Research in Nursing & Health, 1996, 19, 207-290

Sense of Coherence as a
Predictor of Quality of Life
in Persons With Coronary
Heart Disease Surviving
Cardiac Arrest
Sandra Underhill Motzer and Barbara J. Stewart

The unique contribution of sense of coherence to explained variance in quality of life was studied
in 149 persons with coronary heart disease who survived cardiac arrest. Using hierarchical
multiple regression, 16 predictors, including 5 social status variables related to poor health
vulnerability, perceived social support, self-esteem, and 9 variables reflecting instability and
work of the chronic illness trajectory, accounted for 50% of variance in quality of life. The
addition of sense of coherence resulted in a 15% increment to the explained variance (total R* =
.64). As a strong independent predictor of quality of life, sense of coherence has promise as a
variable that might be strengthenedby nursing interventionsand merits continued study. o 1996
John Wiley & Sons, Inc.

Quality of life is a concept of increasing inter-
est in studies of health and wellness in persons
with a chronic illness (Agency for Health Care
Policy and Research [AHCPR], 1990; Stewart,
1992). In previous studies of persons with a
physical chronic illness, less than 50% of the
variance in quality of life has been explained by
such predictors as severity of illness, social sup-
port, and self-esteem (Burckhardt, 1985; Win-
gate, 1992).The specific aim of this study was to
test whether Antonovsky’s (1979, 1987) sense of
coherence construct explained additional vari-
ance in quality of life in persons with chronic
coronary heart disease who had survived a cardi-
ac arrest.
Coronary heart disease affects over 6 million
Americans and is the leading cause of death for
both men and women (American Heart Associa-
tion, 1991). It is characterized by episodes of
acute exacerbation, such as a cardiac arrest. The
synonymous terms cardiac arrest and sudden
cardiac death are defined as cessation of heart
beat occurring within 1 hr of symptom onset and,
as suggested by the medical history, without any
other probable cause (Cupples, Gagnon, & Kan-
nel, 1992). Underlying, advanced coronary heart
disease is reported in up to 75% of cardiac arrest
victims (Main, 1995). Annually, of the 300,000
to 400,000 Americans who have an episode of
out-of-hospital cardiac arrest related to coronary
heart disease (Cupples et al., 1992; Hurwitz &
Josephson, 1992; Myerberg, Kessler, & Cast-

Sandra Underhill Motzer, PhD, RN, is a senior fellow, Department of Biobehavioral Nursing
and Health Systems, University of Washington. Barbara J. Stewart, PhD, is a professor, School
of Nursing, Oregon Health Sciences University.
The project was supported by a Professional Nurse Traineeship and an NRSA predoctoral
fellowship from NINR, NIH.
The authors acknowledge Patricia G. Archbold, Christine A. Tanner, and Carol S. Burkhardt,
Oregon Health Sciences University School of Nursing for their guidance, and the late Aaron
Antonovsky for his encouragement.
This article was received on January 21, 1994, revised, and accepted for publication on
February 5, 1996.
Requests for reprints can be addressed to Dr. Motzer, School of Nursing, University of Wash-
ington, Seattle, WA 98195-7262.

