Last April The General Hospital "Agostino Gemelli" has started at its Surgical Theatre an innovative experience of helping communication among the sanitary staff, the patients and their relatives.

This plan joins in a process of communication flows' strengthening inside the General Hospital; on this project the Sanitary Management has concentrated the efforts during last two years.

The families' uncontrollable wave

The need that has inspired this initiative is containing and giving information to the families of patients that undergoes a surgery in the Hospital's Surgery Theatre. Actually the families are "the relatives' uncontrollable wave" that assails the Doctor when he goes out of the surgical rooms to venture on technically called "transit way room"; the same room for the families, instead, seem to be an "uncomfortable and aseptic waiting room".

Though the prescription given to the relatives about waiting the patient in the Ward or in the Emergency Waiting Room, anyway they take them until the "red door" above that the modern and symbolic word (that remind us of Dante) " No Entrance " dominates. At that doorway the relatives' procession stops while the patient is swallowed up by the lay-out of the Surgical Theatre.

During the realization of the New Multi-purpose Technological Surgical Theatre, the affective component, that ethologically starts from the cradle (The Bowlby's Attachment Theory ) probably has been underestimated; this component pushes people near whom they love, especially in a time of pain and danger; then, because of this reason, the families wait near the surgical room for all the time of the surgery. All the people transmit the anxiety and the loss felt, waiting for hours in front of the "Red Door". In fact, when Surgeons and Anaesthetists concentrate their attention on the well-outcome of the surgery, at the same time the emotional dynamics of the families are the understandable and necessary background noise of the surgical phase.

Then the first purpose of the new plan has been to deal with the relational paradox that often comes out in the medical procedure: the attaching a lot of importance to an aspect of the patient with the risk of neglecting meaningfully other ones, important in the same way.

As a whole the Surgical Theatre seems to be a technologically advanced building but in the planning the families', the patients' and the medical staff's affective need and emotional dimension

have been neglected in part. In fact, during this first working year of the Surgical Theatre, some relationship tensions between Surgeons, Anaesthetist and Paramedics have seemed to come out.

Sometimes, while the Surgeons at the end of his shift took alternative way out, the OTAs many times pass through the fateful Door and, against their will, gave partial information about patients within only reach distance, doing inevitably discrimination against the users and nourishing the bewilderment of relatives who didn't know where their patient was.

The 100 faces of anxiety and relief

"You are our own Navarro-Valls!"

When the patient go into the Surgical Theatre, usual procedures start: preparation of the Surgical room, check in , the moving of the patient from his own bed to the operating one, the wait in the anaesthesia room until the beginning of anaesthesia moment sheer; these procedures happen even though the surgery phases will be "quite shorts". After the surgery the patient is gradually woken up and carried to the Recovery Room where he stay for a hour more before leaving the Surgical Theatre. The sanitary and the surgical staff live this time in a rational, totally organized, unsettled and functional way; but at the same time it seems to be endless, empty and painful to the relatives because of lacking of information about a surgery that maybe "would has last for a few hours" but that instead has prolonged itself for a number of reasons.

The request of information often follows statement of dismayed: "my parent went in at 9, please can I know how he is?". The legitimate request has often inside a worried, troubled and excited emotional tone that the stress for an uncomfortable and anxious wait and the lack of further news mainly bring to. The Surgeons who pass through the corridor protect themselves in a understandable and tactful way from the families' wave that all together asks information about patients placing in the 25 surgical rooms. Moreover in the "transit room" there are the parents of both the patients hospitalized in the General Surgery and the ones in Emergency Surgery, in TIPO Unit and in Orthopaedic Surgery.

The relative needs in this situation a holding group that helps to hold and process the anxiety. Even if it is temporary , the relatives' group in the waiting room shares several dimensions: the relationship, the situation , the space and the time of the wait.

