*3.3. Intervention Studies*

A total of six studies analyzed the effect of an intervention on nurses' Sense of Coherence. Only two studies observed a significant improvement in the SOC scores [36,37]. In the first study, nurses participated in a modified version of the Mindfulness-Based Stress Reduction (MBSR) program, lasting two weeks. After the intervention, it was observed a significant decrease in GHQ and its subscales (Physical Symptoms, Anxiety/Sleep, Social Activities and Depression), indicating an overall improvement in general health. Furthermore, SOC increase was significant, compared to the control group, as it was the increase in the meaningfulness subscale score, compared to comprehensibility and manageability scores [36].

Sarid et al. investigated the effect of Cognitive-Behavioral Intervention (CBI), comprised of 16 meetings, once a week, on nurses' SOC. At baseline the two groups did not differ in respect to SOC, perceived stress and mood states [37,38]. At T2 (four months after the beginning, upon completion of

the program), nurses of the intervention group scored higher in SOC and vigor scales, whereas reported decreased level of perceived stress and fatigue. Such changes were not reported in the control group.

Nurses in the study conducted by Shimizu participated in an Assertive Training program. Although no significant changes in SOC were reported, the effects of the intervention were appreciable as an improvement in Self-esteem scores in the sample analyzed [39].

Berg 1999 and Pålsson 1996 both investigated the outcomes of systematic clinical supervision strategies on nurses. The two studies did not report significant changes in SOC after the intervention [21,23].

Only one study observed a reduction of mean SOC scores of nurse managers in early years of their supervisory roles, after the participation in a four-month experiential learning-based program [40].

The effect of an IT support project on SOC was considered in one study: no significant within-subject effects for the total SOC scale and meaningfulness subscale was observed both in the group receiving the intervention and the control group. However, IT support improved the perception of psychosocial job satisfaction and the quality of care; in this sense the study showed a significant interaction effect for the family relation factors, close friend relation (LSQ), total SOC scale and meaningfulness subscale [41].

#### **4. Discussion**

The nursing profession is characterized by taking care of patients and their families, it is a factor increasing the mental and emotional burden, and for this reason nurses' Sense of Coherence needs to be strong enough to deal with several stressful working experiences. Among others, most of the strain experienced by nurses derives from heavy workload, unsatisfactory work environment and work conditions, deep emotional involvement in others, organizational structure, lack of resources, inter-professional conflicts and professional uncertainty [21].

The majority of nurses spend more time at work than on their private life and report significantly higher SOC scores for those whose percentages were proportionally lower, and the lowest scores were for nurses with higher percentages of time spent on working activities [2,17].

Nurses face moral distress and feel so powerless because of the management policy of institutions [13]. The crucial role of institutions in cooperating in the hospital management is also correlated to a positive perception of safety, which in turn is correlated with absence of burnout and a strong Sense of Coherence [24].

The raising of SOC and organization environment reduces sickness-absence. Improving comprehensibility by enriching professionalism, recovering meaningfulness and manageability through optimizing work-life balance and social support may also raise SOC.

SOC and social support were found to be significant predictors for all QoL domains. Social support had the most relevant influence on nurses' QoL and is considered as a buffer in the stressful situations of healthcare working environment to help the individuals to cope. Cultivating social support could indeed help the individuals to improve their coping abilities and their general health status [2].

Occupational stress is a major contributing factor to burnout [15]. This correlation is also supported by studies, showing that individuals with high burnout levels are expected to possess poor stress coping abilities, specifically in the manageability dimension of the Sense of Coherence, which was found to be related to emotional exhaustion of burnout [15]. Burnout is defined as a syndrome of emotional exhaustion, depersonalization and decreased sense of self-achievement, unfortunately, occupational burnout affects a considerable proportion of nurses who face daily stress experienced at work [25].

Despite the relative stability of SOC after the third decade, it may be shaped progressively throughout the whole course of someone's life and the GRRs [42], which are mobilized by the Sense of Coherence, arise from the cultural, social and environmental conditions of living, in addition to idiosyncratic factors [43].

This concept could explain why the analysis of the correlation between SOC and individual characteristics (age, sex, marital status and educational background), taken into account only in few studies, yield discordant results.

An interesting point was explored by Kretowicz et al., who correlated positively SOC and educational background: as SOC is considered to have an educational value and the progress in the academic education could elevate it, it is reasonable to think that this relationship could influence task completion in managerial positions [7].

Furthermore, Antonovsky did not exclude a possible influence of negative life events on SOC, especially for those with low or moderate SOC [42]. Starting from this assumption, Hochwälder et al. in two different studies [29,35] have investigated this relationship: no association was found between negative life events and nurses' SOC, however those who experienced a negative life event had initially a weaker SOC, compared to those who did not experience any [35]. This result led the authors to consider a low SOC as a vulnerability factor, rather than considering a high SOC as a protective factor. This finding is in accordance with Antonovsky's assumption that a high SOC could prevent the experience of negative life events, both helping individuals to avoid potential stressors and not allowing them to perceive them invariably as negative [4].