0 1996 John Wiley & Sons. Inc. CCC 0160-6891/96/040287-12 287

288 RESEARCH IN NURSING & HEALTH
ellanos, 1992), only 25% to 30% survive (Myer-
berg et al., 1992). These survivors become part
of a highly vulnerable group; 40% can expect
another cardiac arrest within the next 2 years
(Hurwitz & Josephson, 1992).
Clinical observations indicate that some sur-
vivors with underlying coronary heart disease en-
joy life to the fullest extent possible and are gen-
erally satisfied with their lives in spite of chronic
health problems associated with heart disease and
the unpredictable threat of a recurrent cardiac ar-
rest. Other survivors with underlying coronary
heart disease, apparently with the same chronic
illness demands and unpredictability of recur-
rence, appear to do less well and be less satisfied.
What accounts for the difference in life satisfac-
tion?
Antonovsky (1979, 1987), a medical sociolo-
gist, initially was intrigued by why some holo-
caust survivors did well in their everyday lives
while others, exposed to the same conditions, did
poorly. He proposed the salutogenic theory
(1987) to explain why persons remain healthy
during times of extremely stressful conditions.
He used a holistic conceptualization of health that
encompassed physical, psychological, and social
well-being. In contrast to the traditional medi-
cally oriented approach that focuses on why per-
sons get sick, the salutogenic theory asks why
people stay healthy.
The key construct within the salutogenic theo-
ry is sense of coherence (Antonovsky, 1987), de-
fined 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 struc-
tured, predictable, and explicable; (2) the re-
sources are available to one to meet the demands
posed by these stimuli; and (3) these demands are
challenges, worthy of investment and engage-
ment” (p. 19). Could a strong sense of coherence
equip some persons who have survived a cardiac
arrest with the strength and endurance to main-
tain or attain a high quality of life?
Antonovsky (1987) believed that there are
three domains within the sense of coherence con-
struct: comprehensibility, manageability, and
meaningfulness. A person with high comprehen-
sibility would expect stimuli to be predictable, or
at least orderable and explicable. Regardless of
the nature of the stimuli, sense could be made of
them. A person with a high sense of man-
ageability would not feel victimized or treated
unfairly, and thus would be able to cope and not
grieve endlessly. A person with high meaningful-
ness willingly would take the challenge, deter-
mined to seek meaning in it, and would do the
best to overcome it with dignity. Based on inter-
views with 51 Jewish persons living in Israel,
Antonovsky quantified this construct as the 29-
item Sense of Coherence Questionnaire. Al-
though Antonovsky believed that the sense of co-
herence is crystallized around the age of 30
years, he proposed that it can be changed in both
temporary and permanent ways. The focus of our
study was sense of coherence because it might
ultimately be a variable amenable to change
through intervention.
The only study found in which sense of coher-
ence was used as a predictor of life satisfaction
was that of Sagy, Antonovsky, and Adler (1990),
who studied 805 Israeli retirees. Sense of coher-
ence was strongly correlated with life satisfaction
( r = .54, p < .001). Total explained variance in
the path model was 31% ( p < .001), with sense
of coherence having a direct effect on life satis-
faction (standardized path coefficient f3 = .49, p
4 .001).
Coronary heart disease often requires major
lifestyle change in order to control symptoms and
minimize disease progression. Corbin and Strauss
( 1988) believed that there are extensive human
costs involved in accommodating continuously to
the demands of chronic illness and its manage-
ment. Strauss and his colleagues (1984) coined
the term illness rrajecrory, “that refers not only to
the physiological unfolding of a sick person’s dis-
ease but also to the total organization of work
done over that course, plus the impact on those
involved with that work and its organization”
(p. 64). Thus, their theory of chronic illness fo-
cuses on commonly experienced illness demands
rather than disease-specific demands.
Corbin and Strauss (1988) viewed illness tra-
jectory as the key concept within their theory of
chronic illness, with variability and phase as the
two components of a trajectory’s shape. There-
fore, trajectories can be either stable or acute,
unstable, or deteriorating (progressive disable-
ment or death). Additionally, periods of physical
and emotional recovery, called comeback phases,
might be involved. Cardiac arrest survivors are
likely to be affected by the underlying chronicity
of the coronary heart disease process and its ram-
ifications, by the acute event itself, and by the
uncertainty of cardiac arrest recurrence. Thus,
the instability of their chronic illness trajectory is
reflected by: (a) presence of coronary heart dis-
ease symptoms prior to first cardiac arrest; (b)
larger number of cardiac arrests; and (c) shorter
time since last cardiac arrest. Maintenance of tra-
 SENSE OF COHERENCE I MOTZER AND STEWART
jectory stability is a primary concern for cardiac
arrest survivors, their families, and their health
care providers.
Corbin and Strauss (1988) posited that manag-
ing an illness and accommodating to its demands
require considerable work on the part of the ill
person and his or her family. Work is necessary to
carry out a management plan focusing on multi-
ple aspects of illness and of personal and family
life. For cardiac arrest survivors, work-related
tasks might involve meeting demands from other
chronic illnesses (e.g., chronic obstructive pul-
monary disease), carrying out complex medical
regimens (i.e., antiarrhythmic drug therapy, cor-
onary artery bypass graft surgery, and/or car-
dioverter-defibrillator implantation), managing
physical and emotional discomfort, and manag-
ing functional limitations. Successful manage-
ment of these tasks should contribute to quality of
life.
There is little consensus about the definition of
quality of life. Some researchers advocate for a
holistic definition (Burckhardt, Woods, Schultz,
& Ziebarth, 1989; Ferrans, 1990; Flanagan,
I982), whereas others believe that health-related
quality of life is appropriate in health care re-
search (e.g., CASS Principal Investigators and
Their Associates, 1983; Schron & Shumaker,
1992). A holistic approach is important because
chronic illness is multidimensional (Corbin &
Strauss, 1988; Strauss et al., 1984), potentially
affecting all aspects of life. Direct assessment of
satisfaction with life is important because health
care provider assessment most often is based on
symptoms or functional limitations alone, which
may not be congruent with patient perceptions
(Mayou & Bryant, 1987).
In his holistic approach to defining quality of
life, Flanagan (1982) asked two critical-incident
questions of 3,000 subjects (500 men and 500
women in each of three age groups: 30, 50, and
70 years old). On the basis of about 6,500 critical
incidents, 15 categories of critical incidents
emerged and could be placed within 5 domains:
physical and material well-being; relations with
other people; social, community, and civic activ-
ities; personal development and fulfillment; and
recreation. Flanagan used the 15 categories as
items to reflect life satisfaction in his Quality of
Life Scale. He considered these domains valid
for the general population and recommended
studying quality of life in the disabled by focus-
ing on problems specifically created by their dis-
abilities.
In their study of quality of life in 204 persons
