Effects of a gratitude intervention on job engagement among newly recruited nurses: A randomized clinical trial

Abstract

Background

Gratitude at work is defined as the tendency to notice and appreciate aspects of work, how it affects one's life. Studies show that gratitude education can alleviate individual burnout and increase the ability to resist pressure, but it is not clear whether gratitude intervention can improve individual job involvement.

Objective

The purpose of this study is to determine whether gratitude intervention can reduce stress, job burnout and enhance job involvement of new nurses.

Methods

A randomized controlled trial was conducted from September 2020 to September 2021. A total of 118 new nurses in China were randomly divided into gratitude group and control group by random number table method. The control group received routine training for new nurses, and the intervention group received, in addition, a gratitude intervention for 2 months. The primary outcome measure was the Utrecht Work Engagement Scale-9 score (UWES-9). Secondary outcome indicators were Gratitude Questionnaire score (GQ-6), The Perceived Stress Scale score (PSS), and Maslach Burnout Inventory score (MBI). This study was reported using the CONSORT checklist.

Results

A total of 118 new nurses were included. The scores of UWES-9 scale of the gratitude group were significantly higher than those in the control group immediately after intervention, 3 months and 6 months after intervention, as the main observation index. Among the secondary outcome indicators, GQ-6 and MBI Personal Accompli-shment scores in the gratitude group were significantly higher than those in the control group immediately after intervention and 3 months after intervention. The PSS, MBI-Emotional Exhaustion and Depersonalization scores in the gratitude group were significantly lower than those in the control group immediately after intervention, 3 months and 6 months after intervention.

Conclusions

Gratitude intervention can effectively improve the level of job involvement and gratitude, reduce stress and burnout of new nurses. However, this was a relatively short follow-up period. Further studies are needed to assess the long-term effects for new nurses.

Keywords

gratitude occupational health stress management burnout work engagement positive psychology mental health promotion

Introduction

The nursing profession entails not only heavy work, but also direct contact with patients’ pain, pain and death, with higher work pressure involving psychological and emotional aspects. Moreover, various factors such as specific work conditions as well as the economic crisis for nursing personnel contribute to the undersupply in the nursing industry.¹ According to reports, it is estimated that by 2030, there will be a shortage of nearly 2.5 million nurses in 23 Organization for Economic Co-operation and Development (OECD) countries.² Due to experiencing the gap between ideal and actual working conditions as new nurses learn to cope with their new professional roles, as many as 66% of nurses report a significant level of burnout during their first few years of practice.³ What is worse is that a startling 71.8% of new nurses in China harbor the intention of leaving their posts.⁴ Yu et al. 's study shows that among newly graduated nurses in South Korea, turnover intention is related to burnout in an unfavorable work environment.⁵ Khamali has implemented a multi-modal process for ICU nurses with more than 6 months of ICU experience to change the work environment, reducing the work stress of ICU nurses and reducing nurse turnover.⁶ Therefore, we can find ways to reduce the turnover rate of nurses by changing the working environment and improving nurses’ ability to cope with stress.

Job involvement refers to the enthusiasm and cognition of the individual to the work in which she/he is engaged, which mainly refers to the degree of work vigor, absorption and personal dedication.⁷ Bargagliotti⁸ conducted a thorough conceptual analysis of work engagement, indicating that in nursing practice, work engagement manifests as a state of total concentration and dedication of nursing staff, which is often nurtured and developed in an autonomous and trust-filled work environment. The practical application of work engagement helps to enhance the safety and cost-effectiveness of nursing work, ultimately leading to better patient care outcomes.Yu and Lee⁵ conducted a cross-sectional study and structural equation modeling to investigate 371 new nurses who had worked in hospitals for no more than 18 months. The research found that job engagement had a negative impact on turnover intention. Therefore, it is of great significance to improve the job engagement of newly graduated nurses and reduce their turnover intention.Previous studies have reported that positive psychology interventions can improve general well-being and enhance work engagement among those with low work engagement,⁹ and have particularly great potential as a self-care technique for caregivers.¹⁰

Gratitude is a positive emotion which can occur when a person receives kindness from others. Gratitude potentially exerts an influence on specific aspects of physical well-being. As exemplified by the study conducted by Redwine et al.,¹¹ the implementation of gratitude interventions during the execution of diary tasks yielded encouraging outcomes, specifically an elevation in heart rate variability (HRV). Nevertheless, among this distinct cohort of patients suffering from heart failure stage B, no significant alterations were observed in resting HRV following the intervention. Consequently, there is a pressing need for comprehensive and extensive future investigations in this regard. After Hazlett and et al.¹² explored the health benefits of gratitude and the neural mechanisms behind it, they found that although there were no significant differences between the gratitude intervention and the control group intervention in terms of visual stimulus response, social evaluation, and amygdala activity, people who increased their supportiveness before and after the intervention had a greater decrease in amygdala reactivity after completing the gratitude task, and the production of inflammatory biomarkers (such as TNF-αand IL-6) after stimulation was also significantly reduced. This suggests that gratitude may benefit health by reducing responses to threats and increasing supportive behaviors, especially in reducing inflammatory responses. How does gratitude at work, defined as noticing and appreciating aspects of work, affect one's life and can this trend be enhanced by regularly recording that for which one is grateful or expressing gratitude to others?^13,14 The purpose of gratitude intervention activities is to improve practitioners’ understanding of personal experiences related to gratitude emotion.¹⁵

When Copeland et al.¹⁶ explored the brief gratitude intervention for nurses, the results showed that the intervention was feasible and acceptable. Participants conducted the intervention during most of their working hours and expressed willingness to continue after the six-week intervention period, suggesting that the intervention had a positive impact on the perception of burnout, compassion fatigue, and teamwork.Adair and et al.¹⁷ conducted an intervention measure called "thank-you letter writing" among 1575 medical staff. The results showed that writing thank-you letters significantly improved the participants’ sense of happiness, job satisfaction, work-life balance, and emotional exhaustion (EE). Research shows that gratitude education can help alleviate individual burnout and increase stress resistance.^18,19 Few studies, however, have clarified the effects of gratitude intervention for job involvement of new nurses.

