Sense of Coherence and Well-Being in Care Professionals

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1		Francisco González-Sala	--	3430	2022-08-04 10:19:23	\|
2	Format correction	Sirius Huang	Meta information modification	3430	2022-08-05 03:32:50	\| \|
3	No changes	Manuel Martí Vilar	Meta information modification	3430	2023-10-17 04:17:55	\|

This entry is adapted from the peer-reviewed paper 10.3390/healthcare10071347

Job-related stress affects the physical and psychological health of professionals dedicated to care, and consequently affects the effectiveness of the entities for which they work. It is important to determine the relationships between a sense of coherence (SOC) and work stress and well-being perceived by care professionals.

sense of coherence stress job well-being care professionals

1. Introduction

According to the World Health Organization (WHO), work-related stress negatively affects the psychological and physical health of workers and therefore the effectiveness of the entities for which they work ^[1].

Healthcare professionals, as well as other professionals dedicated to care, are considered to be one of the sectors most exposed to high levels of stress, both occasional and sustained ^[2]. Must be understood care professionals in a broad sense, from a biopsychosocial perspective, as those people who promote the health and autonomy of other people and provide a point of support through functional social interaction ^[3]. In Spain, 44.1% of doctors and nurses report living under stress, as reflected in data published by the European Foundation for the Development of Working Conditions ^[4]. Healthcare workers and those engaged in caregiving require a series of tools, competencies, skills, and attitudes to maintain a professional relationship with their patients ^[4].

Aaron Antonovsky, in his 1979 book Health, Stress and Coping, presented the salutogenic model, asking, “What is the origin of health?” The answer to this question was the sense of coherence (SOC), and this question and its answer became the fundamental core of the model ^[5].

The salutogenic model is opposed to the deficit model, and in this sense, it proposes a modification of the concept of health promotion instead of understanding health as a low-risk factor, it proposes that healthy factors be taken into account as those that actively promote health ^[6]. This model rejects the idea that stressors are intrinsically negative, introducing the possibility of healthy consequences of stressors depending on the person’s ability to resolve them ^[7]. Antonovsky ^[6] understood the most accurate conception of reality as a model in which each person, at any given time, is situated somewhere along the health/illness continuum and asked the following question: How can a person, regardless of where he or she is on this continuum, be helped to move toward better health?

To answer the latter question, two fundamental concepts were developed: general resilience resources (GRRs) and SOC ^[7].

GRRs are biological, material, and psychosocial factors that come from one’s own self, from the sociocultural context, and from the physical and natural environment; they make it easier for the individual to perceive his or her life as coherent, structured, and comprehensible, sustaining the individual’s behavior ^[8]. A person can successfully cope with stressors by applying GRRs, thus preventing the tension caused by stressors from transforming into stress ^[5]. These GRRs are prerequisites for the development of SOC ^[9].

The optimal use of GRRs results in a particular way of perceiving life and an ability to successfully manage the infinite number of complex stressors that one has to cope with throughout life. This way of perceiving life that is a common factor to all individuals who optimally apply their GRRs was what Antonovsky called a SOC ^[7]. SOC is understood as a general orientation that involves seeing life as understandable, manageable, and meaningful and having the ability to cope with stressful situations ^[10].

According to Antonovsky ^[6], a person with a strong SOC, when faced with a stressor, will believe that he or she understands the challenge (understandability), will believe that he or she has the resources available to cope (manageability), and will desire and be motivated to cope with the stressor (meaningfulness). In addition, Antonovsky ^[6] proposed that the strength of one’s SOC is a significant factor in facilitating his or her movement toward health.

2. Pathogenic Perspective

This section includes studies whose research focus is centered on diseases, disorders, and the variables associated with them.

2.1. Negative Mood States

Gebrine et al. ^[11] explored how SOC and work values (WVs) impact midwives’ stress and perceived health, finding a significant negative correlation between SOC and work-related stress and a positive correlation between SOC and self-reported health. The results suggested that WVs could be positive mediators of the relationship between stress and health. Sarid et al. ^[12] investigated the effects of cognitive behavioral interventions (CBIs) on nurses’ SOC, perceived stress, and mood states. At baseline, the two groups did not differ with respect to SOC, perceived stress, and mood states; however, after the intervention in the CBI group, statistically significant changes were found in four of the psychological measures: SOC and vigor mood values increased, while perceived stress and fatigue mood values decreased significantly. In contrast, no changes were observed in the control group.

Several articles focused on studying the relationship between SOC and depression. Mackie et al. ^[13] examined SOC as a possible mediator of the relationships between work environment, work stress, and depression, based on the idea that participative work environments have been associated with better mental health. The results suggested that greater exposure to employee participation practices was indirectly associated with lower levels of depression through perceived job stress and SOC.