Then it seemed necessary to the Sanitary Mangement of the Hospital, to the Surgery Manager (Professor Aurelio Picciocchi) and to Psichiatric Clinic (Professor Pietro Bria ) to give an answer to this need, setting up an operating group - with shifts dislocate during the entirely week - of Apprentice Psychologists and Psychoterapy Trainees who try to find the best way to give information, carry out communication and modulate the anxiety.

It seemed necessary to begin a work of "communicative bridge" to give answer to the parents' request of information. The presence of Psychologists team is born for this aim. We've been gathering some eloquent episodes during this first year of work.

Symbolic was the exclamation of a man who saw the young Psychologist to go in and out by the "red area" to give "private" information to the relatives: curiously he came up and with shyness asked to her which role she had in the Operating Theatre. After receiving the answer, said " I understand! You are our own Navarro-Valls , because your work consists of giving information about our patients ". The flattering comparison is a pleasure but at the same time suggests three reflections:

•  being object of a personalized communication can mean for the families and for the same patient that the hospital institution cares about them.

•  also gives meaning and worth to the work of the Psychologist

•  the frank, implicit comparison between one's patient and the His Holiness - in those months hospitalized to Gemelli General Hospital - lets us to fix our attention on the deep and strong feeling of the all families who wait.

Psychologists as spokespeople

The new experience of the presence of the psychologists in hospital, in the area called surgical Theatre, has started like a trip with a few space-time coordinates but with a lot of ideas and images that immediately began settling a "transitional area" between the inside and the outside, between the body and the mind, the word and the look. Urged by the own personal motivations, full of our and someone else's emotions, we started living in a place at first considered unfamiliar, where the psychologist didn't know well how to put himself. This is the main point: why just "us"? Does our duty consist of letting the information flow from inside to outside and then making easer someone else's work? We felt as a "corridor".

As we really went in that setting, little by little an idea came out: the feeling of "non-enhancement of value" maybe could be explained by the lack of definition about a entirely new experience that we had to set up necessary. We tried to set up on the spot the function of helping communication: we got ourselves into the lack and the empty of the wait, undertaking to do the movers of solitary emotions that asked to be shared and understood. The Psychologist is a spokesperson because he reports and brings to the relative the voice of the patient who's waking up and then testifies the patient's aware presence and well-being

Our aims: to try to carry the emotion, modulating and managing it, and to set up a place for the affections only.

In the Recovery Room

After wearing the green uniform, the Psychologist goes to the recovery room where there is a calm atmosphere; the anaesthetist and the nurse receive us warmly, immersing us into an atmosphere of big collaboration.

We notice the monitor where we can see the different phase of the arranged operations. When the first patients arrive in Recovery Room, immediately the staff starts the routine activities. We see the nurse's facility in receiving the patients with warmth, respect and empathy; at the same time she keeps on monitoring so that makes the setting as "natural", above all in case of the most serious pathology; those things affect us. The observer can see how wide is the nursing staff's emotional and affective ability. The Psychologist can learn a lot of things by the collaboration with these people. Mainly all concerns the non-verbal communication, the physical closeness and the visual contact. As he wake up, the patient's glance seems to have a special intensity and feature: the crossing that glance seems to us like to catch a biography.

Is a pleased thing to the patient, who's waking up, to see the face of who speaks with him, calls his name and gives to him information about his relatives that are waiting outside anxiously.

Two episodes:

•  A man in the waiting room invited the psychologist to bring to his wife, who had just undergone a surgery for tumour, a coloured hat so that she wouldn't has felt uneasy going out.

•  An Egyptian patient, as soon as woken up, looked at the Psychologist with moist eyes and started speaking with nostalgia about Alexandria of Egypt and her wonderful library . Outside nobody was waiting for him.

Does the body or the soul hurt more in the Recovery Room?

