Behavioral Health Unit Gratitude Intervention Study: Patient and Nurse Perceptions

Gratitude is the positive experience of feeling thankful and appreciative when receiving something beneficial. It is linked to psychological well-being, but more evidence about its impact on physical well-being is needed. When providing holistic healthcare, there is an opportunity to inquire into what a patient is thankful/grateful for, to offer insight into other patient-centered caring actions that may improve their overall well-being and/or hospitalization experience. This is of particular importance for hospitalized patients with primary admission psychiatric-related diagnoses. Adult inpatient behavioral health evidence-based gratitude interventions are needed to facilitate this approach.

Background

Boggiss et al. (2020) conducted a systematic review (19 of 1433 articles included) of gratitude interventions and their effects on physical health and health behaviors. Researchers concluded that gratitude interventions may improve subjective sleep quality, and more that gratitude intervention efficacy and improved health outcomes research is needed. They also concluded the need for research and interventions in patient populations with psychosocial interventions that are clinically useful. Of these 19 articles, none included adult inpatient behavioral health research.

Diniz et al., (2023) conducted a meta-analysis of 64 randomized trials investigating the effects of gratitude interventions. Researchers reported that patients who underwent gratitude interventions had more gratitude, better mental health, and fewer anxiety and depression symptoms. They concluded that acts of gratitude can be a therapeutic complement for treating anxiety and depression and can increase positive feelings and emotions in the general population. They also identified a great diversity in patient characteristics. Of these 64 trials, only one addressed psychiatric-related conditions, which was a gratitude diary for the management of suicidal inpatients (Ducasse et al., 2019).

Jans-Beken et al., (2020), published an overview of 64 experimental studies, complemented with longitudinal studies with at least two measurement waves. Both state and trait gratitude were included. State gratitude was identified as an attribution-dependent or affective-cognitive state based on the individual's ability to be empathic, which results from appraising a received benefit as a positive outcome recognized from an external source. Trait gratitude was identified as a wider life orientation towards noticing and being grateful for the positive in the world. Researchers reported connections between gratitude and human health, including gratitude interventions moderately benefiting mental well-being factors (e.g., emotional, social, and psychological well-being) but not reducing psychopathological symptoms. While several of these studies included psychiatric disease states, such as schizophrenia, substance use problems, depression, and anxiety, none were conducted on an inpatient adult behavioral health population.

From a holistic perspective, while nurses and interprofessional teams work to improve the patient experience during hospitalization, patients are not being asked to routinely communicate what is going well with their hospitalization or what they are thankful/grateful for in life. Accordingly, nurse researchers innovated a nurse-led, patient-centered gratitude intervention with an interprofessional focus on 91 adult hospitalized medical patients, evaluating their perceptions of the gratitude intervention, and whether nurse-identified actionable items improved patient hospitalization experiences (Lindauer et al., 2021). Patients completed gratitude forms twice daily for up to 6 shifts and a study discharge form documenting intervention perception. In response to patient gratitude-related feedback, Registered Nurses (RNs) documented actions that they, and interprofessional teams, could implement to improve patients’ hospitalization experience. On average, patients perceived the nurse-led gratitude intervention as helpful (4.2/5) and improved hospitalization experiences (4.3/5). Most of the time, actions were required or taken based on patient gratitude intervention responses. Researchers concluded that patients perceived the nurse-led gratitude intervention as helpful and improved the hospitalization experience.

In translating findings into practice, nursing leadership at our hospital noted the opportunity for inpatient behavioral health nurses to include an evidence-based gratitude intervention into patient care. Accordingly, researchers studied the gratitude intervention in the inpatient behavioral health unit. The medical-surgical gratitude intervention methodologies from the previous research were used, as described below for this study, and as previously published (Lindauer, 2021). The following additional methodologies were added to the inpatient behavioral health unit study: interventions were completed every shift through patient discharge; patients were asked whether the gratitude intervention should be completed every shift; and RN study participants were asked to rank the helpfulness of the gratitude intervention.

Theoretical Framework

Kristin Swanson's (1991) Caring model has been adopted within our organization, with the tenet of caring for patients and families at the center of all activity. Swanson's definition of caring includes a person's biopsychosocial and spiritual well-being as a fundamental component of good nursing care. This model has five essential components of the nurse-client relationship: knowing, being with, doing for enabling, and maintaining belief (Al Yasin, 2023). These elements have been woven through our professional practice model and consequently used as a foundation for the current study.

