. A backward-stepwise selection was performed determined by AIC (Akaike Information Criterion) to select the best multivariate model. The statistical analysis was carried out using STATA/IC statistical software package version 15.1. The chosen level of significance was <0.05.

Results and discussion

Among the 314 respondents, 31% reported undergoing a molecular/PCR test and 49% undergoing an antigen test (Table 3). These percentages are to be correlated to the intensive engagement interventions by the University Health Care System to spread awareness regarding the COVID risk factors among the university employees.

No workplace COVID-19 clusters were detected among the university employees.

Tab. 3 – Comparison of the COVID-19 prevention measures
* χ2 test
**Fisher’s exact test

Participants assessed their perceived COVID-19 infection risk on a scale from 1 to 10 (mean 7.11±2.26).

Average age is higher in the group that reported a greater perceived risk for COVID-19 (52.05±10.98 vs 46.73±11.26, p<0.001). The respondents who showed a high-risk perception also reported undergoing antibody tests (96.86% vs 90.97%, p=0.029) and implementing protective health behaviours and using PPE more frequently than the respondents who reported a medium-low perceived risk for COVID-19 infection (93.08% vs 83.87%, p=0.010). 

The perceived risk for COVID-19 infection increases with age (OR 1.04, IC 95% 1.02 – 1.06, p=0.001) and decreases where a family history of diabetes was reported (OR 0.53, IC 95% 0.28 – 0.99, p=0.049). The respondents who reported a higher perceived risk (8-10) have a personal medical history of cancer (8.23% vs 3.36%, p=0.069), hypertension (16.03% vs 9.40%, p=0.083), or were prescribed at least one drug for the treatment of a chronic condition (37.34% vs 29.53%, p=0.147). The respondents who had a lower perceived risk (1-7) reported a regular alcohol consumption (36.91% vs 26.75%, p=0.056). 

Thus, chronological age results to be a statistically significant factor associated with a higher perceived risk for COVID-19 infection and a greater health concern. Concern and implementation of protective behaviours increase with age. This association reflects the correlation spread by scientific studies and the mass media among the negative effects of the Sars-Cov-2 and age. (6,7,8).

Thus, age and cardiovascular and oncological conditions affect risk perception and the perceived health risks associated with worse prognosis (9). 

The correlation between alcohol consumption and the low-risk perception is interesting. We do not know whether alcohol has a calming effect that reduces risk perception or whether the consumption was related to an initial greater risk perception.

Among the participants in the study, the individual sensitive attitudes leading to greater adherence to prevention and awareness campaigns did not imply different perceived risks for Covid-19 infection. Instead, there is a statistically significant relationship between health promoting and Covid risk perception. In line with the requirements of Italian Legislative Decree No. 81/08, workplace health promotion is an effective tool for raising awareness about health in general and about the Sars Cov 2 risk. In order to assess the effectiveness of the health promotion measures, a comparison with other Italian universities would be useful.


  1. WHO, 2020a. .
  2. L. Dietz, H.F. Patrick, C. David, F. Mark, J.A. Eisen, V.D.W. Kevin, 2019 novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission, M. Systems. 5 (2020), e00245–20.
  3. W. Tan, X. Zhao, X. Ma, A novel coronavirus genome identified in a cluster of pneumonia cases—Wuhan, China 2019–2020, China CDC Weekly 2 (2020) 61–62, https://
  4. Documento tecnico sulla possibile rimodulazione delle misure di contenimento del contagio da SARS-CoV-2 nei luoghi di lavoro e strategie di Prevenzione Aprile 2020 ISBN 978-88-7484-911-5; Sergio Iavicoli, Fabio Boccuni, Giuliana Buresti, Diana Gagliardi, Benedetta Persechino, Bruna Maria Rondinone, Antonio Valenti; www.
  5. Protocollo condiviso di aggiornamento delle misure per il contrasto e il contenimento della diffusione del virus SARS-CoV-2/COVID-19 negli ambienti di lavoro- Accordo sindacale
  6. M. Cristina Polidori, Helmut Sies, Luigi Ferrucci, Thomas Benzing COVID-19 mortality as a fingerprint of biological age Ageing Research Reviews 67 2021 101308.
  7. Abbatecola, A.M., Antonelli-Incalzi, R., 2020. COVID-19 spiraling of frailty in older italian patients. J. Nutr. Health Aging. 1359.
  8. Akbar A.N, Gilrov D W 2020 Aging immunity may esacerbate Covid 2019 Science 369 (6501) 256-257.
  9. Yangyang Chen  , Jiahao Feng  , An Chen  , Jae Eun Lee  , Longtian .Risk perception of COVID-19: A comparative analysis of China and South Korea. International Journal of Disaster Risk Reduction 61 2021 (102373).

