This study confirmed a correlation between the sense of coherence and coping strategies in the examined group of nurses. These results correspond to conclusions presented by both Polish and foreign researchers [2, 13, 14, 18] concerning the pro-health and buffer role played by the sense of coherence in a stressful working environment.
The studied group presented a varied level of sense of coherence and its components, similarly to the results published in literature. The research on the sense of coherence showed that nurses had a sense of coherence at a level similar to that indicated by Polish researchers - the lowest level of the sense of coherence among nurses was reported by Koniarek (1992): M = 124.60 [19], while the highest - by Kretowicz (2011): M = 145.02 [19]. Polish nurses presented a similar level of the sense of coherence to paediatric nurses in Hong Kong: M = 135.75 [20], in South Africa: M = 137.92 (SD = 20.46) [21], in Brazil: M = 144.60 (SD = 22.60) [22], as well as in Japan: M = 124.40 (SD = 21.20) [23].
The sense of coherence can protect an individual from the destructive effects of difficult and stressful situations. Many studies have shown that a high sense of coherence significantly reduces the effects of stress and helps cope with the difficulties and challenges of life [2, 12, 14, 16, 18, 19, 21, 24]. The components of the sense of coherence also have a significant preventive effect [10, 14]. The sense of coherence determines the way of perceiving stressful situations at work, favours engaging in problem-oriented strategies and also plays a role in protecting employees from the negative effects of stress experienced. Studies conducted in a group of over a thousand nurses in Poland have shown that a high sense of coherence reduces the level of experienced stress, irrespective of the strength of the stressors and weakens the negative effects of stress. The buffering role of the sense of coherence was confirmed primarily in relation with the sense of manageability and the sense of meaningfulness [11, 15].
This is important for nursing staff, whose work is performed in situations of emotional stress and tension. Antonovsky proved that in stressful situations a high sense of coherence encourages more adaptive strategies for coping with difficult situations, i.e. focusing on the task instead of on emotions, and seeking social support [14]. Medical Universities in Poland include Antonovsky's theory into practice, offering, in accordance with current teaching curricula and standards, study modules which help students strengthen their sense of coherence. These include, among others, psychology with elements of interpersonal communication, health promotion, basics of psychotherapy. The process of strengthening the sense of coherence should be continued in the working environment of nursing staff. According to Korcz and Korcz-Biernat, it seems reasonable to take measures that would allow nursing staff to increase their participation in decision-making, also through partnership-based relations with other members of the interdisciplinary team. The authors also emphasize the importance of developing an ability to cope with stress at work [25]. The objectives of salutogenesis are addressed at people who in their everyday work help others and perform duties in conditions of high emotional tension and stress. The author of the theory of salutogenesis stated that his book "Unraveling the Mystery of Health. How People Manage Stress and Stay Well” was also written with nurses in mind, hoping for his theory to be empirically verified by that professional group [10].
The examined group of nurses more often reported choosing pro-health, problem-oriented stress management strategies (i.e. Active Coping, Planning, Seeking Instrumental Social Support and Seeking Emotional Social Support), which corresponds to the results of other authors' research in this area. Polish nurses most often reported choosing active and constructive actions as a strategy for coping with occupational stress [16]. According to Perek et al., this is a typical way of coping with stress in this occupational group [7]. Active stress management strategies are more commonly used by people with a higher level of coherence. This was confirmed by our own research. Basińska and Andruszkiewicz, using the AVEM Questionnaire and the Latack Scale, studied stress management strategies and work-related experiences among 150 nurses working at different wards. The authors proved that there were no differences between coping strategies chosen by nurses depending on the department they worked at. Those who coped with problems at work through the use of Suppression of Competing Activities/ Behavioural Disengagement strategy used offensive problem-solving strategies less often. Nurses who coped with problems through the Positive Reinterpretation and Growth strategy used more offensive ways of solving problems and were more satisfied with their lives. More often, offensive methods and a task-based mode were used by nurses using Active Coping, Seeking Emotional Social Support and Seeking Instrumental Social Support strategies [16]. The results of the Polish study correspond to the reports of other researchers. Australian nurses, as Lim indicates, choose problem-oriented strategies more often than emotion-oriented ones [26]. Studies on the use of stress management strategies by French nurses indicate that they most often choose Active Coping, Restraint Coping and Positive Reinterpretation and Growth strategies [27]. The study also found that nurses turned to strategies to reduce emotional tension, such as: Seeking Emotional Social Support, Positive Reinterpretation and Growth and Acceptance. The least respondents chose evasive strategies, which are primarily aimed at forgetting or distracting attention from the problem.
