IMPACT OF SENSE OF COHERENCE ON WORK ABILITY:  
A CROSS-SECTIONAL STUDY AMONG CROATIAN NURSES
Martina SMREKAR1,2, Lijana ZALETEL-KRAGELJ2, Alenka FRANKO2,3*
1University of Applied Health Sciences Zagreb, Mlinarska cesta 38, 10000 Zagreb, Croatia
2University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloska 4, 1000 Ljubljana, Slovenia
3University Medical Centre Ljubljana, Clinical Institute of Occupational 
Medicine, Grablovičeva ulica 42, 1000 Ljubljana, Slovenia
Received: Feb 3, 2022
Accepted: May 24, 2022
Original scientific article
*Corresponding author: Tel. + 386 31842308; E-mail: alenka.franko@siol.net
10.2478/sjph-2022-0022 Zdr Varst. 2022;61(3):163-170
163
VPLIV OBČUTKA KOHERENCE NA DELOVNO ZMOŽNOST:  
PRESEČNA ŠTUDIJA MED HRVAŠKIMI MEDICINSKIMI SESTRAMI
© National Institute of Public Health, Slovenia. 
Smrekar M, Zaletel-Kragelj L, Franko A. Impact of sense of coherence on work ability: a cross-sectional study among Croatian nurses.  
Zdr Varst. 2022;61(3)163-170. doi: 10.2478/sjph-2022-0022.
ABSTRACT
Keywords: 
nursing, SOC-29 
instrument, stress, 
work ability index, 
work environment
IZVLEČEK
Ključne besede: 
zdravstvena nega, 
vprašalnik SOC-29, 
stres, indeks delovne 
sposobnosti, delovno 
okolje
Introduction: Aimed at preparing the basis for planning evidence-based public health measures for preservation/
improvement of nurses’ work ability (WA), the objective was to assess the relationship between WA and sense 
of coherence (SOC). 
Methods: A cross-sectional study was conducted in 2018 among 713 nurses in Croatia. The association between 
poor WA index (PWAI) and SOC score (SOCS), adjusted for possible confounders, was determined by binary 
logistic regression analysis.
Results: The results of univariate logistic regression analysis showed a statistically significant negative 
association between SOCS and PWAI (OR=0.977, 95% CI 0.968 – 0.986, p<0.001). The results of multivariate 
logistic analysis showed an even stronger statistically significant negative association between SOCS and PWAI 
(OR=0.966, 95% CI 0.954 – 0.977, p<0.001) when adjusted for confounders.
Conclusions: The present study suggested SOC as an important health promoting resource of nurses which 
might offer protection regarding work-related stress. Weak SOC could be an important explanatory factor of 
poor WA. Accordingly, improving SOC by implementing health promotion measures in nurses’ workplace could 
be an important way to increase the WA among nurses.
Uvod: Namen raziskave je bil pripraviti temelje za načrtovanje z dokazni podprtih javnozdravstvenih ukrepov 
za ohranitev/izboljšanje delovne sposobnosti medicinskih sester, pri čemer je bil cilj oceniti odnos med delovno 
sposobnostjo in občutkom koherence.
Metode: Presečna raziskava je bila opravljena leta 2018 na vzorcu 713 hrvaških medicinskih sester. Povezanost 
med nizko vrednostjo indeksa telesne sposobnosti in povzetno mero lestvice občutka koherence smo ob 
upoštevanju motečih dejavnikov ocenili z metodo binarne logistične regresije. 
Rezultati: Rezultati univariatne logistične regresije so pokazali statistično pomembno negativno povezanost 
med povzetno mero lestvice občutka koherence in nizko vrednostjo indeksa telesne sposobnosti (OR = 0,977; 
95-odstotni IZ 0,968-0,986; p < 0,001). Rezultati multivariatne logistične regresije so pokazali še močnejšo 
negativno statistično pomembno povezanost med povzetno mero lestvice občutka koherence in nizko vrednostjo 
indeksa telesne sposobnosti (OR = 0,966; 95-odstotni CI 0,954-0,977; p < 0,001).