Work-Related Stress And Covid 19 Pandemic Stress



Ruotolo Fabrizio1, Fusco Antonio2, Vanacore Giuseppe3, Niola Giovanni4

1Tecnico della Prevenzione - ASL Napoli 1 Centro - Ispettore Vigilanza
2Capo Ufficio Sorveglianza Sanitaria e Gestione Documentale - Università degli Studi di Napoli Federico II
3Capo Ufficio Primo Ufficio Prevenzione e Protezione - Università degli Studi di Napoli Federico II
4Addetto al Servizio Prevenzione e Protezione - Primo Ufficio Prevenzione e Protezione - Università degli Studi di Napoli Federico II


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Since the 1990s, the world of work in Italy has undergone a process of organizational and economic transformation. The changes, underestimating the impact on the well-being of workers, have generated significant discomfort, not exclusively of a material nature, for larger sectors of the working population. Consequently, we found ourselves directly facing the consequences of this discomfort characterized, on the one hand, by forms of work organization pathology and, on the other, by adverse effects on the psycho-physical health of individuals.

The current emergency situation caused by the Covid 19 pandemic represents a stressor both for the organization of work and for the psycho-physical health of individual workers. Pandemic stress is, in fact, a completely new condition, which is leading to an unconventional state of stress, consequent on the one hand to the strong concern of the contagion, on the other to the new working methods also determined by technological progress (eg work. remotely or home working, smart working, teleworking). The activity of the smartworker, in fact, is characterized by different and generally greater responsibilities since remote work or home working is frequently an activity with objectives, often in the absence of the support deriving from belonging to a work group, as is normally the case. occurs in face-to-face activities.

The proposed method of assessing the work-related stress risk, with particular attention to what can be related to the Covid 19 factor, will be even more relevant for the purposes of post-pandemic management, in consideration of the uncertainty that may concern the socio-economic implications in the near future. economic and health care.

Methodology And Materials

The processing of the work was conducted in accordance with Article 28 paragraph 1, Legislative Decree 9 April 2008 no. 81 which provides, in the global context of risk assessment, also that of work-related stress risk, according to the contents of the specific European Agreement of 8 October 2004. Specifically, the work has set out to proceed with a revision of the method prepared for the assessment and management of work-related stress risk, as indicated by the 2010 and 2017 Inail Guidelines.

The procedure for conducting the assessment and management of work-related stress risk is divided into the phases referred to below.

  • Communicative and informative actions: it consists in communicating the employer’s will to proceed with the evaluation, clarifying that the essential element for conducting the evaluation is the participation of all workers, or their representatives, and of the figures of the Company’s Prevention and Protection . Equally essential is identifying the work-related stress risk factors present in the work cycle, potentially capable of causing damage to biopsychic homeostasis.
  • Documentary and objective analysis of work organization: corresponds to the verification phase of all the documentation available in the company being evaluated and the actual situations (company organization chart, work environments, health data, human and instrumental resources management, legal data , Risk Assessment Document, periodic meeting reports).
  • Subjectivity analysis: this involves identifying the homogeneous groups, or workers, to whom the survey checklists are to be administered.
  • Risk assessment: operational phase in which the checklists are administered on which, once collected, the data is evaluated and any further investigations are carried out. From what emerged in this evaluation phase derives the need, or not, to prepare a plan of interventions and corrective actions, and / or any specific training program, and / or also the need to proceed to investigations on identifiable cases individuals and / or collectives through the collaborative support of specialist figures.
  • Monitoring and control: Provides for the indication of the timing of monitoring and control of interventions and corrective actions, as well as the indication of the timing of risk re-evaluation in the presence of organizational changes.

Operationally, the assessment of the work-related stress risk is divided into two phases, as shown below.

  • Phase 1: is conducted by the figures of the Company Prevention and Protection with the consultative participation of the RLS, and reaches the evaluation by administering to the identified homogeneous groups of check-lists built on the dimensions “Sentinel Events, Work Content and Work Context” , taking into consideration the Covid 19 factor. The checklists administered consist of a series of analysis indicators and for each of these three choice situations are identified (optimal, alert, alarm), each with a respective score. In addition, a specific column “NOTES” is included in the check-lists, in which the reasons and rationale for the chosen situation are reported.

Phase 1 is broken down into two sub-phases, listed below.

  • Phase 1a: In this phase, the preliminary assessment is carried out and the check-lists are administered to the homogeneous groups identified. If the overall result of the evaluation is estimated at medium-low, the results of each indicator evaluated are analyzed considering the organizational complexity, the company size and the homogeneous group, with indication of control and monitoring measures.
  • Phase 1b: If the result of the overall assessment and of the individual indicators is estimated to be medium-high, we proceed to the in-depth analysis by analyzing the reasons given for the chosen situations and the ordinary risk elements emerged in the activities (in presence and in home working and smartworking). From this stage, through the administration of specific checklists elaborated according to the emerged risks, collective and individual interviews and focus-groups, proposals for corrective and improvement measures are developed and, where possible, a training program that can have an effective impact on the prevention of any critical issues that have emerged. To conduct this phase, the evaluators can request the support of a special commission, made up of specialist figures (for example psychologists, psychotherapists) and can also decide on the transition to Phase 2.
  • Phase 2: this phase is the exclusive responsibility of the commission which carries out an assessment of individual and / or collective identified cases of high risk, with subsequent identification and implementation of targeted collective and individual psycho-social analysis interventions.