with one of four chronic illnesses or conditions-
289
diabetes mellitus, ostomy secondary to colon
cancer or colitis, osteoarthritis, and rheumatoid
arthritis-Burckhardt and her colleagues ( 1989)
found that all four groups used similar terms to
describe quality of life. Moreover, they found an
additional theme in all four groups that could not
be placed within the existing Flanagan (1982)
domains: independence, or being able to do for
oneself. Thus, Burckhardt and her colleagues
recommended adding an independence-related
domain to enhance the content validity of
Flanagan’s original scale for use in persons with
chronic illness. That the domain of independence
was important regardless of disease condition
supports the contention by Strauss and his col-
leagues (Corbin & Strauss, 1988; Strauss et al.,
1984) that many aspects of living with a chronic
illness are experienced across various conditions.
Thus, the definition of quality of life used in this
study was satisfaction with: physical and material
well-being; relations with other people; social,
community, and civic activities; personal devel-
opment and fulfillment; recreation; and indepen-
dence (Burckhardt et al., 1989; Flanagan, 1982).
Researchers have focused on explaining vari-
ance in quality of life in persons with chronic
physical illness (Burckhardt, 1985; Wingate,
1992) or have developed models of quality of life
in the chronically physically ill (Cowan, Graham,
& Cochrane, 1992; Graham & Longman, 1987;
Wingate, 1992) using a variety of instruments
(Ferrans & Powers, 1985; Flanagan, 1982;
Graham & Longman, 1987). Findings from these
studies suggest that perceived social support,
self-esteem, variables reflecting instability of the
chronic illness trajectory, and variables reflecting
the work of the chronic illness trajectory are pre-
dictors of quality of life.
Our conceptualization and measurement of the
outcome of quality of life in persons with a
chronic illness was influenced by Burckhardt’s
(1985) study of the impact of arthritis on life
quality ( N = 94). Although Burckhardt’s original
interest in quality of life focused on persons suf-
fering from arthritis, her recent psychometric
study (1989) included other chronically ill popu-
lations. However, she has not made her chronic
illness theory explicit. The chronic illness theory
proposed by Strauss et al. (1984) and expanded
by Corbin and Strauss (1988) provides a theoreti-
cal foundation for the generalization of our work
across chronic illness populations. The work of
Cowan and her colleagues (1992) demonstrated
similar quality of life predictors in persons with
myocardial infarction and malignant melanoma,
lending further support to this approach.
290 RESEARCH IN NURSING 8 HEALTH
The process of stressor appraisal is a major
difference in the stress and coping framework
proposed in this study compared to that used in
Burckhardt’s (1985) study. Here, a salutogenic
approach (Antonovsky, 1979, 1987) was taken in
which successful coping results in a strengthened
sense of coherence. In the Lazarus and Folkman
(1984) paradigm used by Burckhardt, stressors
were appraised in terms of their potential threat to
the individual-a pathogenic orientation. The sa-
lutogenic theory and its key construct, the sense
of coherence, have not been used before in an
attempt to explain the variance in quality of life
in persons with chronic illness.
Our conceptual model of quality of life in-
cludes six predictor constructs: social status vari-
ables related to poor health vulner$jlity, per-
ceived social support, self-esteem,’h6tab‘ility of
the chronic illness trajectory, work of the chronic
illness trajectory, and sense of coherence. Vul-
nerability to poor health was thought to be pri-
marily a result of older age and low socio-
economic status (Thoits, 1984), and may be
especially true for older women (Thoits, 1987)
who live alone (Thoits, 1987; Wood, Rhodes, &
Whelan, 1989). Married persons, regardless of
gender, report greater well-being than unmarried
persons (Wood et al., 1989). Persons from minor-
ity groups may have greater vulnerability to poor
health than persons from nonminority groups,
probably due to lower average income levels.
However, in Burckhardt’s (1985) path analysis of
quality of life in persons with arthritis, neither
age, gender, nor socioeconomic status had signif-
icant direct effects as predictors. Despite mixed
results regarding their predictive strength (Bur-
ckhardt, 1985; Wood et al., 1989), we controlled
for the construct of social status variables (older
age, female gender, minority race, lower socio-
economic status, and currently not married) in
our model.
Because of the evidence that perceived social
support and self-esteem are positively associated
with quality of life (Burckhardt, 1985; Wingate,
1992), these variables also were included. Bur-
ckhardt operationalized perceived social support
as how much physical help, social time, and ad-
vice or problem-solving help one could expect to
receive from each support person if one needed
or wanted the support. Self-esteem is defined as
“a liking and respect for oneself and the belief in
one’s ability to get along with other people” (Par-
kerson et al., 1981).
Variables reflecting instability of the chronic
illness trajectory were presence of coronary heart
disease symptoms prior to cardiac arrest, the
number of cardiac arrests experienced, and time
since last cardiac arrest (with shorter time reflect-
ing more instability). The work of the chronic
illness trajectory included emotional comfort,
physical comfort, New York Heart Association
(NYHA) Functional Class (1964), as well as
presence of other chronic illnesses, prescribed
treatment for coronary heart disease, and social
function.
We hypothesized that physical and emotional
consequences of a chronic illness, such as coro-
nary heart disease, coupled with an acute event,
like surviving a cardiac arrest, would influence
quality of life negatively through the degree of
instability of the chronic illness trajectory as well
as through the amount of work required to man-
age and shape the trajectory. Further, we hypo-
thesized that cardiac arrest survivors with a
strong sense of coherence would be more satis-
fied with their quality of life than those survivors
with a moderate or weak sense of coherence.
Specifically, we hypothesized that a strong sense
of coherence in cardiac arrest survivors would be
manifest in a dynamic feeling of confidence in
their ability to: (a) make order of the variability
associated with instability of the chronic illness
trajectory; (b) accomplish trajectory shaping
work; (c) have the motivation necessary to initi-
ate a comeback phase, accommodate to an unsta-
ble or stable but diminished trajectory, and mini-
mize the impact of coronary heart disease upon
the family; and (d) engage in meaning-making
activities around the chronic illness experience.
Our primary study hypothesis was that, after con-
trolling for social status variables related to poor
health vulnerability, perceived social support,
self-esteem, and variables reflecting the insta-
bility and work of the chronic illness trajectory,
the addition of sense of coherence would improve
estimation of quality of life.
METHOD
Design and Sample
A nonexperimental, correlational design was
used to test the study hypothesis. After obtaining
Human Subjects Review approval, all out-of-hos-
pita1 cardiac arrest survivors with underlying cor-
onary heart disease who were patients in cardiac
electrophysiology clinics of two metropolitan
medical centers were invited to participate in the
study. In order to pilot the data collection proce-
 SENSE OF COHERENCE I MOTZER AND STEWART 291