Though all five elements are essential, two are particularly valuable for this study. "Being with" is one of the most vital elements because it is about being emotionally available or present in the moment for our patients. Asking what is important to them and what they are grateful for is taking the time to engage the patient in a meaningful conversation about their well-being. "Doing for" is another essential element because it identifies future needs and specific items that the nurse can act on and advocate for the patient. The nurse-led, interprofessional focused gratitude intervention is an approach to facilitate more holistic healthcare for our hospitalized patients.

Study Aims

Our study aims were to evaluate 1) the effect of a nurse-led, interprofessional-focused gratitude intervention on the patient experience, and 2) if, by asking gratitude-related questions, nurses were able to identify actionable items for nurses and / or interprofessional team members to improve the patient experience.

Materials and Methods

Study Design and Setting
This mixed-methods, prospective study was conducted on a 20-bed acute behavioral health unit in one academic community-based hospital, part of a six-hospital system in the United States mid-Atlantic region.

Patient inclusion criteria were adults, expected to be hospitalized for at least two days on the inpatient behavioral health unit, who could read and write in the English language. Those with conditions precluding the ability to participate in this study were excluded. RN study participants were required to be employees.

Ethical Considerations
The hospital Institutional Review Board approved this study. A confidential informed consent process was followed for each potential patient and RN participant. All participants provided signed consent. Confidentiality and anonymity of participant information was ensured through utilization of unique study identifiers and participant data was maintained in a secure database accessible only to researchers.

Nurse-Led Gratitude Intervention and Measures
At the beginning of every 12-hour shift, unit RNs caring for study patients asked them to complete two questions on a Gratitude Entries Form: 1) Please share what is working well for you during this hospitalization or what you are generally thankful/grateful for in life, and 2) Please share how your nurse and/or other healthcare team member might be able to improve your experience as a patient regarding your response to question #1 above. Every unit RN leads the gratitude intervention by communicating patient responses with other interprofessional team members, including during interprofessional rounding, determining what needs to occur on the current and/or subsequent shifts by nurses and/or by interprofessional teams/team members. RNs utilized the gratitude intervention patient response information as part of a dual focus on patient care (i.e., stabilizing the patient, managing problems), and a more holistic approach to facilitating what is working well, and what the patient is generally thankful/grateful for in life.

The intervention was continued through patient discharge or patient request to end study participation. At discharge, patients were asked to complete the following: helpfulness and improvement of hospitalization experience of the gratitude intervention rankings, comment on how the gratitude intervention affected patient experience, provide recommendations for the frequency of conducting the gratitude intervention (e.g., every shift), and comment.

All unit RNs were required to provide the gratitude intervention for study patients every shift and to complete documentation on actions taken as a result of the intervention. Only RN study participants provided rankings of the intervention's helpfulness. These RN study participants were also asked to comment on the following question: Please comment on how the patient answering the question(s) affected your care of the patient.

Hypotheses, Sample Size and Methods of Analysis
A total sample of 75 patients provided a statistical power of 80% to test the hypotheses' mean score on the helpfulness of the gratitude and improvement questions. Significance was a mean score greater than 3.0, for normally distributed data. The power analysis was conducted assuming an observed mean of 3.5, standard deviation (SD) of 1.5, and alpha level of 0.05. This sample size allowed the detection of a significant effect for the hypothesis that the percent of times the gratitude form led to an action by the RN is greater than 50% if the observed percent is 67% or higher, with an alpha of 0.05 and statistical power of 80%. As the RN employee potential sample was small (n = 25), RN perceptions of the helpfulness of the gratitude intervention was not powered.

Statistical analysis was completed in SAS version 9.4. As the data for the gratitude and improvement outcomes revealed asymmetric distributions, these were analyzed nonparametrically. Accordingly, both the median (inter-quartile range, IQR) and mean (SD), and median (IQR) were more appropriate statistics than mean (SD) with such asymmetrically distributed data. To test the hypothesis that the gratitude ranking would be significantly greater than a median of 3 for three variables, a Wilcoxon signed-rank test was used instead of testing for a mean using a one-sample t-test, as the distributions were not normal. These variables were the following three questions (See specific Likert type rankings for individual questions in Results section below):

Question 1. As a patient, how helpful was it for your overall experience to share what was working well regarding your hospitalization, or what you were generally thankful/grateful for in life?