Each identified homogeneous group is given a series of Check-lists on the three assessment areas, consisting of event indicators as shown below:

  • Sentinel Events Area
    • Business Indicators Checklist
  • Job Content Area
    • Check-list of Work Environment Indicators and work equipmentChecklist Indicators Task planningCheck-list Indicators Workloads and work rates
    • Check-list of Working Time Indicators
  • Context Area of ​​Work
    • Check-list Indicators Function and Organizational Culture
    • Checklist Indicators Role within the organization
    • Career Evolution Indicators Checklist
    • Check-list of Decision-Making Autonomy Indicators – Work Control
    • Check-list Indicators Interpersonal relationships at work
    • Covid 19 Employment Indicators Checklist
    • Check-list of Home Work Interface Indicators – Work / Life balance

From the sum of the scores obtained in the three areas examined, the overall risk level is obtained, which is compared with the numerical and descriptive strings for interpreting the risk, as shown below.

  • LOW RISK 25%: The analysis of the indicators does not highlight any particular organizational conditions that can determine the presence of work-related stress, it is advisable to monitor the organization every two years (Phase 1 a).
  • MEDIUM RISK 50%: The analysis of the indicators highlights organizational conditions that can determine the presence of work-related stress. For each condition identified, targeted improvement actions must be adopted. It is advisable to implement a prevention policy and actively involve the competent doctor and the person in charge (Phase 1 b). Monitor the indicators every year.
  • HIGH RISK + 50%: The analysis of the indicators highlights organizational conditions that indicate the presence of work-related stress. An assessment of the workers’ perception of stress must be carried out by involving the competent doctor or other specialized figures (Phase 2). Monitoring of stress conditions and the effectiveness of improvement actions after 6 months.

In addition, the results of the checklists of the three assessment areas identify the level of risk in each area as well as that of each individual indicator, allowing to define, for the specific assessment area or for the specific indicator, a control plan and monitoring and specific corrective and / or improvement actions.

Results And Discussions

With the pandemic, workers have had to redefine their lifestyles and adapt to work differently due to adapt to agile ways of working. This new modality configures a sort of hybrid work for which no guidelines have been defined regarding the aspects that characterize it. This lack is also found in the checklist provided by the INAIL guidelines proposed for the assessment of work-related stress risk.

In fact, the new working methods can highlight critical issues in the “Work Content” area, specifically, in the “Work Environment and Work Equipment” dimension since the workers of the same work context, even of the same group, no longer share the same same work environment. The “Working Hours” dimension could also be different from that of home working, being potentially influenced by the hyperconnection event. It is clear that the stress assessment must take into consideration the risks related to the issue of staying at work (and therefore connected and available) beyond one’s working hours, together with those of worker-technology interaction, a potential factor of techno-stress. ().

In the “Work Context” area, the “interpersonal relationships at work” dimension could be reviewed, which could be revised with the addition of indicators that investigate any changes in the quality of relationships with colleagues / superiors and / or if the the climate of trust previously created has had variations and / or, again, whether the new methods of communication dictated by the pandemic are effective. The “decision-making autonomy-control of work” dimension could be integrated with indicators that assess the quality of work independently and the perceived degree of isolation.

Even in the “Sentinel Events” area it is conceivable that the analysis of these objective data, whose evaluation is expected every three years, will be modified if the work activity is mainly done from home. In fact, it is conceivable that a series of indicators such as “sick leave”, “percentage of absences from work and holidays not taken”, “proceedings and disciplinary sanctions” should be eliminated.

For what has been highlighted, it is necessary to ask whether it is still conceivable to use a single checklist, as provided by the INAIL guidelines, for all types of work and whether the focus should be organized only on homogeneous groups and not on individual workers. In light of this, the assessment methodology proposed through this work seeks to help Employers to be able to carry out an assessment of the work-related stress risk that takes into account the changes deriving from the pandemic, on the one hand to adapt it to the type of work activity, on the other hand to refine the analytical interventions on homogeneous processing groups, up to the single worker in Phase 1b.


  1. European agreement on stress at work of 8 October 2004. (Agreement signed by CES – European trade union; UNICE – “European confindustria”; UEAPME – “European association of crafts and SMEs; CEEP -” European association of publicly owned and general economic).
  2. Interconfederal agreement for the transposition of the European framework agreement on work-related stress concluded on 8 October 2004. 9 June 2008 ? section = activities
  3. Approval of the information necessary for assessing the risk of work-related stress referred to in Article 28, paragraph 1 bis, of Legislative Decree 81 of 9 April 2008, and subsequent amendments. Circ. November 18, 2010 – Ministry of Labor and Social Policies – Directorate General for the Protection of Working Conditions Ministry of Labor – Circular 18/11/2010. Approval of the information necessary for assessing the risk of work-related stress referred to in Article 28, paragraph 1-bis of Legislative Decree 81/08 and subsequent amendments
  4. Inail 2011. Assessment and management of work-related stress risk <https: // – vulnerable-workers / work-related-stress-risk.html>
  5. Inail 2017. The methodology for the assessment and management of work-related stress risk – Manual for use by companies in implementation of Legislative Decree 81/08 and subsequent amendments. <>
  6. Shared protocol regulating measures to combat and contain the spread of the Covid 19 virus in the workplace of 14.03.2020, as integrated on 24.04.2020 and subsequent amendments.
  7. Di Tecco, C. INAIL (2020) – Considerations and research experience on the management of work-related stress risk in relation to the Covid 19 emergency.
  8. Shared protocol for updating the measures to combat and contain the spread of the SARS-CoV-2 / COVID-19 virus in the workplace of 6.04.2021

