Does a Gratitude Self-Care Practice Improve Nurses’ Well-Being?

About 4.4 million nurses practice in the United States. Lengthy shifts, demanding workloads, and under-staffing are common. Critical care nurses also face complex clinical environments, high-acuity cases, advanced technology, and exposure to environmental stressors (noise, lights), traumatic events, and ethical issues—all of which may have a negative impact on nurses' physical and psychological health and well-being.1–4 In a prepandemic survey, more than half of responding critical care nurses reported suboptimal levels of physical and mental health, and many were experiencing some degree of stress, anxiety, and depressive symptoms and lower professional quality of life (QOL).5 These findings illustrate how workplace demands may have a negative impact on the well-being of health care professionals (HCPs), threatening the quadruple aim: high quality care, reduced health care costs, enhanced patient experience, and improved clinician satisfaction.6,7During the COVID-19 pandemic, stress and exhaustion reached unprecedented levels and led to substantial turnover and staffing crises8 despite organizational efforts to improve nurse resiliency. In a 2022 national survey, more than 50% of nurses reported contemplating leaving the profession primarily due to the detrimental impact of work on their health.9 Indeed, nurses have individual accountability and an ethical obligation10 to care for their unique needs for emotional, psychological, spiritual, and physical well-being. Studies have also shown that leader support and encouragement are major facilitators of self-care.1,5 In particular, critical care nurses who perceived greater support for workplace wellness had better physical and mental health and a higher professional QOL.5 Thus, organizations have a critical responsibility to mitigate sources of workplace stress and assist nurses to adopt healthy behaviors that improve well-being.8,11,12One lens through which one can view self-care options is the National Center for Complementary and Integrative Therapies' (Figure 1) classification of physical, nutritional, and psychological practices. Because an extensive comparison of various self-care practices is out of the scope of this column, this evidence synthesis focuses on gratitude, a psychological strategy currently receiving much attention in public and professional communities alike. Gratitude has been described as an attitude, emotion, habit, or coping response.14,15 It may also be defined as the appreciation of what is valuable, positive, and meaningful in one's life.16,17 Gratitude can be narrowly focused toward actions of specific people or more broadly on things like spirituality or nature.14,18,19 High-level evidence is available on the effects of gratitude on emotional and psychological well-being among healthy people,15 medical populations,20 and clinical nurses21; however, authors of other meta-analyses express caution in claiming physical health improvements resulting from gratitude.22–24 These findings fueled our curiosity to better understand what is known about the impact of gratitude among HCPs. Thus, the PICO (patient, intervention, comparator, outcome) question: What effect do gratitude practices (I) have on holistic well-being outcomes (O) of HCPs (P), compared with self-care routines without gratitude (C)?The strategy included searching CINAHL and PubMed. Key words included nurses, critical care, self-care, practices, gratitude, health, and well-being. The search was limited to English articles published in the past 7 years. Both research and quality improvement studies were considered if nurses were included in the study samples.Table 1 outlines findings of 7 studies. Of these, 2 were randomized controlled trials, 3 were nonrandomized trials, 1 was a qualitative study, and 1 was a quality improvement study. Settings ranged from primary care to inpatient units to long-term care. Most interventions involved gratitude diaries or journals used on a daily, semidaily, or weekly basis. Some used text and email reminders to increase adherence, which waned in some studies.14,18,25,28 Some studies emphasized workplace gratitude, but most stressed personal and workplace gratitude. Other studies also included thank you notes14 or focused on thanking and complimenting people (no diary),26 while others compared gratitude with practices like mindfulness.16,26,27 Outcomes evaluated covered most categories common in gratitude research (Figure 2),23 with positive effects found in at least 1 study at 2, 3, 4, 6, or 8 weeks. Outcomes related to patients' experience also improved in one study.27 Qualitative themes revealed that workplace gratitude often involved "having a good day at work," "a day that was not busy," "teamwork," and "good collegial relationships,"18,25,28 whereas personal gratitude was focused on "supportive relationships," "meaningful use of time," and "self-care."25,28This synthesis provides encouraging evidence (levels B and C; Table 2) in support of the positive effects of gratitude on HCPs' psychological health (stress, depression, burnout) and their emotional (self-kindness, empathy, coping self-efficacy, self-care, mindfulness, gratitude), psychological (autonomy, compassion satisfaction, job satisfaction), and social (mutual support, situational awareness) well-being. Further research on the effect of gratitude on HCPs' health outcomes as well as patients' experience is warranted. Research is also needed to identify the "dose" or frequency of feeling gratitude required to improve these outcomes without being burdensome.18As a self-care option, gratitude can be practiced anywhere.14 It begins with intention to learn to see the positive, deepening our awareness of what we appreciate (Figure 3). When we practice gratefulness, scientists have demonstrated that reward pathways in the brain related to stress and interpersonal bonding are activated,19 improving connections and relationships that strengthen support networks.18 Thus, by engaging in small moments of gratitude throughout the day, we retrain these neural networks to shift from a negative to a positive focus and thereby change our emotional responses to everyday situations. Repetition is what retrains our brains, so striving for a feasible gratitude practice is key. As consistency is gained, we can start monitoring how aspects of our well-being such as self-kindness, mindfulness, coping, stress, and burnout may be improving.Promoting healthy self-care practices is as much of an organizational imperative as an individual priority. Nurse leaders can foster a culture of gratitude (Figure 3) by infusing it into the routines of their role and teams as well as into the fabric of the larger organization. Studies in this synthesis found gratitude practices can also affect professional life by enhancing autonomy, compassion satisfaction, and job satisfaction of individual HCPs, as well as situational awareness and mutual support that improves teamwork—all characteristics of healthy work environments. Therefore, as influential role models, leaders can set the stage11,26–28 for a "surround sound" where gratitude permeates the everyday organizational experience.11Just imagine—as the culture of gratitude takes shape—how it ripples among nurses, HCPs, and patients and their families alike.