Table 1. Reliability and Descrlptive Statistics for Dependent and Predictor Variables

No. of Cronbach’s No. of Potential Actual

Variable Items Alpha Cases Range Range M SD

Dependent variable: Ouality of life

QOL 16 .91a 149 16-112 36-1 12 84.79 14.04
Social status variables reflecting poor health vulnerability
AGE 1 - 148 - 30-85 63.15 11.07
GENDER 1 - 149 0- 1 0-1 .27 .44
RACE 1 - 145 0-1 0-1 .02 .14
EDUCATION 1 - 149 1-5 1-5 2.72 1.18
MARITAL 1 - 149 0-1 0-1 .18 .39
Perceived social support
SUPPORT 24 .90a 134 0.00-3.00 0.13-3.00 2.06 0.59
Self-esteem
SELF-ESTEEM 5 .50 149 0-100 40-100 77.36 17.22
Instability of the chronic illness trajectory
SYMPTOMS 1 - 149 0- 1 0-1 .60 .49
NUMBER 1 - 141 1-3 1-3 1.45 .70
TIME 1 - 149 1-8 1-8 4.91 2.00
Work of the chronic illness trajectory
PROBLEMS 1 - 145 0-1 0-1 .47 .50
TREATMENTS 3 - 148 0-3 0-3 1.46 .72
PHYSICAL 7 .74 149 0-100 14.3-100 62.48 19.25
EMOTIONAL 9 .85 146 0-1 00 0-1 00 70.72 21.93
SOCIAL 2 .65 149 0-100 0-100 60.24 27.42
NYHA 1 - 146 1-4 1-4 1.87 .88
Sense of coherence
SOC 13 .87 147 13-91 31-91 69.21 12.95