The Importance And / Or The Need For Environmental Assessments For Environments At Risk During The Pandemic: Types Of Reliefs, Changes In The Use Of Environments Starting With The Risk



Prete Mario1, De Rosa Annalisa2, Basile Maria Rosaria2, Speranza Antonella2, Izzo Luigi2, Finizio Rosaria2

1Degree in Techniques of prevention in the environment and in the workplace), professional consultant at UOC PREVENTION AND PROTECTION ASL NA2 NORD


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Sanitary emergency

The Covid-19 emergency and the need to cope with it have led to a profound restructuring – in a very short time – of the Italian hospital system, entire departments or sectors, in fact, have been reconverted with total reorganization.

This radical change, therefore, inevitably marked major changes in the methodology of carrying out environmental monitoring as well as on the methods of endorsing decisions regarding the conversion of hospitalization environments.

What previously appeared to be standardized actions, have been subjected to a radical revolution in order to also preserve the health of the company’s Prevention Technicians, who, on the front line and in full pandemic, have never stopped accessing in hospitals and especially in the new Covid-19 wards to ensure continuity in monitoring the company prevention and protection system, thus avoiding exposing health workers, who are committed to coping with the significant workload, to further risks.


Planning and management of environmental monitoring

The planning of the planned monitoring and checks was carried out, as a practice, taking into account the frequency and the last control date, or in conjunction with any structural and / or equipment change.

At present, the main parameters monitored in each hospital are:

Monitoring of anesthetic gases

It allows you to check the concentration of anesthetic gases (nitrous oxide and halogenates) during surgery, in order to assess the exposure of healthcare workers, the efficiency of the air handling unit and the correct functioning of the system and devices for anesthesia as they are subject to progressive deterioration of the pneumatic seals;

Circular no. 5/89 of the Ministry of Health. (a) TLV-Ceiling

Microclimatic monitoring

It allows you to check the correct functioning of the controlled contamination ventilation and conditioning system, in order to ensure the correct air changes and the “thermal comfort” of the health workers who work within the operating room;

Presidential Decree n. 37/97, ​​D.G.R. Campania 7301/2001 and Microclimate Guidelines, ventilation and lighting in the workplace (I.S.P.E.S.L. 2006); Guidelines for the definition of safety and hygiene standards in the workplace (I.S.P.E.S.L. 2009) and UNI EN ISO 7730: 2006.

Particle monitoring

It allows you to check the correct functioning of the controlled contamination ventilation and conditioning system, in order to ensure the retention of particulate matter, a potential carrier of microorganisms present in the environment, depending on the ISO class of each individual operating room.

ISPESL 2009 Guidelines

Microbiological monitoring

It allows to check the level of contamination by microorganisms on surfaces and in the air and therefore to evaluate the effectiveness of the sanitization / disinfection protocols adopted, the effectiveness of the air handling unit, compliance with the behavioral procedures by the staff .

UNI EN 13098: 2002; UNI EN ISO 14698: 2004

Chemical Monitoring and Antiblastic Drugs – UMACA

It allows you to check, on the basis of actual use, the methods and quantities used, the level of contamination of chemical agents, paying particular attention to the presence of carcinogens and mutagens.

The checks are carried out on surfaces (floors, handles, work tools), monitoring the presence of tracer drugs such as:

  1. coordination compounds of platinum
  2. 5-Fluorouracil
  3. Cyclophosphamide

Technical Standards of Oncological Galenics (SIFO 2016), Legislative Decree 81/08 and subsequent amendments Title IX chapter I

Legionella Pneumophila monitoring

This monitoring allows to prevent colonization and bacterial multiplication in water distribution, heating and air conditioning systems and reduce the risk of Legionella pneumophila pneumonia in hospitalized people and hospital staff.

Guidelines for the prevention and control of legionellosis

Activities undertaken

The Prevention and Protection Unit of the Napoli 2 Nord ASL, in the face of the radical and necessary change in monitoring due to the Covid-19 emergency, immediately undertook training and training campaigns for personnel dedicated to the activities.

Dressing and undressing, disinfection and sanitization of instrumentation and rescheduling of monitoring times are just some of the initiatives implemented by the U.O.C:

  • The main training and training activity regarding dressing and undressing was carried out through the dissemination of demonstration videos in compliance with the anti-contagion measures provided for by the Prime Minister’s Decree;
  • For the disinfection and sanitization of monitoring equipment (microclimatic station, particle counter, anesthetic gas monitor, sas, bubbler for peracetic acid, sound level meter, accelerometer), the UOC has set up filter areas dedicated to the sanitization of the equipment through the use of the Micro-Defender system.
  • This technique, through aerosolization interventions, allows a highly effective preventive action against all pathogenic microorganisms;
  • Finally, thanks to a great coordination work between UOC and the staff of each single hospital unit, it was necessary to reshape the monitoring times in compliance with the routine activities carried out by the health personnel, thus avoiding interference between the various activities carried out and drastically reducing the contamination risk.