The main objective of the study was to assess the correlation between the sense of coherence and the strategies used to deal with stress. These study confirmed the existence of such a correlation. The examined nurses with a high level of coherence were less likely to use evasive strategies, i.e. Denial, Behavioural Disengagement and Focus on and Venting of Emotions, than those with a low and average level of sense of coherence, which has a positive impact on their health and professional functioning. According to Antonovsky, “people with a strong sense of coherence choose a specific strategy of coping, which in their opinion is most adequate for a given stressor”, therefore, they use more adaptive techniques to deal with problems that may contribute to better functioning and maintaining good health [28]. They are also able to make optimal use of the resources available to them, updating and flexibly adapting to changing circumstances those coping strategies that prove to be the most effective in a particular situation. The choice of stress management strategies that are beneficial to human health has an effect on maintaining health potential and functioning in a stressful work environment. Active strategies make it easier to stay healthy. Evasive strategies may reduce the positive impact of the sense of coherence and make it difficult to maintain good health.
In our study, we also observed an increased tendency for choosing an evasive stress management strategy - Alcohol/Drug Use - by nurses with low levels of coherence. This trend is in line with Antonovsky's theory. People with a weak sense of coherence more often experience negative emotions such as shame, discouragement, anxiety, which in effect inhibits action-taking. They perceive problems inaccurately, which leads to a failure to make the necessary efforts to cope effectively [11–13, 20].
Empirical research has shown that the sense of coherence and its components correlate with strategies used to deal with stressful situations. A high level of comprehensibility reduces the intensity of assessment of stressful situations, especially those related to threat and loss. The sense of manageability works in a similar way, which additionally influences the perception of the situation as a challenge. Whereas a strong sense of meaningfulness maximizes the perception of stressors as challenges and limits the perception of a situation as a loss. People with a strong sense of meaningfulness take on the challenges of life, search for meaning and make an effort to solve and deal with problems [12, 14].
The study found that nurses with a stronger sense of comprehensibility, manageability and meaningfulness were more likely to choose emotionally focused strategies, and least likely to use non-adaptive strategies, whose consequences may be detrimental to the one’s functioning and health. The sense of meaningfulness, the component Antonovsky treats as a motivational-emotional one, and according to Antonovsky, the most important one in creating the sense of coherence, correlated with the more frequent choice of the Seeking Emotional Social Support strategy, and the least frequently with the choice of the Focus on and Venting of Emotions strategy. What is important, the weaker the sense of meaningfulness of the respondents, the more often they used the Alcohol/Drug Use strategy. The use of this and other evasive strategies by nurses may contribute to deterioration of health, ineffective functioning in the work environment and absenteeism, which in the current situation of shortages in nursing staff is an undesirable situation. In relation to the above, it is justified to implement psycho-educational measures developing an ability to choose adaptive stress management strategies, which should be addressed especially at people with a weak sense of coherence. Strengthening the potential of the sense of coherence is in line with both Antonovsky's idea and the contemporary trend of positive psychology [29].
Investing in employees means reaching to their internal resources and developing their ability to cope with difficult situations. This investment will contribute to effective operation at work and better quality of services provided to the society. Implementation of strategies aimed at preventing stress and its consequences in the workplace should take place on both a personal and organisational level. Stress management programmes including education and training on stress management are a personal-level strategy that provides support for nurses experiencing stress. An organisation-focused approach addresses work-related stressors by reducing or eliminating them. Long-term implementation of this strategy will allow for better management of nursing staff and for ensuring adequate resources [30].
The presented research results may constitute a source of knowledge for designing psycho-educational programmes addressed both at students - future nurses and active professionals in order to minimize the occurrence of risky behaviours and to help develop skills to cope with them.