Question 2. As a patient, how often was a nurse and/or other healthcare team member able to improve your hospitalization experience after sharing your response to the above question?

Question 3. Please specify how helpful it was for you as the RN to conduct this gratitude intervention with your patient.

Question 4. For this question, a dichotomous measure, a binomial test was used with 50% as a test value: Do you recommend that sharing what was working well regarding your hospitalization, or what you were generally thankful/grateful for in life, should be done at every shift? (yes/no).

Question 5. To analyze the gratitude intervention actionable related question, Please specify actions that you took as the RN after learning the patient’s response [to the two columns to the left] that you otherwise would not have taken, as measured by ‘Action required,’ the percent an action was taken was calculated for every patient across the number of times that the patient received a gratitude intervention over different shifts.

Qualitative analysis was used for open-ended questions obtained from patient and RN responses. Codes were identified and aggregated into categories (Hsieh & Shannon, 2005). Researchers independently coded data, reviewed findings, and resolved discrepancies to reach a consensus to develop themes. The top three primary themes for every question are reported below when the total units coded were 10 or greater.

Results

This study included 75 patient participants and 16 RN participants (see Table 1). Most patients were female (42, 56.0%) and non-Hispanic (72, 96%), with an average age of 43.5 years, and length of stay of 12.0 days. Primary admitting diagnoses were major depressive disorder (n = 40, 53.3%) and bipolar disorder (n = 18, 24.0%). Most RN participants (n = 16) were female (15, 93.8%), with a bachelor’s degree or higher in nursing (13, 81.2%) and six or more years of unit experience (10, 62.6%).

Table 1. Demographics

*Not mutually exclusive, no secondary admitting diagnosis for 10 patients

Patient Evaluations at Study Discharge
The mean number of gratitude entry forms completed per patient was 7.9 (SD=5.39) (Table 2). Forms may not have been completed every shift due to, for example, patient condition, patient not available to complete, and the patient opted to not complete the form.

Table 2. Patient Perceptions of a Nurse-Led, Interprofessional Focused Gratitude Intervention

*p<0.001
+Wilcoxon signed-rank test
++Binomial test (test value=50%)

Patient rankings of the gratitude intervention as helpful were significant (M=4.2, median=5; p <0.001). Responses for Question 1, As a patient, how helpful was it for your overall experience to share what was working well regarding your hospitalization, or what you were generally thankful/grateful for in life? were ranked 1=Very unhelpful; 2=Somewhat unhelpful; 3=Neutral; 4=Somewhat helpful; and 5=Very helpful. When analyzed by helpfulness and primary admitting diagnosis, the most frequent diagnoses associated with the very helpful category (n = 45) were major depressive disorder (22, 48.9%) and bipolar disorder (12, 26.7%). Five (6.7%) patients ranked the intervention as very unhelpful; their diagnoses were major depressive disorder (2,40.0%), bipolar disorder (2, 40.0 %), and schizoaffective disorder (1, 20.0%).

Patient rankings of the gratitude intervention as improving their hospitalization experience was significant (M=4.2, median=4; p <0.001) Responses for Question 2, As a patient, how often was a nurse and/or other healthcare team member able to improve your hospitalization experience after sharing your response to the above question? were ranked 1=Never; 2=Seldom; 3=Somewhat often; 4=Very often; and 5=Always. Primary admitting diagnoses associated with the always category (n = 35) were major depressive disorder (19, 54.3%) and bipolar disorder (9, 25.7%). Two (2.7%) patients ranked the never category; their diagnoses were major depressive disorder (1, 50.0%) and adjustment disorder (1, 50.0%).

Question 4, Do you recommend that sharing what was working well regarding your hospitalization, or what you were generally thankful/grateful for in life, should be done at every shift? was scored as Yes/No, with an opportunity to comment). Patient recommendations to complete the intervention every shift were significant (59, 78.7%; p<0.001).

Actionable Specifications Identified by Nurses
Question 5 asked of RNs, Please specify actions that you took as the RN after learning the patient’s response that you otherwise would not have taken. Of a total of 526 shifts, action was required or taken 130 (24.7%) times (see Table 3). Most action types were interprofessional collaboration (48, 37.5%), and nurses positively recognizing a healthcare team member based (22, 17.1%).