aThe formula for standardized alpha was used

dure, 8 cardiac arrest survivors were sent ques-
tionnaires; 4 questionnaires were completed and
returned. Pilot data were evaluated, and some
reductions and other refinements were made in
the questionnaire. However, the nature of these
changes allowed the pilot data to be included in
the data obtained from the overall sample.
Revised questionnaires were mailed to 295 po-
tential subjects. Because 34 questionnaires were
not deliverable and 8 deaths were reported by
family members, the potential pool of subjects
was reduced from 303 (which included the 8 pilot
subjects) to 26 1. As 3 respondents did not meet
eligibility criteria, this potential pool was further
reduced to 258. Of the 159 persons who returned
questionnaires, 149 met analysis requirements (8
had extensive missing data and 2 were extreme
outliers for age), for an overall 58% response rate
(149/258). Based on an a priori power analysis
(Cohen, 1988), a sample size of 130 was consid-
ered adequate to detect a 10% increase in vari-
ance in quality of life by sense of coherence after
controlling for the other 16 predictors (listed in
Table 1).
The sample was largely Caucasian (95%) and
male (73%), with percent female (27%) slightly
higher than the 23%-to-77% female-to-male ratio
reported for out-of-hospital cardiac arrest (Cup-
ples et al., 1992). Most respondents were married
(82%), only 16% had not completed high school,
and 63% were retired. Many had experienced
heart disease symptoms prior to their first cardiac
arrest (60%) and only 1 1% experienced 3 or more
cardiac arrests. Time since last cardiac arrest was
variable, ranging from less than 3 months (3%), 3
months up to 1 year (24%), 1 year up to 3 years
(38%), 3 to 5 years (16%), to greater than 5 years
(19%). Inclusion of this wide range was neces-
sary in order to obtain an adequate sample size.
Seventy-four percent reported that they were
NYHA (1964) Functional Class I (without limita-
tion in physical activity as a result of heart dis-
ease) or I1 (with slight limitation of physical ac-
tivity as a result of heart disease).
292 RESEARCH IN NURSING & HEALTH
Measures
Measures were chosen based on documented evi-
dence of content and construct validity and inter-
nal consistency reliability. An additional selec-
tion criterion for the measures included their
generic applicability. The measures and number
of items in each, along with reliability and de-
scriptive statistics for the current study, are pre-
sented in Table 1. If subjects were missing not
more than 20% of the items in a scale, the overall
group mean on that item was used to estimate the
missing item score.
The dependent variable, quality of life (QOL),
was measured using the 15-item Flanagan Quali-
ty of Life Scale (1982), modified by adding a
16th item on independence as recommended by
Burckhardt et al. (1989). The response format
used was the 7-point Delighted-Terrible Scale
(Andrews & Crandall, 1976) (where 7 is de-
lighted, 6 is pleased, 5 is mostly satisfied, 4 is
mixed, 3 is mostly dissatisfied, 2 is unhappy, and
1 is terrible). In their study of four chronic illness
groups, Burckhardt’s group reported Cronbach’s
alphas of .86 to .89 with Flanagan’s original 15-
item Quality of Life Scale. They demonstrated
convergent and discriminant validity between the
Quality of Life Scale and other scales, and sup-
ported their hypothesis of differences in mean
values in groups of chronically ill persons known
to be stable or unstable across time (known
groups technique), providing evidence of con-
struct validity.
Social status variables related to poor health
vulnerability were measured using a set of five
variables in which higher vulnerability was re-
flected by older age, female gender, minority
race, lower socioeconomic status (reflected by
fewer years of education), and currently not mar-
ried. Perceived social support (SUPPORT) was
measured by the Burckhardt Perceived Support
Score (1985), modified to enhance content validi-
ty by adding an item about financial help to the
other three areas of assistance (physical help, so-
cial time, and advice or problem-solving help)
that one could expect to receive from each of six
support persons if one wanted or needed the sup-
port. This 24-item measure reflected degree of
perceived social support on a 0 = none to 3 = a
lot scale. Although 70% of the respondents sup-
plied information for all 24 items, 2 1% gave an-
swers for some but not all support persons or
categories and 9% skipped the scale entirely.
Cohen and Cohen (1983) cautioned that dropping
subjects when data are missing nonrandomly
risks -nonrepresentivenessof the sample. To ac-
commodate the extent of missing data but to re-
tain the intent of the Perceived Support Score, we
computed the average degree of perceived social
support for respondents who had answered at
least 4 of the 24 items, which was equivalent to
rating one support person on all four categories of
support. Thus, the total score was averaged
across the four categories and the network, re-
sulting in a possible range of 0.00 to 3.00, with
10% of the sample receiving a missing score.
Self-esreem was measured by the 5-item Duke
Health Profile Self-Esteem Scale (Parkerson,
Broadhead & Tse, 1990); Cronbach’s alpha was
.64in Parkerson’s 1990 primary health care clin-
ic sample but was only S O in this sample. Evi-
dence of content and construct validity and inter-
nal consistency reliability for the Duke Health
Profile was just beginning to be published as we
planned our study (Parkerson et al., 1990).
Instabilio of the chronic illness trajectory was
reflected by (a) coronary heart disease symptoms
prior to first cardiac arrest (SYMPTOMS; 1 =
yes, 0 = no); (b) number of cardiac arrests
(NUMBER; I , 2, 3 or more); and (c) time since
last cardiac arrest (TIME; 1-8 scale, where 1 =
<3 months, 8 = >5 years). Work of the chronic
illness trajectory was indicated by (a) reported
other medical problems (PROBLEMS; 1 = yes, 0
= no); (b) reported number of three possible
medical treatments used for heart rhythm distur-
bances (TREATMENTS; medication, surgery,
implantable cardioverter-defibrillator); (c) phys-
ical comfort (PHYSICAL) (Duke Health Profile
Modified Physical Health Scale); (d) emotional
