By Jill Suttie | Greater Good Magazine
Imagine you are a nurse who has been working day and night during the COVID-19 pandemic. You’ve seen patients become sick and die, met with grieving families, and, in some cases, haven’t even received adequate protective gear to do your job safely. No doubt, you’d be physically and emotionally drained.
This is a recipe for burnout. And, no surprise, many nurses are burned out. Emotional exhaustion has been an ongoing risk for nurses in their job, even long before the pandemic. Now it’s only gotten worse: 62% of registered nurses report feeling more sad and depressed than they were before the pandemic.
This is obviously bad news for many reasons. Nurses who are burned out suffer from mental and emotional exhaustion, feel more detached from their patients, and are less engaged at work. They are more prone to sickness and may be more likely to leave the profession. This should concern not just nurses but the rest of us who depend on them to care for us when we’re at our most vulnerable. Their well-being is both a moral and practical concern.
What can be done to help nurses be more resilient and avoid burnout? Certainly, they need the basics: protective gear to keep them safe, reasonable schedules, and patient loads. But they also can benefit from a workplace culture that values their well-being and takes steps to support it.
Research has found that one of the most effective ways to support well-being is by building a culture of gratitude—and recent studies show how the benefits of gratitude extend to nurses in particular. When nurses experience gratitude at work—whether they practice it themselves or express it to a colleague—it helps to reduce their stress, build positive relationships, and increase their sense of meaning on the job. While it may not replace other workplace supports, it can help fuel the resiliency they need to do the difficult work they do.
“After studying the literature around resilience, well-being, burnout, and gratitude, I became a full convert,” says Perry Gee, a scientist studying nurse wellness who advises large health care organizations. “Gratitude is one of the main interventions we could use to help increase nursing resilience.”
Why gratitude benefits nurses
Gratitude has been studied as a key to happiness for years now, with its benefits for personal well-being well-established. Being thankful for the good in your life can make you happier, healthier, and more resilient. Expressing gratitude toward others inspires them to be kind and helpful, improving social relationships. And, since even just witnessing gratitude encourages people to pass it along, it can easily spread within groups.
At work, gratitude improves how people handle stress, boosts their job satisfaction, and increases their sense of self-efficacy. Generally, it improves people’s overall well-being, which means fewer sick days and more attachment to their workplace.
While fewer studies on gratitude have looked at nurses specifically, recent research suggests giving thanks provides many of the same benefits to them, too. For example, in one study, researchers asked 1,575 health care workers (about 22% of the nurses) about their levels of emotional exhaustion, then had them spend seven minutes writing a gratitude letter to someone who’d done something special for them. The letters focused on thanking someone for who they are or what they did or expressing how their actions benefitted the writer. Ultimately, these letters significantly decreased emotional burnout up to a week later.
This mirrors findings from another recent study by lead author Kathryn Adair of Duke University, where health care workers who wrote a gratitude letter—or listed three good things from their day over a two-week period (another gratitude practice)—had reduced symptoms of burnout.
Adair suggests that writing gratitude letters has ripple effects, too, as 75% of the participants in her gratitude letter study reported finding it easier to think of other things to be grateful for after writing their letter.
“Gratitude shifts one’s mindset from what one is lacking to a focus on what one does have and how fortunate they are to have it,” says Adair. “This shift makes one more likely to look around and appreciate hard-working and caring colleagues.”
Though Adair didn’t use the most rigorous study design (a randomized controlled study) another recent paper did.
Health care workers from five Chinese hospitals (about half nurses) were randomly assigned to journal twice a week over a month about things for which they were grateful, work hassles, or nothing at all. Those who journaled about gratitude were significantly less stressed and depressed than other health care workers in the study, even three months later.
As the study authors conclude, “Counting blessings is an effective approach to reduce the stressfulness and depressive symptoms among practitioners.” The practice was popular with health care workers and easy to do, they add, and can augment other institutional changes promoting wellness.
“Without diminishing the role of the working environment and other important factors, the findings provide a new, psychological dimension to look at ways to reduce stress and improve the well-being of health care workers,” they write.
Other studies have found that nurses with a grateful mindset have greater well-being and better work performance, while those practicing gratitude may become more satisfied with their jobs. A recent analysis of several studies of gratitude in health care noted that while research is limited, “gratitude should be recognized as integral to the social relations that significantly influence what people think, feel, say, and do in relation to health care.”
Real-world results
Before his current position at Intermountain Healthcare in Utah, Gee worked at Dignity Health in California, tasked with finding ways to build nurse resilience. When he learned about the work of pioneering gratitude researcher Robert Emmons, a professor of psychology at the University of California, Davis, it convinced him to try out gratitude journaling—first on himself.
“I had never been a grateful person; in fact, I used to complain a lot,” he said. “But once I began this practice, I became a very happy, grateful person. I think it may have changed my brain chemistry.”
After that, Gee was sold on the practice and began promoting it to tens of thousands of nurses and nursing units working at Dignity Health. Anecdotal stories convinced him it was working. But rising nurse “employee engagement” scores, reflecting more job satisfaction, a greater sense of meaning, and better team relationships among nurses, provided more evidence.
“Now, I regularly preach about the benefits of gratitude,” he says. “It’s simple, and it’s something nurses can easily do.”