Table 3. Actionable Results from Nurse-Led, Interprofessional Focused Gratitude Intervention

*Not mutually exclusive,
+Although the form was checked for 48 entries, data on type identified were available/recorded for 29 cases only, i.e., type data was missing for 9 cases (48=29+9)
++Of 98, type of action data available/recorded only for 94 cases
+++Of 38, team membership data available/recorded only for 33 cases

The RNs also documented responses to the following question: As a result of the patient response(s), will additional actions be required for following shifts? For these 531 shifts, most action types were interprofessional collaboration (38, 30.4%), and actions for the oncoming RN (35, 37.2%).

Nurse Perceptions of Gratitude Intervention Helpfulness
RN participants provided rankings of the gratitude intervention as significantly helpful. The question, Please specify how helpful it was for you as the RN to conduct this gratitude intervention with your patient was ranked 1=Very unhelpful; 2=Somewhat unhelpful; 3=Neutral; 4=Somewhat helpful; and 5=Very helpful. The ranking of the gratitude intervention as helpful (somewhat helpful or very helpful) was 63.8% (mean=4.0, median=4) (p<0.001) for 359 shifts Table 4 lists these RN helpfulness rankings.

Table 4. RN Participant Gratitude Intervention Helpfulness Rankings

*p<0.001 Wilcoxon signed-rank test

Qualitative Analysis of Patient Comments
Table 5 describes the primary themes that emerged from patient comments when they were asked the following two questions every shift. For the first question, Please share what is working well for you during this hospitalization or what you are generally thankful/grateful for in life, most (84.0%) comments were coded as hospital-related; 16.0% were external to the hospital. Primary themes from the 1,209 units coded suggested that patients were thankful/grateful for caring team members (584, 48.3%), condition-related resources and management (253, 20.9%), and external factors (197, 16.3%).

For the second question, Please share how your nurse and/or other healthcare team member might be able to improve your experience as a patient regarding your response to question #1 above, most (54.3%) comments were coded as recommendations for improvement; 45.7% were to continue what was occurring. Primary themes from the 415 units coded for improvement were condition-related resources and management (164, 39.2%), team care (129, 30.9%), and hospital-related resources (125, 29.9%).

Table 5. Primary Themes Patient Comments
(Note: Bulleted comments are direct quotations from participants)

At discharge, two questions were asked. For the first discharge question, Please comment on how responding to these questions during your hospitalization affected your patient experience, the primary themes for the 100 units coded were that the gratitude intervention helped the patient feel more comfortable (35, 35.0%), it was an outlet to express being thankful/grateful (16, 16.0%), and it improved patient experience (15, 15.0%).

For the second discharge question, Do you recommend sharing what was working well regarding your hospitalization, or what you were generally thankful/grateful for in life should be done at every shift?, only one primary theme emerged from the 42 units coded. This was a recommendation to complete the gratitude intervention every shift as it was helpful (33, 78.6%).

Qualitative Analysis of RN Participant Comments
Table 6 provides primary themes that emerged from RN participant comments on the question, Please comment on how the patient answering the question affected your care of the patient. Of the 259 units coded, most comments (66.0%) affected patient care; 34.0% had no effect on patient care. Two primary themes emerged for affecting care from the 171 units coded: the gratitude intervention enables the provision of more patient-centered care (114, 44.4%), and patient expression of appreciation of good care being received was helpful (47, 18.1%).

Table 6. Primary Themes RN Comments
(Note: Bulleted comments are direct quotations from participants)

Discussion

These inpatient gratitude intervention findings are some of the first reported for nurses and interprofessional teams to consider as an approach to more holistic inpatient healthcare that improves patient experience. Previous findings from inpatient adult behavioral health and medical-surgical unit (Lindauer et al., 2021) studies demonstrated statistically significant patient rankings of the gratitude intervention as helpful and as improving their hospitalization experience. Additional findings from the behavioral health unit demonstrated that the behavioral health unit patients recommended completion of the gratitude intervention every shift, a statistically significant finding. As well, behavioral health RNs who participated in the study ranked the gratitude intervention as helpful (also statistically significant).

Findings of the behavioral health unit gratitude intervention, the medical-surgical unit gratitude intervention study, and extensive reviews completed by Boggiss et al., (2020), Diniz et al., (2023), and Jans-Beken et al., (2020) supported gratitude interventions. Our findings also supported the gratitude intervention as a patient experience tool to be completed every shift by RNs and interprofessional teams to facilitate more holistic care. The gratitude intervention may be considered by nursing management as a professional engagement tool based on participating nurses’ perceptions of the helpfulness of the intervention. Further, the gratitude intervention findings related to nurse-client relationships align with this hospital’s caring model (Swanson, 1991). For example, because of the intervention, nurses were able to take more actions (i.e., doing for) based on the needs of patients. Also, nurses identified that the intervention enables more patient-centered care.