Zaključki: Ta študija nakazuje, da je občutek koherence lahko pomemben vir dobrega zdravja pri medicinskih 
sestrah in bi lahko predstavljal zaščito pred stresom, povezanim z delom. Nizek občutek koherence je lahko 
pomemben dejavnik, ki pojasnjuje slabo delovno sposobnost. Krepitev občutka koherence z uvedbo ukrepov 
promocije zdravja na delovnem mestu medicinskih sester bi lahko bil pomemben način za izboljšanje delovne 
sposobnosti med njimi.
1 INTRODUCTION
Work ability (WA) is an evidence-based concept defined 
as a balance between worker’s personal resources 
and work-related factors (1). In order to obtain more 
knowledge about an individual’s WA, the Finnish Institute 
of Occupational Health constructed an instrument, the 
Work Ability Index Questionnaire (WAIQ) (2, 3), as a tool 
for investigating how long individuals are actually able to 
work (1). The measure obtained by the WAIQ is the Work 
Ability Index (WAI). WAIQ was recommended to be used as 
a diagnostic instrument for the development of measures 
for health support (4).
Sense of coherence (SOC) is a coping resource that 
helps individuals to identify and use their external and 
internal resources (Generalized Resistance Resources 
- GRR) for problem solving and managing stressful life 
events (5, 6). Additionally, SOC was supposed to allow 
the individual experience of a stressful event to be 
perceived as meaningful, manageable and comprehensible 
by mobilizing GRRs, which arise from cultural, social and 
environmental conditions of living and early childhood 
rearing, and socialization experiences (6). Literature has 
shown that strong SOC has a positive effect on health and 
quality of life (7). It is also suggested that SOC is a health 
resource positively associated with well-being in a work 
environment (6, 8); furthermore, it moderates the effects 
of unfavourable working conditions on health outcomes (6).
Considering that the nursing profession is mentally and 
physically demanding and stressful (9, 10), it is necessary 
for nurses to maintain good mental and physical health in 
order to adequately perform their job. Unfortunately, a 
recent study revealed that they had poorer health compared 
to the general population (11). According to Prochnow et 
al., exposure to stress can have negative consequences on 
nurses’ WA and health (12). Consequently, it is essential to 
recognize the importance of ensuring a positive and healthy 
working environment to avoid such consequences (13). 
In the context of nurses’ WA, SOC could be seen as a 
resource for adequate coping with workplace stressors (6). 
The literature demonstrates that a strong SOC protects 
nurses from stress (14) and contributes to nurses’ healthy 
functioning at work (8). The literature has also shown that 
healthcare workers, including nurses, with strong SOC more 
often seek strategies for coping with stress (15). According 
to Masanotti et al., nurses’ individual and work-related 
factors, such as age, gender, marital status, educational 
level, years of work experience, type of employment, 
shift work, work department, job satisfaction and 
work engagement, are an integral part of the GRRs and 
participate in the modelling of the nurses’ SOC (16). All 
this is closely related to health promotion, more precisely 
to the workplace health promotion concept for nurses 
(17). Health promotion measures in nursing environments 
are more effective if they are evidence-based (18).
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In Croatia, a study by Golubic et al. carried out about a 
decade ago showed that occupational stress was present 
also among Croatian nurses (19). The organization of work 
and financial issues, lower educational level and older age 
are the factors significantly associated with low WA (19). 
According to our knowledge and available literature, the 
relationship between WA and SOC in the population of 
nurses has not yet been explored either among Croatian 
nurses or elsewhere in the world. Consequently, aimed 
at preparing the basis for planning evidence-based health 
promotion measures for the preservation/improvement of 
nurses’ WA, the objective of this study was to assess this 
relationship among Croatian nurses.
2 METHODS
2.1 Study design, research method and population
A cross-sectional study (survey type: health interview 
survey) was conducted. Data were collected in 2018 at 
the University Hospital Centre (UHC) in Croatia, a large 
health institution similar to other institutions around the 
world, which employs a large number of nurses. A total 
population of 1,465 nurses of different profiles (nurses with 
secondary school education, bachelors of nursing, masters 
of nursing) employed in different departments of the 
UHC were considered for inclusion in the study. The only 
exclusion criterion was absence from the work-place at 
the time of the survey. Due to sick leave, annual leave and 
study leave 165 nurses were excluded and consequently 
1,300 were invited to participate in the study.