Laurie Combe, president of the National Association of School Nurses, has also found practicing gratitude helpful in her personal and professional life. When she faced a difficult illness, she began regularly listing three good things in a journal each day to combat the stress she was experiencing. She started encouraging nurse colleagues to insert gratitude practices into their workplace, helping them to not only feel better but improve collegial relationships.
“When you practice intentional moments of gratitude, you really build team spirit,” she says. “It’s contagious.”
This was true for Kelly Carter, who ran a nursing surgical unit within Virginia Commonwealth University. Worried about nurse wellness in her unit, she looked to the research of Bryan Sexton, a colleague of Adair’s, and decided to test out a gratitude practice with her team. At the end of a morning “safety huddles,” where nursing staff review patients’ needs, she added a “gratitude huddle,” asking each nurse to say something they felt grateful for at work—like a colleague who helped answer patient calls. Soon she noticed a change in her staff.
“People started helping each other before they were asked, anticipating their needs,” she said. “It was amazing.”
She believes that there was a lot of “unspoken gratitude” that nurses had been feeling already but hadn’t expressed out loud before. Verbalizing gratitude made it more salient, she says, helping staff to “look for the good” and spreading to the whole team, “transforming” the unit.
Eventually, Carter’s nurses began a gratitude practice at the end of their workday, too. Carter put up a gratitude board where they could leave Post-it notes with gratitude missives, which were then shared at the next shift’s huddle, helping goodwill to spread.
While she can’t be sure gratitude directly prevented burnout, she, like Gee, saw employee engagement scores rise significantly after instituting these practices—a trend repeated for many years afterward.
“When you have a high nurse satisfaction and communication because of gratitude, that contributes to a healthy, happy work environment,” she says.
Which gratitude practices are right for nurses?
There are many research-based gratitude practices that have been found to promote happiness and well-being. But since nurses are often swamped on the job, wellness interventions need to be fast and easy to implement, as well as effective. Here are some gratitude interventions that nurses recommend.
Gratitude journaling. There are many ways to keep a gratitude journal, but the basic instruction is this: Write down two to five things you are grateful for, two or three times a week, and savor the warm feelings that come from doing that. You can express gratitude for small things (like enjoying a delicious peach) or bigger things (like the birth of your grandchild), as long as you write about something specific and personal to you that feels like a gift.
Gee says that gratitude journaling at home is easy to do. ”It doesn’t have to be for something like a new car or a house; it might be that you were first in line at Starbucks,” he says. “Whatever it is, just writing it down makes you feel happier—and it’s easier to think about other things you’re grateful for afterward, too.”
He also suggests it’s a good idea for nurses to incorporate this type of practice into everyday moments at work, noticing the good things in their life—for instance, by thanking security guards for keeping their workplace safe or by taking a moment while washing their hands between patients to remember something that went right from their workday.
“Nurses need something they can integrate into their job,” he says. “I hear so many nurses saying, ‘Do not give me one more thing to do!’”
Gratitude letters. To write a gratitude letter, call to your mind someone who did something for you for which you are extremely grateful—a relative, friend, teacher, or colleague. Then write them a letter thanking them, letting them know what you appreciated about them and what they did, sharing how they made your life better.
Though some research suggests taking 15 minutes to compose a gratitude letter, a shorter version can easily fit into a nurse’s busy schedule, says Adair. In her study, people only took about seven minutes to write one letter, and it still made a difference.
“Compared to other established well-being interventions, writing a gratitude letter may pack a pretty big punch,” she says.
If the person you’re writing to is still alive, you can enjoy even greater well-being by hand-delivering the letter or reading it to them via phone or Zoom. Though Adair’s study didn’t ask participants to share their letters with others, 64% of the participants requested a copy of their letters after the fact, presumably to do just that.
“People sharing letters likely receive an even greater boost of gratitude and other positive emotions, including increased social connection, warmth, and trust,” she says.
Gratitude huddles. A gratitude huddle is an opportunity for people to gather and share things they are grateful for in a group setting, to build a sense of community. This can happen during a staff meeting or, as Carter found, during routine safety meetings when nurses come on shift.
Carter specifically asked staff to say thanks for things they appreciated about being at work and working with colleagues—rather than giving thanks for getting time off from work, for example.
“We kept the gratitude work-focused because I wanted to make the work environment better,” she says. “It was one of the most important things that we did as a team at the beginning of our shift.”
Gratitude as part of a nurse wellness program
While evidence suggests that practicing gratitude can improve nurses’ resilience, it’s also important to keep in mind that it’s not a panacea. Organizations need a multi-pronged approach to nurse wellness, says Combe. That might include making accommodations for individual needs through flexible schedules (which prevents burnout) or giving nurses more autonomy and putting them in positions to influence policy (which improves retention).
Carter also believes that we can’t press nurses to be grateful without taking a comprehensive approach to caring for their well-being. “You can’t just do gratitude and expect everybody’s going to be grateful even though they don’t have PPE at their organization,” she says.
While past experiences introducing gratitude practices into health care settings have been positive, they seem to work best when they are seen as authentic and as part of a workplace culture rather than a one-off exercise. If nurse leaders embrace gratitude and practice it consistently, it’s more likely to make a difference in helping nurses thrive.
“Just pausing for a moment every day to say thank you to a colleague feeds the giver as well as the receiver, which definitely builds resilience,” says Combe. “We need to take these moments for our own self-care if we want to be able to care for our patients.”
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