Worry about the families and homesickness. The anxiety of the patients waking up

We often see that the patients, waking up from anaesthesia in Recovery Room, are interested in both surgery outcome and worried about the own relatives. Sometimes the matter of homesickness and own family nostalgia seem to prevail over all. They speak a little about the surgery or the last hospitalization. On the contrary comes out the presence, and sometimes the absence, of the own relatives, the wish of informing and reassuring them as though the patient feels themselves as the reason of the families' uneasiness.

In literature there are many studies and patterns of psychological intervention pre- and post- surgery over the patient based on hypothesis that preoperative anxiety influences the coming out both of postoperative maladaptive behaviours and of a delirium more or less lasting .

In the Palese and Conte's research about the perception of anxiety and stress by patients, family members and nurses, comes out that both the family members and the nurses overestimate the patients' anxiety. In particular they are afraid of the outcomes of surgery, the loss of patients' independence, the worry about the pain, the anxiety for the anaesthesia phase. However this anxiety inducing factors can be cut down through adequate strategy of information.

The tale of the " Sleeping Beauty " and the Paediatric Surgical Room

Near to the twelve rooms of the Surgical Theatre, there is a Paediatric Surgical Room where a emphatic and experienced team has thought a path of special accompaniment for the little patients. The experience of the surgery is made easier to the child because of the presence of the parents and of the quality of the environment that is full of happy and funny images of fables .

The paediatric surgical room evokes, particularly, the tale of Rosaspina, the Sleeping Beauty: it narrates that, stung by a spindle, she attended to be woken up again by the kiss of the Prince. " And after the awake of the Princess, the whole Kingdom had party ". The games, the peluche , the drawings, the soap bolls, the armchair and the painted walls, create an attractive and distracting atmosphere for the child; moreover they offer a family place to their parents that are there to take care of their child.

We can underline that this ambience, to be effective fully, needs the collaboration with the parents. They represent the first mental holding of the fears of their child. Frequently this happens in natural way; unfortunately, in other situations, the tension, the anguish or the contraposition among the parents may be prevailing, and the preserving of this atmosphere of holding and taking care of the children by medical operators is put to hard risk. Also in this situation the Psychologist's presence can be a very useful to the mediation of the conflicts, both in the immediate situation and, if is necessary, after the surgery too

Did the sanitary operators appreciate the presence of the Psychologists?

In the Surgical Theatre the activity of the small team of Psychologists don't passes unnoticed. At the beginning, the presence of psychologist only has aroused, in the sanitary operators, curiosity and interest and it has been perceived as "useful" even if hadn't an immediate placing inside the setting of the Surgical Theatre yet.

The Anaesthetists and the Nurses of the Recovery Room asked to the young Psychologist of turn: "What are you doing here?" and also "Does "Gemelli" Hospital pay you for this work?". The answer seems to clear up them and to open, in the relationship, unexpected communicative channels.

The collaboration among different professionalisms is always useful. And the recognition of the mutual competences is the ground of any collaboration. Behind the "Total Quality of the Service" there is the awareness of the need of a "communication" clear and effective. Containing the suffering and the uneasiness, recognizing them and, at the same time, managing them with professionalism and steadiness. For these aims can properly be opportune the collaboration, among the surgeon and an intermediary figure who entrusts with tasks of communication, and also post-communication, about the outcomes of a surgery, above all in the most serious cases.

An appropriate strategy of communication must esteem the emotional aspects of the person and the tolerance to the frustration of That particular patient in That particular circumstance. In some situations we see communications perfectly clear and circumstantial, but that don't take high care of the setting at the same time, and that therefore risk to result inadequate to the situation and the subjects.