2.2 Data collection procedures
The principal investigator held a meeting with the head 
nurses of each clinic at the UHC and presented to them 
the aim and objectives of the research and the research 
protocol. The paper-and-pencil self-administered study 
questionnaire was distributed to the nurses in all hospital 
departments personally by the first author. Anonymity 
was assured by using special identification codes unique 
to each participant. Written informed consent was 
obtained from each participant, gathered separately from 
completed questionnaires. 
2.3 Measurement instruments
The two main instruments used in this study were WAIQ 
and the ‘orientation to life questionnaire’, also called the 
SOC scale. 
The WAIQ consists of 10 questions divided into 7 items: 
1 - current WA compared to highest WA ever (1 question; 
scoring 0-10), 2 - WA in relation to demands (2 questions: 
physical job demands, mental job demands; scoring 2-10), 
3 - current diseases (1 question/14 diseases; scoring 1-7), 4 
- estimated work impairment due to diseases (1 question; 
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scoring 1-6), 5 - illness within last year (12 months) (1 
question: number of whole days being off work; scoring 
1-5 points), 6 - estimation of own work ability in 2 years 
(1 question; scoring 1, 4 or 7), and 7 - mental capacities 
(3 questions; scoring 1-4). Detailed description of the 
instrument and scoring is provided elsewhere (3). In our 
study the Croatian version of a WAIQ (WAIQ-CRO) was used, 
which demonstrated satisfactory internal consistency 
(Cronbach’s α=0.71) and a three-factor structure (20). 
The SOC scale could be short (13-item scale or SOC-13) or 
long (29-item scale or SOC-29). In either of them items 
are scored on a seven-point scale (5). In this study the 
Croatian version of the SOC-29 (SOC-29-CRO) was used, 
which demonstrated high internal consistency (Cronbach’s 
α=0.89) and a one-factor structure (21).
2.4 Variables in the study
The observed outcome (a central phenomenon in the 
study that is intended to be explained to the greatest 
extent possible) was based on the WAI obtained by the 
administration of the WAIQ (2, 3). The WAI is a summary 
measure obtained by summing up the scores of individual 
responses to all items of WAIQ ranging from 7-49 points. 
A higher WAI suggests a better WA. The WAI could be 
analysed as a numeric value or categorized into four 
categories: 7-27 points indicating a poor WAI, 28-36 points 
a moderate WAI, 37-43 points a good WAI, and 44-49 points 
indicating an excellent WAI (2, 3). For the purposes of our 
study, based on previous studies (10, 22), the WAI was 
dichotomized into two groups: poor (<37 points) and good 
WAI (≥37 points). The poor WAI (PWAI) was considered the 
observed outcome and was included in the analysis as a 
dependent variable.
The explanatory factor (a phenomenon by which the 
occurrence of the observed outcome is intended to be 
explained) was the SOC score (SOCS), a summary measure 
obtained by summing up the scores of individual responses 
to all items of SOC-29, ranging from 29 to 203 points. A 
higher SOCS suggests a stronger SOC (5, 6). 
As potential confounders (control variables) (phenomena 
that could potentially distort the assessment of the 
association between the observed outcome and explanatory 
factor), four groups of phenomena were considered. The 
first group consisted of socio-demographic characteristics: 
gender (female, male), age (≤40 years, >40 years), marital 
status (married, other), educational level (secondary school, 
bachelor of nursing, master of nursing), ongoing education 
(yes, no). The second group consisted of health behaviour: 
number of cigarettes per day (0, 1-5, >5), and physical 
activity (maximum 2 days per week, about 3 days per week, 
every day or almost every day). The third group consisted 
of work-related factors: work length (<1 year, 1-20 years, 
>20 years), work department (departments with special 
demands: polyclinic, oncology/haematology, psychiatric 
and paediatric units; other), time getting to work (≤30 
minutes, >30 minutes), transportation mode (by car only, on 
foot only; other). The last group consisted of self-reported 
health conditions: injury from accidents, musculoskeletal 
diseases, cardiovascular diseases, respiratory diseases, 
mental disorders, neurological and sensory diseases, 
digestive diseases, genitourinary diseases, skin diseases, 
tumours, endocrine and metabolic diseases, blood diseases 
and birth defects (all of them yes, no).