comfort (EMOTIONAL) (Duke Health Profile
Modified Mental Health Scale); (e) social func-
tion (SOCIAL) (Duke Health Profile Modified
Social Function Scale); and (f) reported NYHA
Functional Class (1964).
The 63-item Duke-UNC Health Profile (Par-
kerson et al., 1981) had been mailed to the pilot
sample, but because of concern about respondent
burden (possibly contributing to the 50% re-
sponse rate in the pilot group), the newer and
shorter i7-item Duke Health Profile (Parkerson
et al., 1990) was substituted in the overall sam-
ple. Evidence of content and construct validity
and internal consistency reliability for the Duke-
UNC Health Profile is well-documented (Burck-
hardt et al., 1989; Parkerson et al., 1981). Evi-
dence of internal consistency reliability was not
as strong in the shorter Duke Health Profile,
which had been tested in 683 primary care pa-
tients (Parkerson et al., 1990). We modified two
of the Duke Health Profile Scales-Mental
Health and Social Health-because several items
 SENSE OF COHERENCE / MOTZER AND STEWART
in each scale were also used in computing the
Self-Esteem Scale. Redundant items were as-
sessed for appropriateness and retained in the
scale with the best fit (in both instances, the Self-
Esteem Scale). To enhance content validity for
persons with coronary heart disease who had sur-
vived a cardiac arrest, additional modifications
were made in the Duke Health Profile by adding
two items to the 4-item Physical Health Scale and
six items to the 3-item Mental Health Scale.
Based on the investigators’ clinical experience,
two physical symptoms applicable to cardiac ar-
rest survivors were added to modify the original
Physical Health Scale: heart palpitations and los-
ing consciousness. Based on the study of Fin-
kelmeier, Kenwood, and Summers (1984), six
emotional symptoms applicable to this popula-
tion were added to the Mental Health Scale: anxi-
ety, restlessness, fear of recurrent heart rhythm
disturbance, discouragement, irritability or tense-
ness, and having bad dreams.
Sense of coherence (SOC) was measured by
the 13-item Sense of Coherence Questionnaire,
Short Form, having a 7-point response format
where 7 represents the strongest sense of coher-
ence and 1 represents the weakest sense of coher-
ence (Antonovsky, 1987). After the pilot study, a
decision was made to use this 13-item version
rather than the 29-item version in an attempt to
reduce respondent burden. Based on previously
reported Cronbach’s alphas of .84 to .93 for the
29-item version (Antonovsky, 1987; Sagy et al.,
1990), we estimated that the reduced Cronbach’s
alphas (Nunnally, 1978) from using the 13-item
version would range from .70 to 36. The longer
version had been used extensively in 12 samples
(total N = 2,740) from Israel, the United States,
Canada, and Norway (Antonovsky, 1987; Sagy et
al., 1990). These samples ranged in age from 18
to 65 years, with student or occupational status
rather than health status as the basis of sample
selection.
For measures of quality of life and perceived
social support, internal consistency reliabilities
obtained in this study were similar to the re-
liabilities (*.05) obtained in other studies of per-
sons with a variety of chronic illnesses or condi-
tions. For the Sense of Coherence Questionnaire,
internal consistency reliability of the 29-item ver-
sion reported for a presumed healthy population
also was similar (+.06) to the internal consisten-
cy reliability of the 13-item version in our sam-
ple. Thus, these scales performed similarly
across a number of populations, supporting their
generic applicability. It remains unclear why the
Duke Health Profile Self-Esteem Scale per-
293
formed differently. The modifications made to
eliminate overlapping items and to improve con-
tent validity by adding items in the other three
Duke Health Profile Scales (Physical, Mental,
Social) resulted in improved internal consistency
reliabilities in our sample, from .67 to .74 for
PHYSICAL, from .68 to .85 for EMOTIONAL,
and from .55 to .65 for SOCIAL.
Analysis Procedures
Descriptive statistics, independent t tests, x2,hi-
erarchical multiple regression, and regression di-
agnostics (residual analyses, casewise analyses,
and partial plots) were utilized in analysis. Order
of variable entry into the regression equation was
driven by our conceptual model and hypotheses
of the importance of the predictor variables. So-
cial status variables related to poor health vul-
nerability were considered to be antecedent fac-
tors that existed prior to the coronary heart
disease and cardiac arrest. Perceived social sup-
port and self-esteem were entered at the second
and third steps, respectively, to examine their
separate contributions. Because self-esteem was
expected to contribute the larger proportion of
variance, self-esteem was entered after perceived
social support to be certain that its contribution,
if any, would be detected. The fourth and fifth set
of predictors were the instability and work of the
chronic illness trajectory, respectively. The work
variable follows the instability variable because
work was expected to explain a larger proportion
of variance of quality of life. The instability vari-
able was entered first to assure any significant
contribution of instability would be detected.
Sense of coherence, the predictor variable of in-
terest, was entered last in order to examine its
independent contribution to explained variance in
quality of life.
For hypothesis testing, the a priori level of sig-
nificance was .05. Respondents (N = 149) were
included in the regression analysis based on hav-
ing a valid score on the dependent variable,
QOL, and at least 20% or 14 of the 17 predictors.
The extent of multicollinearity was quite small.
Of the 136 correlations between all possible pairs
of the 17 predictor variables, the range of abso-
lute values of the rs was .OOto .67, with a medi-
an r of .lo. Only 4 of the 136 rs were over .40;
81% of the rs were .19 or less.
The extent of missing data at the scale level
was relatively small; of the 17 predictor vari-
ables, 1 was missing for 17% of the respondents
and 2 were missing for 5%. Compared to respon-
dents missing 0 predictors, respondents who
294 RESEARCH IN NURSING I% HEALTH

