Reflective Tasks With Healthcare Workers During COVID-19

The healthcare workforce is amongst the most stressed in the UK, with 40.3% of staff feeling
unwell as a result of work-related stress in the past year. This is steadily increasing each
year, rising 3.5% from 36.8% since 2016. Chronic stress can cause psychological health
problems, including low mood, anxiety and insomnia. Unfortunately, only 29.3% of staff across
the NHS felt their trust took positive action on health and wellbeing, which may contribute
to and prolong this continued rise in work-related stress.

With the COVID-19 health pandemic adding additional pressure to the NHS, healthcare workers
(HCWs) are at further risk of mental health problems, including post-traumatic stress
disorder, depression and substance misuse, as evident from historical health pandemics.
Furthermore, preliminary data from China during the COVID-19 health pandemic indicated
frontline HCWs experienced depression (50.4%), anxiety (44.6%), insomnia (34%) and distress
(71.5%). A systematic review identified risk factors for increased psychological distress of
HCWs during a health pandemic: being female, a nurse and experiencing stigmatised attitudes
from the general public, as well as being quarantined. Perceived control and social support
were associated with lower distress. Recommendations were made, to encourage a sense of
autonomy (with information and resources), increase social support and to initiate public
health campaigns with accurate facts, to reduce stigma and distress.

Positive Psychology Interventions (PPIs) are one approach for promoting autonomy and reducing
distress, by increasing positive emotions, behaviours, and/or thoughts, thereby increasing
the wellbeing of an individual. Positive psychology focuses on optimism, positive attitude
and gratitude, to encourage creativity, improve happiness and reduce mental barriers to
productivity, as opposed to focusing on 'problems'. PPIs include gratitude journals, using
affirmations, strength focussing exercises and mindful meditations. PPIs in workplaces have
improved performance, job wellbeing, engagement and other areas, whilst reducing negative
performance and negative job wellbeing.

PPIs have focused on gratitude as a target for improving wellbeing, due to the inverse
relationship found between gratitude and burnout. Burnout is a state of emotional and
physical exhaustion, cynicism and detachment from work, caused by prolonged stress. Gratitude
is a positive, social emotion, similar to appreciation, which can either be state (of being)
or trait (dispositional). State gratitude is experienced when undeserved acts of kindness or
generosity are given freely by another person. Whereas trait gratitude is viewed as a
characteristic of a person, that varies in intensity and frequency throughout their daily
life. Gratitude interventions have found improvements (with a small to medium effect size) in
quality of relationships, wellbeing and optimism, alongside job satisfaction . Furthermore, a
reduction in anxiety, depression and negative affect is also evident.

Gratitude interventions utilise both expression and self-reflection as their methodological
properties. Expression includes giving small tokens of appreciation or paying gratitude
visits. Self-reflection includes writing personal gratitude lists or journals. Gratitude
lists were as effective as clinical therapies when working with excessive worry. Whereas,
sharing a gratitude letter was not as effective at improving gratitude, furthermore
expression of gratitude immediately induced feelings of embarrassment and discomfort.
However, increases in elevation were noted here, namely improved job performance,
connectedness, empowerment and autonomy. The reduced effectiveness of this expressive
gratitude intervention, may be due to barriers in engagement with the intervention, including
the expected awkwardness of the situation and the 'gratitude expresser's' mood.

Effectiveness of gratitude interventions in improving gratitude is likely to be affected by
both traits of participants and specificities of the intervention, such as length. Research
found trait gratitude moderated the effectiveness of the gratitude intervention in increasing
gratitude. This supports the resistance hypothesis, suggesting that those who are predisposed
to experience gratitude will not benefit from a gratitude intervention. Irrespective of
gratitude moderation, wellbeing significantly improved. The duration of the intervention may
also have an impact on effectiveness. Research found higher life satisfaction, more gratitude
and an improved positive affect in HCWs, after writing a gratitude diary bi-weekly over
4-weeks. Whereas a shorter 5-day intervention in the workplace, using a similar journaling
methodology, was not effective at improving gratitude. This may be explained by research,
which found a cumulative improvement in gratitude and happiness over 8-weeks of grateful
letter writing, indicating gratitude interventions are required to be of a reasonable length
in order to be effective.

HCWs are suffering from psychological distress as a result of the COVID-19 health pandemic.
It is vital interventions are offered to support their wellbeing. Gratitude interventions are
effective at improving wellbeing and reducing psychological distress, namely the risk factors
associated with psychological distress in HCWs at present. Self-reflective gratitude
interventions, over a period of weeks are effective at improving gratitude with HCWs, without
inducing embarrassment, discomfort or barriers to engagement. However, it is not clear if
there are differences in effectiveness dependent upon the methodological properties of the
intervention.

This study will aim to investigate the effects of a gratitude intervention with HCWs, with a
view to increasing state gratitude and psychological wellbeing (subjective happiness and
positive affect), whilst reducing psychological distress (negative affect and depression).

Objectives

1. To investigate if gratitude interventions are effective at increasing state gratitude in
HCWs

2. To investigate if gratitude interventions are effective at reducing psychological
distress and improving wellbeing in HCWs

3. To investigate if high baseline trait gratitude is a moderator of changes in state
gratitude, psychological distress and wellbeing after a gratitude intervention

Hypotheses

1. A gratitude intervention will increase state gratitude in HCWs

2. A gratitude intervention will improve wellbeing (positive affect and subjective
happiness) and reduce psychological distress (depression and negative affect) in HCWs

3. High levels of trait gratitude will moderate the outcomes