2.5 Statistical analysis
In both the univariate and multivariate analyses of 
association between SOC and poor WAI, binary logistic 
regression was used. In the univariate analysis the direct 
method was used in which all independent variables 
in a block are entered in a single step. In multivariate 
analysis the stepwise method was used, more precisely 
the forward selection method using a likelihood criterion, 
in which independent variables enter the model step by 
step according to the criterion. The dummy variables 
were created for categorical explanatory/confounding 
factors with more than two categories (the simple 
method was applied). P-values <0.05 were considered 
statistically significant. Data analysis was performed 
using IBM SPSS Statistics for Windows (Version 21.0. SPSS 
Inc. Chicago. IL. USA).
3 RESULTS
3.1 Description of the study group
Out of 1,300 nurses 713 agreed to participate in the study 
(response rate 54.8%). The mean age of participants was 
38.4 years (SD 12.5, range 19-65). Table 1 presents their 
characteristics. The lowest response rate to a single 
question was 99%.
3.2 Statistical properties of the main variables observed 
The mean value of total WAI score was 40.6 points (SD 
5.6, range 16-49). According to WAI categories, 2.5% of 
respondents had poor, 19.1% average, 44.0% good, while 
34.4% had excellent WAI. Accordingly, 21.6% of nurses had 
PWAI (WAI <37), while 78.4% had good WAI. The mean 
value of the SOCS was 145.0±22.1 points (SD 22.1, range 
81-200).
3.3 Results of univariate analysis of association between 
SOC-score and WAI
The data for univariate analysis of association were 
available for 685-691/713 participants (96.1-96.9%). The 
main result showed a statistically significant negative 
association between SOCS and PWAI (OR=0.977, 95% CI 
0.968–0.986, p<0.001), meaning that if SOCS increased by 
one point, the odds for PWAI were 97.7% of the odds of 
participants having SOCS value one point lower. Interpreted 
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Gender
Age (years)
Marital status
Level of education
Ongoing education
Number of cigarettes
Physical activity (days per week)
Work length (years)
Work department
Time getting to work (minutes)
Transportation mode
Injury from accidents
Musculoskeletal diseases
Cardiovascular diseases
Respiratory diseases
Mental disorders
Neurological and sensory diseases
Digestive diseases
Genitourinary diseases
Skin diseases
Tumours
Endocrine and metabolic diseases
Blood diseases/birth defects
Characteristic
SOCIO-DEMOGRAPHIC FACTORS
HEALTH BEHAVIOURS
WORK-RELATED FACTORS
SELF-REPORTED HEALTH CONDITIONS
Category n %
Female
Male
≤40
>40
Married
Other
Secondary school
Bachelor of nursing
Master of nursing
No
Yes
0
1-5
>5
Maximum 2 days
About 3 days
Every day/almost every day
<1
1-20
>20
Department with special demands
Other
≤30
>30
By car only
On foot only
Other
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
630
83
408
304
371
341
429
256
28
564
148
437
51
224
409
123
180
23
391
299
146
562
241
469
252
19
435
550
163
497
216
597
116
624
89
692
21
654
59
586
127
645
68
657
56
674
39
611
102
652
61
88.4
11.6
57.3
42.7
52.1
47.9
60.2
35.9
3.9
79.2
20.8
61.3
7.2
31.5
57.4
17.3
25.3
3.2
54.9
41.9
20.6
79.4
33.9
66.1
35.7
2.7
61.6
77.1
22.9
69.7
30.3
83.7
16.3
87.5
12.5
97.1
2.9
91.7
8.3
82.2
17.8
90.5
9.5
92.1
7.9
94.5
5.5
85.7
14.3
91.4
8.6
Table 1. Characteristics of participants in the study of impact of sense of coherence on work ability of Croatian nurses (n=713).
