Why some people do well and others don’t. The role of sense of coherence in disease adaptation

In 2006, the European Journal of Cardiovascular Nursing published a discussion paper entitled: ‘Is sense of coherence a pathway for improving the quality of life of patients who grow up with chronic diseases? A hypothesis’. ¹ The driver for this discussion paper was the observation that young adults with congenital heart disease reported a better quality of life than individuals from the general population. ² In the meantime, this hypothesis has been extensively investigated and confirmed.^3–8 The discussion paper was also the start of a series of publications on sense of coherence in the European Journal of Cardiovascular Nursing.

Sense of coherence is a construct that has been advanced and developed by Aaron Antonovsky, a medical sociologist. Sense of coherence is defined as:

‘a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (i) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable, and explicable; (ii) the resources are available to one to meet the demands posed by these stimuli; and (iii) these demands are challenges, worthy of investment and engagement.’ ⁹

A strong sense of coherence is crucial to coping with the many stressors of life, and consequently, to maintaining good health. From this perspective, sense of coherence may explain why some people do well and others do not.

To date, the journal has published 18 articles, short reports, letters and editorials on sense of coherence.^{1,3,5,10–24} Empirical data on sense of coherence were provided in 13 full articles^{3,10–15,17,19,20,22–24} and two Letters to the Editor.^5,18 The populations in which sense of coherence was studied were coronary artery disease/myocardial infarction;^{10,14,15,17,19} congenital heart disease;^3,5,18,20 heart failure;^11–13 heart transplantation; ²³ atrial fibrillation; ²⁴ and a mixed group of cardiac patients. ²² Furthermore, two editorials have been published to highlight the importance of sense of coherence for cardiovascular nursing ¹⁶ , and to bring research findings alive with a report on individual patient experiences. ²¹ These studies showed that sense of coherence is positively related to quality of life,^3,5,10,14 adaptive coping strategies,^12,17 self-management, ¹³ good health behaviors, ¹⁹ and self-rated health; ²⁰ and negatively associated with depression/negative affect,^12,22 fatigue, ¹¹ perceived impact of stress ²⁰ and uncertainty after transplantation. ²³

In the October issue of the journal, a study is published in which the effects of mindfulness-based cognitive behavioural therapy (CBT) on health-related quality of life and sense of coherence were investigated. ²⁴ A group of 111 patients with atrial fibrillation and their spouses were included in a randomized controlled trial in Sweden. The CBT programme comprised three group sessions lasting 2.5 h each, over a period of nine weeks. Participants were trained to be aware of their breathing, received heart rate variability biofeedback and obtained self-regulation techniques for emotions and behaviours. The programme aimed to build and strengthen personal resilience, and think positively about their hearts and brains. Participants were instructed to conduct the mindfulness practice at home on a daily basis. All participants completed a set of questionnaires twice: before the randomization and 12 months after inclusion in the study. The CBT group had an increase of quality of life and sense of coherence over time, unlike the control group. The relationship between CBT and quality of life, however, was fully mediated by sense of coherence. This means that improvements in quality of life are not directly achieved, but through an enhancement of sense of coherence. This makes sense of coherence an important intermediate outcome and a target for interventions.

This article is the first intervention study on sense of coherence to be published in the European Journal of Cardiovascular Nursing. ²⁴ This shows that a new era of research on sense of coherence has started. From observational studies that aimed to gain a better understanding of the phenomenon, the scientific community is shifting towards intervention studies that purport to improve individuals’ sense of coherence and the related outcomes. Indeed, in a prior editorial, ¹⁶ several avenues for nursing interventions were proposed:

‘First, in order to provide individualized care and to design tailored interventions, nurses could assess levels of sense of coherence in their patients to identify vulnerable patients who may need more support. Second, nurses could strengthen patients’ comprehensibility by providing accessible and understandable information and education. Furthermore, to enhance manageability, it is important to encourage patients to be aware and make use of available resources. In addition, supporting patients to take control and to participate in decision-making could enhance their meaningfulness. In sum, nurses could fulfil the role of a coach by encouraging, empowering, guiding, assisting, and supporting their patients in the recovery or adaptation process.’ ¹⁶

When using strong research designs, such as randomized controlled trials, robust evidence on the effectiveness of interventions that improve sense of coherence is to be provided. This is clearly the way to go. The European Journal of Cardiovascular Nursing wants to pave the way for future developments. Therefore, we stimulate nurse researchers to improve cardiac patients’ sense of coherence by setting-up intervention studies to investigate the effects of specific approaches. We welcome papers on such intervention studies that are using rigorous research methods.