All the above activities were made possible thanks to teamwork and great participation and collaboration on the part of both the Prevention and Protection Unit and the health personnel of the environments being sampled. This meticulous work has ensured that all the personnel dedicated to it have never found any positivity in the course of their work and that all the hospitals in the area have continued to receive support in the field of prevention and protection.

In fact, in full emergency, approximately 360 monitoring of all possible environmental pollutants were guaranteed even in the covid-19 wards, also paying close attention to sensitive departments such as hemodynamics, operating rooms and dialysis.


  1. D.lgs 81/08 e s.m.i ;
  2. D.G.R. Campania 7301/2001 Circolare n. 5/89 del Ministero della Sanità. (a) TLV-Ceiling;
  3. D.P.R. n. 37/97;
  4. Linee Guida Microclima, aerazione e illuminazione nei luoghi di lavoro (I.S.P.E.S.L. 2006);
  5. Linee Guida per la definizione degli standard di Sicurezza e di Igiene del lavoro nel reparto operatorio (I.S.P.E.S.L. 2009);
  6. UNI EN ISO 7730:2006;
  7. UNI EN 13098:2002;
  8. UNI EN ISO 14698:2004;
  9. Standard Tecnici di Galenica Oncologica (SIFO 2016);
  10. Linee Guida per la prevenzione e il controllo della legionellosi

The digitization of construction sites



Piccolo Carmine1, Modestino Raffaella1, Solimene Gianni2

1Inail Uot Avellino
2Centro per la Formazione e Sicurezza in Edilizia della Provincia di Avellino


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


BIM, acronym for Building Information Modeling, is a method of approach to the planning, construction and management of a building that is gaining ground in the world in recent years.

The highly innovative element of the methodology is the possibility to allow the various professional figures involved in the project to collaborate in the creation of the virtual model of the work, each contributing, on the basis of their skills and responsibilities, with the information that concern.

Collaboration, accessibility and interoperability are an important part of the application of this operational methodology. BIM allows to identify in advance any critical issues and errors, and to intervene promptly already in the design phase.

Even if the digitization process has reached the construction sector with a certain delay compared to the other economic sectors, this phenomenon is now inevitable given the spread of digitization techniques that now affect every area of ​​life.

To understand the incidence of this phenomenon in the construction field, it makes no sense to think about the construction site as a generic entity, since there are large, medium, small and micro construction and infrastructure sites, but it is necessary to identify what are the structural invariants on which to reason in order to highlight the integration of information technology in the industry.

In the collective imagination it is easy to associate the digital construction site with places with high levels of automation and robotization, for the increasingly constant presence of SARP Systems (Sistema Aeromobile a Pilotaggio Remoto) for monitoring the progress of the work, sensors for the management of worker safety, smartphones that allow stakeholders to exchange and share information on the construction site. But the true heart of the fourth industrial revolution in the construction sector lies in the “invisible”, that is, in the synchronization of production and decision-making processes, in the ability to digitally manage flows, share the “data” to generate decision-making processes.

Consequently, even the simplest realities can point to high levels of digitization, accelerating a process that has had a slow evolution, perhaps also due to mistrust and cultural blocks typical of the building sector.

The management of the construction site has always been based on a mostly static and documentary approach, however it is evident that the construction site evolves and transforms according to the work to be carried out, leading to the onset of different risks and therefore different prevention measures and protection to be adopted.

Therefore, as regards the aspects of safety management on the construction site, tools that can respond to the dynamism of the activities that follow one another are particularly useful; this goal was achieved by BIM as it introduced another dimension: time. Using this methodology, it is possible to focus attention on particularly sensitive moments, analyze them and understand what the risk factors may be, even more easily evaluating the progress of the work in relation to the programming carried out.

It is possible to cite numerous examples of applications of the technologies for a more efficient management of safety on construction sites:

  • The use of high-precision sensors that measure the pollutants in the air, the noise level and other standard environmental parameters to provide data to artificial intelligence systems capable of offering efficient monitoring of environmental risk in the workplace.
  • The use of sensors and software to control access and monitor worker safety, automate the tracking processes of machines and materials, thus obtaining information automatically.
  • The digitization of information, web platforms and cloud storage that allow the operator on site, through the use of a tablet or smartphone, to quickly connect to the database with the necessary information.
  • The same training and information activity provided for D. Lgs 81/2008 can derive numerous benefits from the application of the Information Tecnology. In this case virtual reality can allow to overcome the limit of a theoretical training that does not contextualize the worker in the space designated for him in relation to his role and therefore to the risks actually present. Training using virtual reality is intended to help workers and technicians familiarize themselves with particularly dangerous areas and situations, since it is carried out within the same construction site where they will work later or for which they will be responsible as personnel for health and safety at work.

From these considerations it is natural to ask at what point is the digitization process of Italian shipyards. Numerous surveys conducted by major associations and organizations highlight the state of the art at national and international level through annual reports; in this work, on the other hand, we wanted to conduct a survey on the local situation, interviewing employers in the province of Avellino.