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Age >40 years
Gender
Marital status
Educational level
Ongoing education
Number of cigarettes
Physical activity (days per week)
Work length (years)
Department with special demands
Time getting to work (minutes)
Transportation mode
Injury from accidents
Musculoskeletal diseases
Cardiovascular diseases
Respiratory diseases
Mental disorders
Neurological and sensory diseases
Digestive diseases
Genitourinary diseases
Skin diseases
Tumours
Endocrine and metabolic diseases
Blood diseases/birth defects
Factor
SOCIO-DEMOGRAPHIC FACTORS
HEALTH BEHAVIOURS
WORK-RELATED FACTORS
SELF-REPORTED HEALTH CONDITIONS
SOCS
Category
Observed Reference (lower-upper) p
95% CI for OROR
Yes
Female
Married
Bachelor of nursing
Master of nursing
Yes
1-5
>5
Maximum 2 days
About 3 days
1-20
>20
Yes
>30
By car only
On foot only
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Male
Other
Secondary school
Secondary school
No
0
0
Every day/almost every day
Every day/almost every day
<1
<1
No
≤30
Other
Other
No
No
No
No
No
No
No
No
No
No
No
No
4.338
2.383
1.320
0.586
0.121
0.372
0.531
2.316
3.003
3.063
0.531
2.316
1.412
0.772
0.666
1.215
7.086
9.969
6.177
3.113
6.694
8.769
5.367
3.069
2.909
3.409
2.902
1.679
0.977
<0.001
0.018
0.137
0.008
0.040
0.001
0.275
0.140
0.001
0.002
0.275
0.140
0.112
0.198
0.045
0.718
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.083
<0.001
(2.926-6.430)
(1.162-4.887)
(0.916-1.904)
(0.393-0.872)
(0.016-0.909)
(0.211-0.658)
(0.171-1.654)
(0.759-7.066)
(1.548-5.824)
(1.506-6.229)
(0.171-1.654)
(0.759-7.066)
(0.922-2.161)
(0.521-1.144)
(0.447-0.991)
(0.423-3.490)
(4.741-10.590)
(6.611-15.033)
(3.997-9.547)
(1.948-4.975)
(2.587-17.325)
(4.852-15.849)
(3.525-8.170)
(1.812-5.198)
(1.645-5.145)
(1.765-6.583)
(1.843-4.572)
(0.934-3.019
(0.968-0.986)
Table 2. Results of univariate logistic regression analysis of association between selected factors and PWAI in the study of impact of 
SOC on WA of Croatian nurses (n=685-691).
Legend: SOCS – sense of coherence score; CI – confidence interval; OR – odds ratio
in another way, if SOCS decreased by one point, the odds 
for PWAI increased by 2.4% (OR: 1/0.977=1.024). The 
details are presented in Table 2. 
3.4 Results of multivariate analysis of the association 
between SOC-score and WAI
Complete data for multivariate logistic regression analysis 
were available for 657/713 participants (92.1%). The results 
showed an even stronger statistically significant negative 
association between SOCS and PWAI (OR=0.966, 95% CI 
0.954-0.977, p<0.001) when adjusted for confounders, 
meaning that if SOCS increased by one point, the odds for 
PWAI were 96.6% of the odds of participants having SOCS 
value one point lower. Interpreted in another way, if SOCS 
decreased by one point, the odds for PWAI increased by 3.5% 
(OR: 1/0.966=1.035). The details are presented in Table 3. 
4 DISCUSSION
The results of our study revealed a statistically significant 
negative association between SOCS and PWAI, indicating 
that the lower the SOC is, the greater the odds of PWAI 
are. In other words, weak SOC could be a predictor of 
PWAI and improving SOC could significantly increase WA 
among nurses. Based on these results, we can propose 
SOC as an important and suitable intervention targeted 
outcome to consider in managing WA difficulties in 
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10.2478/sjph-2022-0022 Zdr Varst. 2022;61(3):163-170
clinical practice in nurses. Bearing in mind that stressful 
job demands are one of the major problems for nurses, 
identifying an independent modifiable coping resource is 
a great contribution. 