Kikuchi et al. ^[14] investigated the relationship between depressive status, job stress, and SOC in nurses at a Japanese general hospital, finding that SOC was inversely associated with depressive state, and age correlated positively with SOC, over-commitment and effort-esteem ratio correlated positively with depressive status, with SOC being the variable with the greatest influence on depressive status. This same inverse relationship between depression with respect to SOC, job satisfaction, and life satisfaction is pointed out by Kikuchi, Nakaya et al. ^[15]. Ito et al. ^[16] investigated whether SOC could be a predictor of future depression after years of medical residency. The results showed that the mean SOC was significantly lower in residents with recent depressive symptoms than in residents without depressive symptoms, and weekly work time was also significantly associated with new-onset depressive symptoms.

Reconciling work and family life can be a stress factor in people’s lives. In this sense, Takeuchi and Yamazaki ^[17] point out how high scores in SOC are related to a lower level of conflict between family life and work life, having a greater incidence on the physical and psychological health of nurses. In addition, these authors identify SOC as a damping factor for depression in family–work conflict. In this line, Makabe et al. ^[18] found that among the nurses who presented a greater imbalance between the duration of work and the time for private life, they presented lower job satisfaction and greater health problems. In turn, the group with a balance (50/50) between working hours and private life presents statistically significant higher scores on the SOC with respect to the rest of the groups in which there was a greater proportion of working hours 60/40, 70/30 and 80/20.

2.2. Burnout

Gilbar ^[19] noted that social workers with a strong SOC experienced less burnout due to a tendency to identify the nature of the stressor confronted and select appropriate resources for the given situation. A possible explanation for the results could be that these workers faced professional demands as challenges worthy of investment and management and felt more fulfilled. Levert et al. ^[20] assessed burnout and different work environment factors in a group of nurses to determine the role of SOC in the relationship between burnout and work environment. Significant positive correlations were found for emotional exhaustion and depersonalization with SOC as well as with all work environment factors; however, personal accomplishment showed very low scores and did not correlate with SOC. In the same vein, Galletta et al. ^[21] investigated the relationship between SOC and burnout in Italian speech-language pathologists, finding that speech-language pathologists with low SOC showed significantly higher burnout scores. Kawamura ^[22] found similar results with respect to a sample of attending physicians in Japan, such that lower scores on the SOC, being female, working more hours, and having fewer years of experience are related to greater burnout.

Nordang et al. ^[23] studied the relationship between burnout and factors such as SOC and work experience in nurses during a period of reorganizations and downsizing. The results showed a rapid and significant development of burnout in nurses with extensive experience and a significant association between burnout and low SOC scores. The most likely explanation for burnout was the stress caused by reorganizations, and low SOC scores on the first measurement may have been a risk factor. Vifladt et al. ^[24] studied the associations between nurses’ perception of patient safety culture, burnout, and SOC in restructured and nonrestructured intensive care units (ICUs). A positive safety culture was significantly associated with a low burnout score and strong SOC; on the other hand, restructurings were negatively associated with safety culture; however, there were no significant differences in burnout and SOC in nurses in restructured and nonrestructured ICUs. Yam and Shiu ^[25] in a sample of intensive care nurses point out how SOC is a protective factor in order to buffer the stress associated with the workplace as well as the level of stress in life.

Cilliers ^[26] includes within the salutogenic model aspects such as the sense of coherence, self-control, and resistance to stress, finding an inverse relationship between these variables and the factors of burnout—emotional exhaustion, depersonalization, and personal accomplishment, although he points out that within the salutogenic paradise, other variables must be included, such as emotional intelligence or resilience, among others. In turn, high scores on the SOC are related to greater personal fulfillment, while low scores on the SOC are related to higher levels of burnout, if the factors emotional exhaustion and depersonalization are taken into account. These same results are found by Tselabis et al. ^[27] in hospital nurses in Greece and by van der Colff and Rothmann ^[28] in a sample of nurses in South Africa. In addition, in this last study, there is a negative relationship between SOC and work stress and a positive relationship with work commitment and coping strategies.

Three articles examined the effects of personality traits and SOC on burnout in different health professions students. Skodova and Lajciakov ^[29] studied personality factors and the effect of psychosocial training on burnout syndrome in undergraduate health care profession students. After the completion of psychosocial training, the degree of burnout in the experimental group significantly decreased, and their SOC increased; there was no change in the control group. Skodova et al. ^[30] examined the effect of type D personality and other personality traits (resilience and SOC) on engagement and burnout. They found positive correlations between burnout and the negative affectivity subscale but not with the social inhibition subscale; on the other hand, SOC and resilience correlated negatively with burnout and positively with engagement.