The detailed description of an amputation has happened in the fateful " transit area " where the privacy of the communication hasn't been entirely respected. Others parents have been already unintentional spectators of this painful communication even if they have been tried because of hours of stressful wait. At the end of his "communication", the Surgeon, grieved, has gone away with his Assistant and the woman has been started turning pale and after supporting herself to the wall, has slipped down slowly. At once it has become a phenomenon of sharing by the group of the other relatives: they have helped the young wife that has been unprepared to manage that pain. She has been repeating "He is so young, he is a sporting man, who will dare to tell him"

The definition "affective neutrality", that appears in all scholastic books has an utopia: it doesn't exist in nature. The man can't be affectively neutral by nature. Between idealism and cynicism it is necessary to opt for the realism. Among the total involvement and a cold behaviour there is the whole range of affections and antipathies, of solidarity and of separation.

It is tried that there is no correspondence among symptoms and gravity of the illness: the meaning that the illness assumes for each person is not always linear and coherent: it can be expiation, escape, rest, break, desired event or hostile mortification. The closeness and the sharing mitigate the pain of the body and of the soul.

Research plans

The Psychologist is also a clinician, with a sensibility for the observation and the research. Then, our team has been immediately involved in new projects of research and in the already started ones; In collaboration with the Department of Anaesthesia and Resuscitation and of the Paediatric Surgery, different projects of research have been carrying out.

•  The aim of the first one is to pick up cognitive data to develop a psychological intervention addressed to the members of the surgical paediatric staff of the Agostino Gemelli Hospital .

•  The aim of the second one is the evaluation of the anxiety tried by the people in the waiting room during the surgery of their relatives. The research intends to verify the possible diminution of the anxiety because of the work of the psychologists in the Surgical Theatre.

•  The third research intends to check if the presence of the anxiety and the depression in the patient, undergoing a surgery, is able to engrave on the perception of the post-surgical pain.

1) Research on the operators: interaction among the group of the psychologists and the group of the sanitary operators inside the Paediatric Surgical Room

The present research is carried out by Dr Francesca Vasta and by Dr. Raffaella Geraci on impulse of the Department of Clinical Psychology - Full Professor Claudio Neri - of the Faculty of Psychology of the University " La Sapienza " of Rome . The research comes out of the request of the subgroup of paediatric anaesthetists of the Agostino Gemelli General Hospital to understand and to appraise an endemic state of uneasiness in their surgical group.

The purpose of this project is to pick up cognitive data to develop a psychological intervention addressed to the members of the paediatric surgery staff. A preliminary investigation in the same structure has highlighted a situation of working uneasiness regarding the members of the sanitary staff, characterized by high inside conflict and occupational stress: this investigation has sprung the hypothesis of a possible burnout of the operators.

The sanitary staff is composed of 3 paediatric surgeons, 4 specialist in paediatric surgery, 2 paediatric anaesthetists, 5 medical frequenters including 3 paediatricians and 2 anaesthetists, 4 paediatric nurses, 2 nurses employed to the recovery room.

From an organizational point of view, the staff works within a structure, "The Surgical Multipurpose Theatre", that includes all the surgical rooms of Gemelli. Such structure has been operational since February 2004. The new organization has produced a notable saving of economic resources but also a way of work very different from the preceding one.

Particularly, the dynamics of the small working group of the paediatric surgery have been changed. In the former organization, in fact, the surgeon choice the members of the staff and he used to choice always the same operators. Today the staff is constitute through organizational criterions where there is a continuous rotation of the members on the base of the working turns. In the case of the paediatric anaesthesiology staff, for example, it often happens that non paediatric nurses or anaesthetists work in.

Our hypothesis is to verify if the stability of the group's field can be a source of safety for its members and may promote the mutual knowledge and the dialogue among the staff, preventing both the inside conflicts and working uneasiness and therefore burnout. At the beginning we want to observe the staff level of uneasiness/burnout and, in the second step, to investigate the relation among the level of stability of the field's group and burnout.

AIM OF THE INTERVENTION

•  Identification of burnout's level of the Paediatric staff's members.

•  Identification of the possible causes of the burnout through an individual and group survey.

•  The planning and the carrying out of a psychological intervention through experiential activity of group.