The legislation governing BIM

In the European scenario, the regulatory cornerstone for the introduction of Building Information Modeling is Directive 2014/24 /EU of the European Parliament and the Council. Introduced in 2014, the legislation obliges EU member states to promote and adapt to BIM for public works by 2016.

Pursuing a strategy aimed at “smart, sustainable and inclusive growth” of the public contracts sector, the Directive considers technology as a necessary tool to achieve this goal.

In Italy, this Directive was implemented with Legislative Decree 50 of 2016, Code of Public Contracts.

With the entry into force of the Code of Contracts and Public Procurement, the BIM methodology also becomes a determining evaluation parameter of the requirements.

The Ministerial Decree n.560 of 2017 (BIM Decree) subsequently sanctions the introduction and mandatory nature of BIM in the public procurement sector, defining the methods, introduction times, methods and specific electronic tools and extending their use to all phases of a work, from planning to management and verification.

Furthermore, a series of definitions are introduced, partly already contained in the Code of public contracts, partly unpublished; in particular, the concept of the data sharing environment is introduced to pursue the objectives of transparency, sharing and traceability. Using digital systems, an environment must be created where all data is produced, collected and shared.

These measures are accompanied by an intense standardization activity that plays an important role in defining the guidelines to be followed in the adoption of this methodology: the UNI 11337 standard.

UNI 11337 regulates the aspects related to the digital management of construction information processes. Specifically, it deals with models, documents and information objects for the development of digitized products and processes. Divided into ten parts each dedicated to specific aspects to be regulated, it is constantly evolving to follow the changes in the process.

The survey at the national level

In recent years, the phenomenon of the digitization of construction sites is a topic of great interest to the scientific community, as the introduction of the BIM methodology in the infrastructure sector has led to a very important cultural change.

To understand the opinion regarding BIM, at national level, it is interesting to analyze the 2020 ASSOBIM report, the association created to promote the dissemination of Building Information Modeling and support the activity of the entire BIM technological chain in Italy and the ” annual survey on the sector of Italian engineering companies, final balance 2020-budget 2021 “of the OICE (Associazione delle Organizzazioni di Ingegneria e Consulenza Tecnico Economica).

The starting point of the 2020 edition of the ASSOBIM BIM Report was the analysis of the degree of knowledge and use of Building Information Modeling and its potential among industry operators. The interviewed sample – largely made up of design firms (over 52% of the sample) and engineering companies (17.1%) – knows and uses the BIM methodology, while a further 40% know it but do not use it or makes partial use of it, and only a marginal number of operators (just over 10%) are unaware of it. The growth in knowledge, skills and use was matched by the data on the degree of awareness of the benefits deriving from the adoption of the BIM methodology in professional practice. Over 80% of the sample – 10% more than in 2019 – are convinced that the adoption of BIM is able to contribute strongly (up to a third less) to the reduction of the initial construction cost and costs relating to the entire life cycle of the building, as well as the reduction (up to 50% less) of the overall time for carrying out the work, from start to completion of the works.

The survey conducted by the OICE, on the other hand, shows that:

86.4% of companies declare that they have made investments in BIM (Building Information Modeling). Investments in BIM were mainly aimed at training (87.4%) and the purchase of software (76.4%).

31.3% of larger companies believe the usefulness of investments in BIM is high, while this percentage drops to 16.3% for smaller companies. At the same time, only 6.3% of larger companies consider the effectiveness of these investments insufficient, while the percentage rises to 20.7% for smaller companies.

Survey methodology in the province of Avellino

The survey on the Avellino area was carried out by integrating the study of the reference framework with the analysis of a questionnaire developed ad hoc to understand the approach to the digitization process of companies in the area.

The questionnaire

The questionnaire was developed in order to provide an overview both on the real integration of technologies and digital processes within construction companies and on the perception of employers towards innovative technologies.

 The questionnaire proposes a series of questions, a total of 18 questions, with multiple choice that provide control tools to assess the actual match between the perception of technologies and their effective integration into the company.

The questions can be grouped into five macro sections:

  • A. Understanding of the type of company, its size and its cultural approach to IT
  • B. Familiarity with new communication technologies and information sharing
  • C. Surveys on the state of use of the software in the company
  • D. Surveys on the status of worker safety management using IT techniques
  • E. Prospects for technological development in the company.


The results are presented below and divided according to the macro-sections identified in the questionnaire.

A. Understanding of the type of company, its size and its cultural approach to IT

The sample analyzed is made up of a total of 37 companies, mainly small businesses (only one company has a number of employees between 51 and 100).

The analysis of the level of availability for innovation and change aimed at understanding any mistrust and cultural blocks offers a very positive data: 57.67% of the interviewees described themselves as open to innovation while adopting a prudent approach, and declares an average age between 41 and 50 years, with some cases, 18.92%, with an age between 61-70 years.