The lack of similar studies makes it very difficult to 
compare our results. However, we can make some general 
comparisons. If we first want to make some comparisons in 
terms of the impact of SOC on WA, we can conclude that 
our results are consistent with the results of similar studies 
conducted on other population groups. To our knowledge, 
the relationship between SOC and WA was explored for 
example among unemployed people (23) and among 
Japanese workers employed in the information technology 
sector (24). Similar to our study, their findings indicated 
that low SOC was related to impaired WA (23, 24). To this 
we can add that the results of our study showed something 
extremely important – SOC as an explanatory factor of WA 
from the univariate to the final multivariate model has 
not lost its power. On the contrary, the power increased 
even more. In parallel, all other factors that entered the 
final model lost a substantial portion of their power. This 
suggests that these factors interact with each other, while 
SOC remains an independent factor. We can also make 
some other comparisons. If we comment on the effect of 
age on WA, the final results of the present study showed 
that nurses older than 40 years have significantly higher 
odds for PWAI in comparison to the younger ones. This is 
consistent with the findings of other studies. Hatch et al. 
demonstrated, for example, that older age is a predictor of 
low WA among nurses from the southeast USA (25). Previous 
studies conducted among Croatian nurses also showed that 
WA decreases significantly with age (10, 19). The reason 
could be found in a reduction of functional capacity of the 
individual due to the aging process and deficit in physical 
health (25). Contrary to our expectations, Rostamabadi et 
al. did not find an association between aging and WAI in 
their multivariate model among intensive care unit nurses 
(26). However, in their study, participants were aged only 
up to 39 years, while in our study a significant part was 
older than 40. Furthermore, it is important to explain why 
the authors of the present study considered it necessary 
for age to be dichotomized into two categories: ≤40 and 
>40 years. It was suggested that nurses over 40 years of 
age can experience visual and hearing impairments, weight 
gain, pain associated with musculoskeletal disorders and 
reduction in strength and flexibility (27) which can result 
in a reduced capacity to perform as well as younger nurses 
(27). Evidence showed that interventions targeting disease 
prevention and health maintenance from midlife and 
earlier may be effective ways to maintain nurses’ WA with 
age (25). This should be a priority as the population of 
nurses is constantly aging (28). 
To discuss the importance of self-assessed health 
conditions for WA, which proved to be important in our 
study, the most difficult thing was finding appropriate 
studies for comparison. Similar findings to our study 
regarding musculoskeletal diseases were reported among 
Brazilian nurses (29). The results of the systematic review 
and meta-analysis of Bernal et al. also showed that 
musculoskeletal diseases among nurses were the main 
causes of disability (30). As the high percentage of sick 
leave among healthcare workers can be largely attributed 
to musculoskeletal disorders, continuous workplace 
health-promoting measures to manage ergonomic risk 
factors in the aging nursing population would be of the 
utmost importance (31). SOC could also play an important 
role in these activities as it was shown that it influences 
nurses’ healthy functioning at work (8). 
Our study has some potential limitations. First, one can 
argue that this study involved participants from only one 
health institution. However, this institution is a typical 
large healthcare facility where a large number of nurses 
performing various tasks are employed. Consequently, 
this allows an in-depth study of health problems related 
to the nurses’ workplace, which is a strength rather than a 
limitation. Second, one could argue the low response rate. 
Age >40 years
Musculoskeletal diseases
Cardiovascular diseases
Neurological and sensory diseases
Injury from accidents
Digestive diseases
Genitourinary diseases
Respiratory diseases
Factor
SOCS
Category
Observed Reference (lower-upper) p
95% CI for OROR
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
2.991
3.509
3.114
4.398
2.833
2.299
2.121
1.939
0.966
<0.001
<0.001
<0.001
<0.001
<0.001
0.004
0.040
0.044
<0.001
(1.739-5.147)
(2.056-5.989)
(1.713-5.661)
(1.992-9.711)
(1.628-4.929)
(1.300-4.067)
(1.036-4.344)
(1.017-3.698)
(0.954-0.977)
Table 3. Results of multivariate logistic regression analysis of the association between selected factors and PWAI in the study of 
impact of SOC on WA of Croatian nurses (n=657).