were missing 1 or 2 predictors scored lower on
QOL, r (43.38) = 2.14, p = .04.Dummy vari-
ables were created in order to test the contribu-
tion of missing predictors to explained variance
in QOL (Cohen & Cohen, 1983). None made a
significant contribution when entered after all
other predictors in the multiple regression.
RESULTS
Descriptive statistics for all scales used in the
regression model are summarized in Table 1. The
average QOL item score was 5.3 on the delighted
(7)-to-terrible ( 1) scale. Satisfaction was highest
for close relations with spouse or significant oth-
er (M = 6.1, SD = 1.12) and having and rearing
children (M = 6.0, SD = 1.10). and lowest for
participating in organizations and public affairs
(M = 4.3, SD = 1.68) and participating in active
recreation (M = 4.5, SD = 1.78). Satisfaction
with health ranked 13th out of 16 (M = 4.7, SD
= 1.48). The primary independent variable of
interest, sense of coherence, had an average item
score of 5.3 (SD = 1.00).
As proposed in the conceptual model, the 17
variables were entered in 6 steps (see regression
summary in Table 2). On the first step, social
status variables related to poor health vul-
nerability did not contribute significantly to ex-
plained variance. Thus, the first significant
change (5%) in the squared multiple correlation
coefficient, was attained on Step 2 with the addi-
tion of SUPPORT to the model. On Step 3.
SELF-ESTEEM contributed 24% to explained
variance. On Step 4, the predictors reflecting in-
stability of the chronic illness trajectory did not
make a significant contribution to explained vari-
ance. On Step 5, with the addition of predictors
reflecting work of the chronic illness trajectory,
the increment in explained variance was 17%. On
the last step, the entry of sense of coherence con-
tributed an additional 15% to the explained vari-
ance ( p < .001), for a total explained variance in
quality of life of 64%.