Škodová and Bánovčinová ^[31] investigated the associations among type D personality components (negative affectivity and social inhibition), SOC and resilience. The results showed that the negative affectivity subscale was a significant personality predictor of resilience and SOC and that students with high levels of type D characteristics had significantly lower levels of resilience and SOC.

2.3. Posttraumatic Stress Disorder and Secondary Traumatic Stress

Jonsson et al. ^[32] investigated the prevalence of PTSD among Swedish ambulance personnel and whether SOC was related to the consequences of traumatic stress. The results showed a high prevalence of PTSD symptoms and indicated that lower SOC predicted PTSD. Schäfer et al. ^[33] investigated the impact of SOC, resilience, and internal locus of control (LOC) in an ICU to identify factors that decreased the risk of psychopathological symptoms. Nurses showed significantly higher PTSD scores than physicians; however, there were no differences between these groups for SOC, resilience, and LOC. On the other hand, SOC was found to be the most important correlate of both general mental health problems and PTSD symptoms.

Professionals working in juvenile facilities may be affected by PTSD and SOC, as they are exposed to threatening situations at work and hear about the traumatic life events of the children in their care ^[34]. These professionals may suffer compassion fatigue (CF), which is composed of burnout and secondary traumatic stress (STS), or feel compassion satisfaction (CS), which refers to the feeling of professional fulfillment derived from helping others ^[35]. Zerach’s ^[35] study assessed the CF and CS of Israeli juvenile center workers (RCWs) compared to educational school workers (BSWs), as well as possible buffers related to attachment orientation, spirituality, and SOC. The research showed significant differences between RCWs and BSWs in CS but not in CF; there were also no significant differences in avoidant attachment, spirituality, or SOC. SOC and spirituality were negatively associated with STS and burnout and positively associated with CS.

Steinlin et al. ^[34] investigated the incidence of PTSD and PTS, as well as burnout symptoms among workers in a residential child and youth center, in addition to assessing the predictive value of SOC, self-care, and job satisfaction. Most of the workers reported having suffered a situation of threat or aggression, and half of them had symptoms of helplessness or fear after the event; with respect to STS, two-thirds reported feeling shocked after hearing traumatic experiences of the child. On the other hand, the authors found that higher SOC was associated with fewer symptoms of PTSD, STS, and burnout those work-related factors (rest, time to eat or use the bathroom, and saying “no”) were associated with fewer symptoms of burnout and PTSD; and that physical self-care factors (regular exercise, balanced nutrition, and time in nature) were associated with fewer symptoms of STS and burnout.

Two studies investigated the relationship between SOC and war trauma in Palestinian health workers. Veronese and Pepe ^[36] investigated whether SOC mediated the relationships between traumatic events and anxiety, social dysfunction, and loss of confidence. The results showed that SOC partially mediated the impact of trauma on both anxiety and social dysfunction with, while it fully mediated the relationship between trauma and loss of confidence, all mediation using negative correlations. Veronese and Pepe ^[37] asked whether intrusion and avoidance contributed to increased psychological distress, whether SOC mitigated such distress, and whether SOC equally affected different professionals. The results showed that psychological distress correlated positively with intrusion and avoidance and negatively with SOC, and the findings confirmed the mediating role of SOC in the relationship between the effects of trauma and the mental health of different professional groups.

George ^[38] explored the relationship between SOC strength and the perceived risks of field workers conducting home visits to home care agencies. The results showed that a strong SOC correlated with a lower frequency of encounters involving risk and with a lower perceived level of risk and that a strong SOC correlated with the ability to refuse high-risk assignments.

3. Salutogenic Perspective

This section includes those studies that place greater emphasis on variables associated with health, job satisfaction, well-being, and quality of life in general.

3.1. Work Behavior, Job Satisfaction and Engagement

Berg and Hallberg ^[39] studied the effects of systematic clinical supervision on SOC, creativity, job-related stress, and job satisfaction in nurses. The intervention consisted of one year of clinical supervision combined with planned and documented individual nursing care. The results improved nurses’ perception of clinical supervision as a type of support strategy for creativity and organizational climate; however, job satisfaction and job strain did not improve with the intervention, and SOC remained stable during the intervention. On the other hand, correlation analysis suggested that a strong SOC decreased work-related strain. In this line, Ida et al. ^[40] find a positive relationship between SOC with job satisfaction and adaptability to the workplace. In turn, high SOC scores decrease sickness absences in nurses with more work experience. Also in Japan, Ando and Kawano ^[41] point out the relationship between the SOC and moral distress with job satisfaction, specifically the meaningfulness factor of the SOC and the acquiescence to patients’ “rights violations” factor in relation to moral distress are the factors that have a greater influence on the job satisfaction of psychiatric nurses.