B. Familiarity with new communication technologies and information sharing
Fig. 1 – Question 5 – how to communicate with employees
Fig. 2 – Question 6 – how to communicate with technicians

The second section of the questionnaire, after the initial questions regarding the classification of the sample, shows, Figures 1 and 2, that the primary form of communication with employees, but also with other safety figures, is contact telephone and instant messaging systems, while there is little inclination towards the issue of cloud computing and digital interoperability between the figures involved in the activity. Even the use of specific applications appears to have a very low response (only 4 companies).

C. Surveys on the state of use of the software in the company
Fig. 3 – Question 4 – digital medium used for site management
Fig. 4 – Question 7 – digitally managed activities
Fig. 5 – Question 9 – using BIM

The third section, Figures 3, 4 and 5, describes the type of software used in the management of the construction site to carry out digitized procedures and understand the level of knowledge of the territory of the BIM methodology. It is interesting to note that 3 companies have declared that they do not use any digital support for the registration of attendance and expenses, but use paper to keep track of the following information.

While it is not surprising that over 88% of the interviewees declare that they use software application for the  metric calculation, it is interesting to highlight that almost the 42% keep digital track of the deadlines related to the training of workers in the field of safety at work and 33% of the deadlines of periodic checks of machines and systems.

The data relating to BIM confirm a lack of knowledge and above all use of the BIM methodology; only 4 companies (approximately 12%) used the model in its entirety.

D. Surveys on the status of worker safety management using IT techniques
Fig. 6 – Question 8 – Cloud propensity
Fig. 7 – Question 10 – digitalized management of means of transport
Fig. 8 – Question 12 – use of augmented reality
Fig. 9 – Question 13 – use of 360 degree cameras and SAPR systems
Fig. 10 – Question 14 – use of sensors for environmental risk assessment
Fig. 11 – Question 15 – use of software for risk assessment

As regards the management of worker safety with the support of information technologies, the data obtained must be read, probably, taking into account the small working realities that characterize the area. Almost 50% of respondents say they are willing to invest in the use of the cloud once they have fully understood how it works and the advantages, Figure 6, while the 16,22% of the interviewees declare that no digital support is necessary for the type and size of their business; this information read taking into account the territory also motivates the scarce application of innovative systems of artificial intelligence and augmented reality such as sensors, SARP systems and more.

It is clear that the aspects managed most in digital form are those related to legal obligations, both as regards machines and people.

E. Prospects for technological development in the company
Fig. 12 – Question 16 – reasons for the use of digital tools
Fig. 13 – Question 17 – obstacles to the digitization of the business

The section on future prospects, however, is heartening; there is an awareness that digital technology can improve work activity according to 65% of respondents, Figure 12, and there is a statement of poor knowledge of the applicability of information technologies in the construction sector, 28.57%, Figure 13, given that it manages to motivate the slow process of digitization in the sector. However, the figure of 25.71%, representing the percentage of interviewees who declares “work culture and deep-rooted traditions” as the greatest impediment to the digitization process, a reason perhaps to be considered taking into account the average age of the employers.

As for the last answer, in which the interviewee was given the opportunity to express their opinion freely, unfortunately there were not many important observations; on the whole, all of them confirm the importance of technology as a tool for improving construction site management, while few focus on the validity of technological supports to improve worker safety. Specifically, an answer confirms the impression obtained by analyzing the data: “for safety it is more difficult, since the only attention is to keep the documents in order”.


The results of the survey conducted allow us to highlight the real problems that the digitalization process is generating in the construction sector in the province of Avellino. A sector fragmented by skills, little available to integrations and innovations.

The greatest limits perhaps derive from the type of companies operating in the construction sector: small businesses not motivated to invest in information technology to manage simple construction sites.

Another limit not to be overlooked is the lack of specific knowledge and therefore

the importance of the study carried out lies in the acquired awareness of the need to promote technological development in the construction sector and to disseminate the benefits deriving from the use of information technologies for the management of worker safety not only to comply with the provisions of the law but above all to disseminate an innovative safety culture.


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The Pandemic Prepares A Changing Job, A New Risk Assessment



Panico Giovanni1, Romano Anna2, Cangiano Antonia3, Albero Simona4

1Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SIAN/SIP ASL NAPOLI 2 NORD ;
2Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SIP ASL SALERNO
3Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SPSAL ASL SALERNO;
4Infermiera Dipartimento di Prevenzione ASL SALERNO


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


The COVID-19 pandemic, which spread from the first months of 2020, although affecting a purely health aspect of people’s lives, has contributed to speeding up changes in the organization of work that have already been in place for years due to technological evolution , causing a strong acceleration towards other organizational types of work including smart working. When we talk about smart working we think of one of the consequences of the virus, such as surgical masks and social distancing, but in reality it is a new organizational structure based on giving people back flexibility and autonomy in the choice of spaces, times and the tools to be used in exchange for greater responsibility for achieving corporate objectives.

The state of the art

Smart working is defined as a subordinate employment relationship, characterized by the absence of time or space constraints and an organization by objectives, established through an agreement between employee and employer. It is a modality that helps the worker to reconcile the times of life and work and, at the same time, favor the growth of his productivity.