Legend: SOCS – sense of coherence score; CI – confidence interval; OR – odds ratio
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However, there is no agreed-upon standard for acceptable 
response rates (32). According to Babbie, cited by Draugalis 
et al., 50% is regarded as an acceptable response rate 
in social research postal surveys (32). Consequently, we 
assumed that the response rate achieved in our study still 
permits robust reliable conclusions to be drawn. Third, 
one could argue that the results are based only on nurses 
employed in a clinical setting. However, regardless of this, 
the results can also be roughly applied to some extent 
to nurses employed at the primary level of healthcare, 
considering the fact that it is possible to find to a certain 
extent an analogy between the work of nurses employed 
at the UHC (especially in the polyclinic departments) and 
primary healthcare nurses. Fourth, confounding factors 
may also be a subject of discussion. On the one hand, it 
could be pointed out that some are missing, e.g. minor 
children or relatives in care or a leading position. However, 
the selection was based on previous studies about SOC and 
WAI among nurses (16, 19). Additionally, some confounding 
factors included seem to be too inclusive, e.g. mental 
disorders (covering very different disorders) or endocrine 
and metabolic disease. In these cases, we were limited by 
the WAI questionnaire, and such details were also beyond 
the scope of this study and may be the subject of more 
in-depth research in the future. In addition, for some 
confounders, one might argue that the categories were 
too broad to allow us to identify a risk area, e.g. work 
department, work length or number of cigarettes per day. 
In these cases, the aggregation of categories was indicated 
by the requirements of statistical methods. Next, one 
could argue how the missing values were dealt with. As 
the minimum response rate to an individual question was 
very high, making the possibility of bias due to missing 
values very small, data imputation methods were not 
applied. Finally, participants’ motivation to respond is a 
limitation of the present study. It is unknown whether the 
nurses who participated in the study had the same level 
of SOC as the nurses who did not participate in the study.
On the other hand, the study also has some important 
strengths. First, this study is the first to explore the 
association between SOC and WA in the nursing population. 
The results of this study might be especially useful for 
implementing health promotion in nurses’ workplaces to 
preserve WA of this high-risk-for-stress population, as SOC 
could be seen as an important coping mechanism that 
nurse educators can integrate into nursing education. 
Second, the results of this study are applicable not 
only in Croatia but also in countries that were part of 
former Yugoslavia due to the similar transition process in 
departing from a common healthcare system. However, 
they are also applicable in general.
The findings of this study could serve as evidence for 
evidence-based planned public health measures for 
maintaining/enhancing good health among healthcare 
workers, especially nurses. Evidence about WA in the 
nursing profession demonstrated that WA is important 
for nurses in order to ensure good working conditions and 
to reduce work-related diseases and illness (33). As the 
evidence also demonstrated that the nursing profession is 
associated with stressful working conditions contributing 
to inadequate WA (34), monitoring SOC could be seen as 
a tool for the identification of nurses in need of support 
to cope better with stress, especially in those working 
environments where higher risk for burnout is expected, 
such as intensive care units (35). Moreover, as SOC could 
be considered an important factor of adjustment to 
difficulties among nurses with poor WAI, since people with 
strong SOC perceive a stressful situation as a challenge 
rather than as a threat (6), interventions for enhancing 
SOC could reduce the rates of poor WAI. An individual’s 
SOC could be helpful in understanding the support needed 
in relation to health and WA and should be considered as 
an intervention outcome (36). 
There is still much scope for further research in this area. 
First, it would make sense to extend the study to nurses 
employed in primary care. Additionally, it would make 
sense to extend the study to other healthcare profiles as 
well as to carry out an intervention study in which the 
intervention would be aimed at strengthening SOC in 
nurses who were found to have low SOC, and then reassess 
whether their WA has changed. 
5 CONCLUSIONS
The present study proved an association between SOC and 
WA. SOC could be helpful in understanding the support 
needed in relation to health and WA, and should be 
considered as an intervention outcome. Improving SOC 
and consequently WA and implementing health promotion 
in nurses’ workplaces could be an important way to 
increase WA.
ACKNOWLEDGEMENTS 
The authors are grateful to all the nurses who took part 
in the survey.
CONFLICT OF INTEREST 
The authors declare no conflicts of interest.
FUNDING
The authors declare no funding.
ETHICAL APPROVAL
The study protocols were approved by UHSM (code EP – 
7811/16-19). The study was carried out in accordance with 
the ethical principles of the Helsinki Declaration. Nurses 
were informed that participation in the study is voluntary 
and anonymous. Informed consent was obtained from 
each nurse before enrolment.
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