Additional gratitude intervention studies are warranted with other inpatient populations for those aiming to facilitate more holistic healthcare and/or to improve the patient experience and professional engagement. This may include any adult and pediatric inpatient and ambulatory settings where gratitude interventions can be measured. Finally, to further expand upon trait gratitude in hospitalized patients, consider adding to a gratitude intervention study a scale that addresses trait gratitude (Lomas et al., 2014).

Limitations of this research study included the following: Some patients did not complete every gratitude data point throughout the study, and unit RNs may not have completed every data point. Trait gratitude was not measured in patients at baseline. Also, due to the nonprobability, convenience sample, findings from this study may not be generalizable to other settings.

Implications for Practice

Findings from this study, and previous research incorporating interprofessional teams to determine patient perceptions each shift about gratitude, provide support for providers aiming to provide more holistic healthcare. This adult behavioral health nurse-led study on an inpatient unit offers evidence of the impact of an interprofessional-focused gratitude intervention. Behavioral health nurses, and any nurses and interprofessional team members on other units, can consider the gratitude intervention as a patient experience tool. (AUTHORS: The above 3 sentences were originally one very long sentence. Even after five or six reads I was struggling to make sense of it. I divided it into these three sentences trying to capture what I believe are your points. Please review this to be sure that it is accurate. If not, I am very open to editing. I do not want to change your meaning, but felt that this needs to be more clear for readers to make sense of your thoughts. Thanks! Jackie) Findings supported the conduct of the gratitude intervention every shift. Lastly, findings support the gratitude intervention as a professional engagement tool based on nurse perceptions of the intervention helpfulness.

Conclusion

In this study, several findings were statistically significant. Patients ranked the intervention as helpful to improve the inpatient hospitalization experience. RN participants also ranked the intervention as valuable to patient centered care. RN utilization of the patient responses to the gratitude intervention was demonstrated in several ways. First, the gratitude intervention became part of a dual focus on patient care to stabilize patients and manage problems. Second, patient comments informed a more holistic healthcare approach to facilitate what worked well and for what these patients were generally thankful/grateful in life. Overall, insight into this information was deemed important to patients and RNs alike.

Disclosures: All authors met the author criteria for publication. Authors have no conflicts of interest to disclose. Address correspondence to: Cathleen Lindauer, Nursing Education, 5300 Alpha Commons Dr. Suite 292 Baltimore, MD 21224 Phone: 410-550-0179 Office; 410-550-4254 Fax.

Acknowledgment: Researchers thank behavioral health unit patients and RNs who participated in this study.

Authors

Karen Gabel Speroni, PhD, RN, BSN, MHSA
Email: ksperon1@jhu.edu
ORCID ID: https://orcid.org/0000-0001-6259-8501

Karen Gabel Speroni is the Perrone Nursing Research Consultant at Johns Hopkins Bayview Medical Center (JHBMC) and adjunct faculty at Johns Hopkins University School of Nursing in Baltimore, MD.

Cassandra Herbert, MS, RN, AHN-BC
Email: charris5@jhmi.edu
ORCID ID: https://orcid.org/0009-0000-5204-1224

Cassandra Herbert is a Patient Care Manager on the Acute Psychiatric Unit at JHBMC in Baltimore, MD.

Kristi Rocha, MSN, RN
Email: krocha1@jhmi.edu

Kristi Rocha is an Assistant Patient Care Manager on the Acute Psychiatric Unit at JHBMC in Baltimore, MD.

Michael Mugo, CRNP, PMH
Email: Mmugo1@jhmi.edu

Michael Mugo is a Nurse II on the Acute Psychiatric Unit at JHBMC in Baltimore, MD.

Chakra Budhathoki, PhD
Email: cbudhat1@jhmi.edu

Chakra Budhathoki is an Associate Professor at the Johns Hopkins University School of Nursing in Baltimore, MD.

Cathleen Lindauer, DNP, RN, NDP-BC
Email: Ccarlen1@jhmi.edu
ORCID ID:  https://orcid.org/0000-0002-5909-6727

Cathleen Lindauer is the Nursing Practice and Professional Development Specialist in theDepartment of Nursing Practice, Education, & Research at JHBMC in Baltimore, MD.