In 2019, in Italy, the percentage of people working from home was 4.8, among the lowest in Europe. Our country was far from the leading Sweden with a percentage of workers equal to 37.8%, but also from European countries such as France 23.1% and Spain 4.8%, or structurally similar such as Germany 12.3%. In April 2020, in full emergency, more than a third (37%) of EU workers appeared to have started working from home and Italy that started from the rear was one of the most participatory countries; smart working workers in March 2020 were over 6.6 million and it is expected that after the pandemic the number will stabilize at 5.3 million.

Advantages and disadvantages

Remote work, albeit over short periods of application, has shown enormous economic and social benefits at various levels.

For workers, this new work organization increases the opportunities for reconciliation in the life-work spheres especially for people with disabilities or with assistance responsibilities and it has been estimated that even a single day a week of remote working can save an average of 40 hours. per year of travel.

For the employer, the application of a well-structured smart working tool can lead to an increase in productivity equal to about 15% per worker, which amounts to 13.7 billion euros in benefits at national level as the workers feel more empowered with an improvement in performance and results and an increase in motivation and satisfaction with their work. Furthermore, by reorganizing the spaces, the company will be able to save on costs related to light, heating, air conditioning, cleaning and consumables to an extent directly proportional to the percentage of Smart working.

The environment would also seem to benefit in the long term with a hypothesized lowering of emissions equal to 135 kg of CO2 per year thanks to the reduction of travel and the redevelopment of extra-urban areas.

But on the other hand, in such a short time of “application” we can already find many disadvantages with repercussions also on the health of the workers: 

  • shifting of connection costs, equipment and adaptation of the premises to the workers to be used for work;
  • lengthening of the working day due to the lack of a clear boundary between work and home which can lead people to work too many hours without the right breaks (overworking), with the risk that they will not be able to return to “normal” ways of working. In fact, it is likely that workers who return to the workplace after a period of isolation have concerns that can cause stress and psychological distress.
  • fragmentation of the workforce and isolation from the organizational and social aspect of the worker as the links between workers can become less close, and the possibility of sharing and insertion into the corporate culture is less. Communication becomes ineffective and slower with difficulties in planning activities, defining priorities and updating workers in real time

Risk and prevention measures

The organizational model of smart working, with which we have been called to confront in this emergency situation, is a model to which the pandemic has only given an acceleration and with which the world of work has to deal with for the present and for the future, especially in relation to the new risk assessment and prevention strategies.

From the first considerations, a difficulty has already been found in the objective assessment of the structural risks to which the worker could be exposed as the employer cannot be aware of all the situations in which the agile worker decides to carry out the own business. In order to be able to manage this aspect without transferring the responsibility for the suitability of the workplace to the worker by means of self-certification in which he is obliged to certify the possession of requisites that he probably does not possess, it could be decided to “contract” the space / premises for the execution of the activity made in compliance with the health and safety aspects by the Employer with the supply of necessary equipment and furnishings and a periodic verification also through digital tools to verify the permanence of the requirements.

Alongside structural risks, however, psychosocial risks that are often treated as a secondary issue require even more attention in this organizational typology of work because it is difficult to objectively talk about issues related to the emotional sphere. Although smart working requires extensive use of digitization, this should not imply estrangement, the isolation of the agile worker who is particularly exposed to hyper-connection, overworking, technological dependence, absence of recovery times, isolation and unclear identification of boundaries between working and non-working spaces and times. These aspects are partially offset by the autonomy in time management. If we try to apply the work-related stress risk assessment according to the INAIL methodology to the organizational typology of smart working, the following can be assumed.

The preliminary stress assessment consists in the detection of objective and verifiable indicators belonging to three categories represented by sentinel events, context factors and content factors.

Sentinel events are alarm bells on dysfunctions and inconsistencies in the organization of work. Remote work would certainly reduce the values ​​relating to accident rates and absence due to illness.

In the content indicators, remote work could have a positive effect on the items relating to the work environment and equipment, working hours and shifts since they would fall within the new organizational autonomy of the worker as well as for the context aspects of work relating to the home-work interface and work / life balance. But some aspects relating to organizational function and culture, work control and interpersonal relationships would certainly have a negative evaluation.

There are no “concrete” prevention measures for psychosocial risks, but it becomes necessary for the employer to intervene with a rational organization of the work model adopted and to help make workers aware of and participate in this new organization of work. Once again the key tool is represented by communication / information and training on the new organizational structure aimed at indicating clearly and unambiguously the objectives to be achieved and the times to be able to do so, study and rational distribution of workloads and in order to avoid the isolation of workers periodic calls or videoconferences where the achievement of the objectives are monitored to contain the levels of stress and avoid the isolation of the worker by encouraging discussion.

Final considerations

 The remodeling of work observed during the health emergency has shifted attention to risks attributable to the psychosocial sphere; this is where the D.L. once again it is called to intervene to safeguard the state of health of workers understood by the WHO as a state of complete psychophysical well-being through a new organization of work that brings the production costs back to the DL and takes into account the need to create frequent moments of confrontation between workers to avoid isolation and encourage aggregation. The taking root of this new form of work will have obvious repercussions both in the workplace on the management of the activity and on the organization of spaces and in the living environments where the times and purposes of travel change in search of a new balance between life. and work-life balance work.


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