Table 2. Quality of Life Multlpie Regresslon Summary (Af = 149)

Variable r at Step 0 p at Last Step RZA, R2, and Adj R2 at each step
Step 1: Social status variables reflecting poor health vulnerability
AGE - .01 - .03 R 2 = .04 Adj R 2 = .OO
GENDER .10 .09
RACE -.12 - .04
EDUCATION .13 .03
MARITAL .04 - .04

Step 2: Perceived social support R2A = .05**

SUPPORT .22** .07 R2 = .09' Adj Rz = .05
Step 3:Self-esteem R2A = .24"
SELF-ESTEEM .50** .17- R2 = .33** Adj R2 = .30
Step 4: Instability of the chronic illness trajectory R2A = .02
SYMPTOMS -.12 -.12' R2 = .35'* Adj R 2 = .30
NUMBER -.05 .06
TIME .01 - .04
Step 5: Work of the chronic illness trajectory R2A = .15*"
PROBLEMS -.11 - .01 R2 = .50*' Adj R2 = .43
TREATMENTS -.01 - .01
PHYSICAL .40" .07
EMOTIONAL SO** - .04
SOCIAL .40** .13'
NYHA -.38"" -.lo
Step 6: Sense of coherence R2A = .15**
SOC .73'* 57" R2 = .64" Adj R 2 = .60
Note. Increments in R2 and R2A do not always correspond because of rounding.
' p < .05. " p < .01.
 SENSE OF COHERENCE I MOTZER AND STEWART
Tests of significance appeared to be valid, as
regression diagnostics suggested a constant error
variance and no departures from the normality
assumption. Using the standardized beta weight,
it can be seen that, on the average, there is a .57
standard deviation increase in the predicted QOL
score for every 1 .OO standard deviation increase
in the SOC score, holding all other independent
variables constant.
Exploratory Analysis of Overlap
Between QOL and SOC
Correlation coefficients between the dependent
variable QOL and each predictor at Step 0 (i.e.,
without controlling for other predictors) as well
as the standardized beta weight at the final step of
the hierarchical multiple regression are shown in
Table 2. Quality of life was more highly corre-
lated to sense of coherence than to any other vari-
able studied (r = .73).
The high correlation between SOC and QOL
raised the question of conceptual overlap and led
to further inquiry about the similarity of the con-
structs. The conceptual distinction between qual-
ity of life and sense of coherence is seen in their
definitions: “satisfaction with physical and mate-
rial well-being; relations with other people; so-
cial, community, and civic activities; personal
development and fulfillment; recreation; and in-
dependence’’ versus “personality orientation that
expresses the extent to which one has a feeling of
confidence in the ability to comprehend, manage,
and derive meaning from life,” respectively. Evi-
dence for the distinction also is apparent from
their indicators. Quality of life is assessed by
satisfaction with life domains (e.g., being de-
lighted with independence), whereas sense of co-
herence is evaluated by one’s affective pattern of
responses to life situations (e.g., very often feel-
ing that one is in a familiar situation, knowing
what to do).
Because there is potential overlap between
SOC and QOL at the measurement level in two
areas (relationships with others and meaningful-
ness), additional analyses were conducted to
evaluate the extent of any redundancy. Four items
on the Modified Flanagan Quality of Life Scale
and two items on the Sense of Coherence Ques-
tionnaire, Short Form, evaluate relationships
with others. Of the eight possible SOC-QOL
correlations, only four were significant at p >
.05 (rs = .20-.30) and all were less than the
average interitem correlation for either the Mod-
ified Flanagan Quality of Life Scale ( r = .40) or
the Sense of Coherence Questionnaire ( r = .34).
295
Thus, it seems that overlaps in the context of
relationships with others did not contribute sub-
stantially to the very high zero-order correlation
between QOL and SOC.
Another area of concern with overlap was
measurement of meaningfulness. Four items on
the Sense of Coherence Questionnaire, Short
Form, and one item on the Modified Flanagan
Quality of Life Scale pertained to meaningful-
ness. Relationships between the QOL item and
the four SOC items were strong ( r = .48 to .52, p
< .001). For demonstration purposes only, a new
quality of life scale without the meaningfulness
item was created. This scale version’s correlation
with SOC was .72 ( p < .001). Thus, elimination
of the item that seemed most directly responsible
for the overlap in meaningfulness did not alter the
strength of the correlation between SOC and
QOL .
Based on these analyses, sense of coherence
and quality of life appear to be distinct concepts.
Therefore, we concluded that sense of coherence
indeed predicts quality of life and that its associa-
tion with quality of life is not the result of mea-
surement artifact.
The variable with the highest beta weight
throughout the regression analysis was SOC,
starting at Step 1 at .73 and ending at Step 6 at
.57 ( p < .001). Thus, the beta weight for SOC
dropped only by .I6 after all other variables had
been entered. The only other variables with a
significant beta weight at the last step were
SELF-ESTEEM (p = .18), SYMPTOMS (p =
--.12), and SOCIAL (p = .13).
DISCUSSION
The findings support the study hypothesis: After
controlling for social status variables related to
poor health vulnerability, perceived social sup-
port, self-esteem, and the chronic illness trajec-
tory shape and work variables, the addition of
sense of coherence improved estimation of quali-
ty of life. The independent contribution made by
sense of coherence-an additional 15% of the
variance in quality of life-exceeded the esti-
mate of 10% made when performing the a priori
power analysis.
Our finding of 50% of explained variance in
quality of life prior to the entry of sense of coher-
ence into the model is congruent with Bur-
ckhardt’s (1985) finding of 46% explained vari-
ance in persons with arthritis. Perceived social
support, negative attitude towards illness, self-
esteem, and internal control over health were her
296 RESEARCH IN NURSING & HEALTH
significant predictor variables. Our finding of
50% explained variance also was similar to
Wingate’s (1992) finding of 45% explained vari-
ance in 96 women after myocardial infarction,
with employment status, social support, and self-
esteem as her significant predictor variables. The
additional 15% contribution by sense of coher-
ence provides new information about quality of
life in persons with chronic illness. The results
also support the findings of Sagy et al. (1990),
who found that the sense of coherence had a di-
rect effect (p = .48, p < .001) on life satisfac-
tion, with 3 1 % of the variance in life satisfaction
explained by sense of coherence and three other
predictors.
The nonsignificant contribution of social status
variables reflecting poor health vulnerability was
expected based on their lack of predictive strength
in previous studies. The contribution of per-
ceived social support to quality of life was less
than expected based on findings of both Burck-
hardt (1985) and Wingate ( 1992). Its contribution
may have been strengthened had a less compli-
cated scale been used or data been collected dur-
ing a structured interview rather than from mailed
questionnaires. That perceived social support
was significant in spite of measurement diffi-
culties supports its continued inclusion in models
of quality of life. Despite its low internal con-
sistency reliability, self-esteem’s contribution to
quality of life was substantial and supports the
assertions of Burckhardt and of Wingate about its
importance. A more reliable measure would have
enhanced its contribution in this study. The lack
of contribution from instability of the chronic ill-
ness trajectory to explained variance in quality of
life probably reflects inadequate measurement of
the construct. The major contribution of work of
the chronic illness trajectory to explained vari-
ance at the next-to-last step of the regression
model strongly supports the chronic illness theo-
ry of Strauss and his colleagues (Corbin &
Strauss, 1988; Strauss et al., 1984). Better mea-
sures of both chronic illness trajectory constructs
would extend our understanding of the contribu-
tions of health care interventions to improved
quality of life.
Quality of life in this sample was high (item
average = 5.3 out of a possible item score of 7).
This finding corresponded with that of Bur-
ckhardt et al. (1989) in their study of persons
with one of four chronic conditions. With the
original 15-item Flanagan Quality of Life Scale,
they obtained an average item score of 5.2. The
similarity of the average item quality of life score
between persons in this study with coronary heart
disease surviving a cardiac arrest and persons
with diabetes mellitus, ostorny secondary to co-
lon cancer or colitis, osteoarthritis, or rheumatoid
arthritis (Burckhardt et al., 1989) is further evi-
dence that many aspects of living with chronic
illness are experienced across various conditions
(Corbin & Strauss, 1988; Strauss et all, 1984).
Sense of coherence obtained in this sample of
cardiac arrest survivors (item M = 5.3, SD =
1.0, on the 13-item SOC scale with a 1-7 re-
sponse format) was compared to the item M ob-
tained by samples described by Antonovsky
(1987) on the 29-item SOC scale. Using the ef-
fect size index (Cohen, 1988),the item average in
the cardiac arrest survivors was about 0.2 stan-
dard deviation lower than the mean scores of
three samples reported to have a strong sense of
coherence (item Ms = 5 . 3 , but a quarter stan-
dard deviation higher than the mean scores of two
of three groups hypothesized to have a moderate
sense of coherence (item M = 5.0-5.1) and
roughly half to three-quarters standard deviation
higher than means obtained by samples reported
to have a relatively weak sense of coherence
(itemM = 4.6-4.8). The influence of surviving a
cardiac arrest, experiencing chronic illness, or
both, might account for the differences in strength
of sense of coherence between this sample and
the comparison samples. Alternatively, because
the shorter version of the Sense of Coherence
Questionnaire was used, it may be that those 13
items typically have higher mean scores than the
other 16 items, which may have resulted in a
higher mean overall for our sample. That possi-
bility remains to be examined.
Quality of life through the eyes of the client
rather than the provider has become increasingly
important as an outcome measure in health care
intervention research (AHCPR, 1990; Stewart,
1992). For the person with chronic illness, inter-
ventions to improve or maintain life quality need
to be directed toward the entire illness trajectory,
which involves multiple aspects of the person’s
life rather than simply the course of the disease.
The most important finding from this research is
the large amount of additional variance in quality
of life explained by sense of coherence after con-
trolling for multiple predictors used in past re-
search.
An important unanswered question is: Does
the relatively high mean sense of coherence of
persons in this study indicate that something
about their situation may have increased their
overall level of sense of coherence? That is, did
sense of coherence change naturally in response
to life events? If so, could interventionsbe devel-
 SENSE OF COHERENCE / MOTZER AND STEWART
oped to facilitate its change? Providing structured
life experiences to assist the ill person and his or
her family to shape the illness trajectory and fa-
cilitating meaning-making activities on the part
of chronically ill persons and their families are
examples of interventions that might b e used to
enhance sense of coherence.
In conclusion, our findings support longitudi-
nal testing of sense of coherence in chronic ill-
ness populations with and without expected life-
threatening events to examine the stability or
changeability of the construct, with further inves-
tigation of sense of coherence as a predictor of
quality of life. Those results could lead to devel-
opment and testing of strategies specifically de-
signed to 'enhance comprehensibility, manage-
ability, and meaningfulness, perhaps ultimately
resulting in improved quality of life.
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