2) The waiting of the relatives in the general surgery: a pilot research

Purpose of the research

The aim of the present work is to investigate the levels of state and trait anxiety in a sample of subjects that are waiting for surgery of their relatives. Previous searches have shown as with a simple increase of information communicated by the sanitary staff to the subjects who are in the waiting room, is possible to reduce the anxiety. Our search proposes to verify and to appraise the diminution of the anxiety inside the waiting room of the General Surgeries of Gemelli, in which is set off the service of "psychologists in the Surgical Theatre".

Hypothesis

With the presence of the psychologists' staff the anxiety profile and the stress of relatives in the waiting room it will decrease .

Method

Sample : 150 subjects

Times : about one year

Control group : relatives in the waiting room of the department of the General Surgeries, in absence of the intervention of the psychologists.

The research utilizes two almost-experimental groups, pre-test post-test, chosen to assess the effect of the psychological team on the reduction of the anxiety.

The group A will submit itself to a pre-test; following it, will receive the psychological intervention; finally it will submit itself to the post-test. The pre-test will be carried out when the subjects arrive in the waiting room and it will consist in the administration of the only state's anxiety component of STAI-Y. The post-test, instead, will be carried out after the subjects will have had news of the end of the surgery of their relatives; in the post-test, it will be administered the whole STAI-Y.

The group B will be submitted to the pre-test and the post-test with the same times of the group A, but in absence of the psychological intervention.

Further Developments

If the hypothesis will be confirmed, further studies could focus themselves on more specific variables than the presence or absence of the psychologists in the Surgical Theatre This would help us to plan and to program a more effective psychological intervention on the subjects that are in the waiting room.

3) A study about the correlation among the pre-surgical anxiety and post-surgical pain. Catholic University of "Sacred Heart".

Dr. M. Luciani, Dr. D. Malizia, Dr.L. Cinque, Prof. G. De Cosmo

Purposes of the search

The purpose of this study is to clarify the relation that anxiety has with the perception of the post-operating pain in patients who undergoes an abdominal surgery. The previous literature has already shown as the anxiety is able to increase the perception of the post-operating pain in the subject. Our study wants to appraise the influence of the independent variable anxiety on the dependent variable perception of the post-surgical pain in subjects that have undergone a abdominal surgery. Anxiety will be assessed through the State-Trait Anxiety Inventory (STAI-Y). The perception of the post-operating pain will be assessed, instead, through two psychological scales of pain assessment: The Visual Analogue Scale (VAS) in which the subject has to put, on a segment of the length of 100 mms, the level of perceived pain, paying attention to that the left extremity corresponds at the most perceived pain and the right the absence of pain . The other Scale of evaluation is the Italian Questionnaire of the Pain (QUID) that furnishes a quantitative and qualitative measurement of the pain's perception.

Hypothesis

To the increase of pre-operating anxiety of the subject, the pain's experience increases in the post-operating phase.

Method.

The plan of search contemplates 70 subjects undergoing a thoracic surgery at General Surgery of the UCSC. The criterions of selection of sample will be:

- Age between the 18 and the 65 years

- Acceptance of the informed permission

- Subjects undergone for the first time to abdominal surgery

During the first contact with the service we explain the project of search to the patient and we ask to fill in the form of the informed permission.

In the pre-surgical phase we administer the STAI-Y to the patient. After the surgery the anaesthetist appraises the level of vigilance of the subject at the awakening. We ask to the subject to compile the QUID and the STAY-Y (6 hours after the surgery) and the VAS, according to the predetermined ranges (to the awakening; 1; 2; 6; 12; 24; 36 hours after the surgery). Then we measure the number of boluses released in 36 hours by PCA.

Further Developments

The purpose in a long time term is to plan a protocol of screening and of psychological support to optimize the intervention of anaesthesia and the post-surgical recovery. To carry out psychological interventions that, reducing the perception of anxiety, will be able also to reducing the perception of the pain in the flowing post-surgical.

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