A strong SOC is believed to be related to general well-being [15]. This relationship was confirmed by Miyata et al., who demonstrated in nurses a positive association between SOC and good mental health status and good physical health status [9].

Moreover, nurses working in hospitals reported, compared to the general population, higher burden of general health problems, as well as symptoms of burden, depression and eating disorders symptoms. SOC was found to be the most important predictor for general mental health problems and post-traumatic stress symptoms. SOC could play a crucial role in the development and course of these health issues, by shaping the perception and attitude toward aversive work experiences and stress [30].

The inverse relationship between SOC and health risk and the identification of SOC as a key determinant of sickness absences demonstrates how a poor coping ability, in the presence of powerful stressors, such as advanced career levels, could represent a health risk, due to a decreased ability to cope successfully with the stress. Nevertheless, Ida et al. advanced the possibility that raising SOC and the organization of the environment could produce a positive effect on sickness absences [14].

The inverse correlation between depression and SOC was strong in several studies [26,30,31].

Possession of a strong SOC allowed nurses to better manage occupational stress due to lack of organizational support and job demands, through the choice of appropriate coping strategies [15], to define themselves as thriving, with a positive use of GRRs [1] and to possess a greater self-motivation [32]. Self- motivation was found related to certain specific behavior attitudes (propensity toward physical activity and giving it value in respect to health) and the hypothesis of Langius et al. of a positive relation to SOC was confirmed by their investigation [32].

Only two studies investigated the correlation between anxiety and SOC. Yoshida et al. confronted two groups, divided based on anxiety presence, assessed by an ad hoc questionnaire: no differences were found among the two groups, possibly explained by the initially high SOC possessed by the group at hand [34]. Palsson et al.'s finding indicated that there is an inverse relationship between self-rated pathogenic anxiety and self-rated salutogenic Sense of Coherence [23].

Among the five studies investigating the effects of an intervention on the SOC, only two studies reported significant results. Stress coping strategies improvement, achieved by the MBSR therapy was demonstrated by a significant increase in SOC scores. Moreover, a significant increase in the Meaningfulness subscale of SOC indicated that, through the program, nurses were able to focus their attention on mind and body, allowing them to find meaning in their life and work activities [36].

The effects of CBI were significant in increasing SOC and vigor levels and in decreasing perceived stress and fatigue. CBI aims to raise the personal awareness on possible stress reaction, to learn how to self-talk in anxiety-producing situation, to gain a balance and awareness on perspective stressful events and to facilitate cognitive restructuring of stressful work situations. These intrinsic characteristics of the therapy explain the improvement in nurses' coping ability and the reduction of negative moods [37,38].

The only study reporting a decrease in mean SOC score investigated the changes produced by an experiential learning-based program. This result was explained by the overload experienced by nurse managers in early years of their supervisory roles when discussing their behavior and stressful situation encountered at work. Furthermore, it has been argued that SOC could possibly increase after an initial decrease, which was not evaluated, due to the short-term follow-up performed [40].

The other intervention studies did no show significant changes on SOC, these results are coherent with the initial description of SOC by Antonovsky, for whom SOC tends to remain stable in adulthood under normal circumstances and can be considered as a moderating factor on negative work environment variables [21]. Moreover, also the well-recognized difficulty in obtaining a significant SOC change in respect to high or low baseline is considered a determining factor of SOC stability in these studies [23].

#### **5. Conclusions**

SOC provides a solid theoretical basis for examining the organization of work [32].

Therefore it has been proposed that nursing management could focus on building a healthy work environment, which fosters SOC, rather than concentrating on resolving the effects of stress and its management at individual level [33].

Comprehensibility is improved by a clear view on roles and responsibilities and by open communication channels; sense of manageability is strengthened by appropriate workload and availability of resources [8,22]. Participation in decision making and the perspective of a clear career path are factors improving the sense of meaningfulness [8,33].

We found that SOC was a protective factor for depressive state, burnout, job dissatisfaction among female nurses, but there is no clear correlation with factors such as working experience or position at work. In addition, a higher SOC enhances a good mental and physical health status, acting as a health promoting resource, according to Antonovsky's theory [44,45].

**Author Contributions:** Conceptualization, G.M.M. and M.C.; Methodology, M.C. and S.P.; Formal Analysis, G.M.M. and M.C.; Investigation, E.A. and C.S.; Resources, M.C. and E.A.; Data Curation, S.P.; Writing—Original Draft Preparation, M.C.; Writing—Review & Editing, G.M.M. and M.C.; Visualization, G.M.M.; Supervision, G.M.M.; Project Administration, G.M.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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International Journal of *Environmental Research and Public Health*