Engström et al. ^[42] studied the satisfaction of the caregiving team in a nursing home before and after 6 and 12 months of the implementation of a support team using information and communication technologies (motion sensors, falls, etc.). There were improvements in psychosocial job satisfaction and quality of care in the experimental group, as well as increased factors such as internal motivation, personal development, and expectations. The results showed significant group-by-time interaction effects on factors such as family relationships, close friends, total SOC score, and the score of the SOC significance subscale.

A study by Basinska et al. ^[43] examined the relationship between SOC (and its components) and work-related behavior patterns. The model of work-related behaviors and experiences developed by Schaarschmidt and Fischer distinguishes four different types of work-related behavior patterns: (1) Type G, healthy; (2) type S, frugal; (3) type A, risky or overloaded; (4) type B, burnout. The results showed a relationship between a high SOC and a healthy pattern of work-related behavior (type G and type S), while a low SOC was related to type B. The authors concluded that SOC and its components appeared to be predictors of work-related behavior patterns, to a greater extent for types G and B and to a lesser extent for types S and A.

Lindmark et al. ^[44] explored the work environment and psychosocial health of Public Dental Service employees in a Swedish county. The results showed higher scores for SOC and job satisfaction in staff in small-sized clinics, and those younger than 40 years had higher scores for meaningfulness, happiness, job satisfaction, and autonomy. By position, clinical coordinators reported better health, more autonomy, and greater manageability. The authors concluded that since variables such as gender, age, position, or size of the workplace were influencing factors, it is important to identify the resources and processes of each workplace.

In relation to resources, Pijpker et al. ^[9] explored the role of conceptual, instrumental, and social learning in the relationship between SOC and key GRRs. A relationship was found between SOC and all GRRs, with work control being the most important, followed by social relationships and task importance. On the other hand, instrumental and social learning played a small mediating role between SOC and GRRs, while conceptual learning played no role. Grødal et al. ^[45] investigated whether a health-promoting work environment (SOC, high job resources, and low demands) strengthened affective organizational commitment (AOC) among nursing home employees. The results showed that work SOC was strongly and positively related to AOC and job resources and negatively related to job demands. Indirect effects of autonomy and supervisor support on AOC were found through job SOC; however, indirect effects with respect to the social community at work, emotional demands, and role conflict were unclear. In conclusion, the results of this study supported the hypothesis that job SOC improves AOC among nursing home employees.

3.2. Quality of Life and General Health

Malagon-Aguilera et al. ^[10] examined SOC in nurses and its relationship to work engagement and overall health. Nurses with high SOC scores showed better health and greater work engagement, in addition to reporting greater social support and less work-related family conflict. The authors found that overall SOC scores and scores for understandability, manageability, and meaningfulness correlated positively with engagement and that nurses without work-related family conflict showed greater work engagement. On the other hand, Kowitlawkul et al. ^[46] investigated the key factors of nurses’ quality of life and work–life balance. The results showed that the key factors of high quality of life were SOC and social support; specifically, social support acted as a buffer for stress by reducing it and improving physical and psychological health and thus the quality of life. In conclusion, factors such as social support and stress management are essential to maintain nurses’ quality of life, as they play a crucial role in direct patient care.

Foureur et al. ^[47] tested the effectiveness of an adapted mindfulness-based stress reduction (MBSR) intervention on the psychological well-being of nurses and midwives who participated in a one-day workshop and engaged in daily meditation for 8 weeks. The quantitative results showed significant improvements in general health and SOC and lower levels of stress. Ando et al. ^[48] applied an intervention program based on mindfulness, based on meditation therapies, to nurses of a geriatric in Japan. The results indicate how this type of intervention increases the scores in SOC, specifically in the meaningfulness factor, improving their psychological well-being, which contributed to the increase in strategies to cope with the stress associated with work situations. Orly et al. ^[49] found an increase in SOC scores and a decrease in stress and fatigue in those nurses who participated in a cognitive behavioral program to reduce the level of stress associated with work compared to those nurses who did not participate in these types of interventions. The results of these studies pointed to the short-term benefits of stress for cognition, emotions, and behavior; therefore, mindfulness practice holds promise for increasing individual and occupational resilience.

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Pablo González-Siles

Manuel Martí-Vilar

Francisco González-Sala

César Merino-Soto

Filiberto Toledano-Toledano

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Update Date: 17 Oct 2023

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