Newly recruited nurses are in the transition stage from school to workplace, facing a series of stressful situations, such as adapting to clinical work, maintaining colleague relationships, professional standardized training, etc. In order to adapt to professional roles as soon as possible, new nurses often do not consider their own physical and mental health. As nursing managers, it is urgent to ensure the safety of clinical nursing and optimize the physical and mental health of new nurses. Therefore, the primary objective of this trial was to assess whether a gratitude education program was effective in improving job engagement of newly recruited nurses. Secondary objectives included assessing the impact of the intervention on perceived stress at work, including assessment of burnout, and stress.

Research design and methods

We conducted a randomized controlled trial from September 2020 to September 2021, which has been registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2300071240). The trial has been approved by the Ethics Committee of Xuzhou Central Hospital (Approval number:XZXY-LK-202221201-114). All procedures followed the ethical standards of the National Research Council and the Declaration of Helsinki²⁰ and informed consent was obtained from the participants.

Participants and randomization

The newly recruited nurses in Xuzhou Central Hospital in 2020 were selected as the research potential participants, by convenience sampling. Inclusion criteria: Having obtained a nurse professional qualification certificate, being a new nurse with no work experience before taking the job, having not undergone standardized training, voluntary participation in this study. (Before the study began, a consent form was provided to the new nurses to ensure that potential participants fully understood the purpose, process, potential risks and benefits of the study, as well as their rights.).

Exclusion criteria: Non-clinical nursing posts; illness, pregnancy or lactation. These criteria aimed to ensure the study's feasibility, participant safety, and ethical considerations.

During the recruitment period, a total of 144 new nurses were contacted, 132 of whom agreed to participate in the study and were randomly assigned to different research groups, namely, the gratitude group and the control group. We applied the inclusion and exclusion criteria to the pool of 132 nurses who agreed to participate in the study. Subsequently, we used random number table method (www.randomization.com) to randomly assign 132 new nurses to odd or even groups, respectively. During the intervention, 5 new nurses were lost to follow-up, 5 new nurses quit their job and 4 new nurses were transferred to other positions. We eventually included 118 new nurses into the analysis. The outcome measurements should have been performed/self-reported by the nurses, all outcome measurements were analysed by professionally trained clinical evaluators. In addition, during the follow-up period, those administering the intervention and the new nurses themselves were required to keep confidential all aspects concerning their participation in the study.

Measures and intervention

Participants responded to the scale at baseline (T1), immediately after intervention (T2), 3 months after intervention (T3) and 6 months after intervention (T4). Before the intervention, the participants also answered a questionnaire that included information about gender, age, marital status, education level and professional title.

Primary outcome

The UWES-9 scale score at immediate, 3, 6 months after intervention was a primary result of this study.

The simplified version of the Utrecht Work Engagement Scale-9 (UWES-9), designed by Schaufeli et al.,²¹ which contains 9 items and a total score of 54. The Likert 7-scale was scored from 0 (never) to 6 (always), with higher scores indicating better job involvement. The correlation coefficient between the simplified version and the original scale was 0.92, showing good reliability and validity.²² This study adopts the version translated by Chinese scholar Zhao²³ and validated in the Chinese population. The Cronbach's α coefficient of the scale is 0.93.

Secondary outcomes

The GQ-6, PSS and MBI scores were the secondary outcomes.

The Gratitude Questionnaire (GQ-6) was designed by McCullough et al.,²⁴ which contains 6 items and a total score of 42. The Likert-7 score was scored from 1 (strongly disagree) to 7 (strongly agree), among them, the third and sixth items are reverse scoring questions. GQ-6 mainly assesses gratitude traits at four levels: frequency, intensity, density and breadth. The higher the score, the higher the gratitude tendency and the more grateful the character. The Cronbach's α coefficient of the questionnaire was 0.75.²⁵ This study adopted the version translated and validated by Chinese scholars Wei et al.²⁶ specifically for the Chinese population. The Cronbach's α coefficient of the scale is 0.89.

The Perceived Stress Scale (PSS) was designed by Cohen et al.,²⁷ which contains 10 items and a total score of 40. The Likert-5 scale was scored from 0 (never) to 4 (always), with higher scores indicating better stress. The Cronbach's α coefficient of the questionnaire was 0.754.²⁸ This study adopted the version translated by Chinese scholar Yang²⁹ and validated in the Chinese population. The Cronbach's α coefficient of this scale is 0.735.

Maslach Burnout Inventory (MBI) was designed by Maslach et al.,³⁰ which contains 22 items and 3 dimensions. Among them, EE has 9 items; depersonalization (DP) has 5 items; reduced personal accomplishment (PA) has 8 items. The Likert-7 scale was scored from 0 (never) to 6 (always), the higher the score of EE and DP and the lower the score of PA, the more serious the degree of burnout. The Cronbach's α coefficient of the total scale and subscales range from 0.65 to 0.91.³¹ This study adopts the version translated by Chinese scholars such as Li³² and validated among Chinese people. The Cronbach's α coefficient of the scale is 0.93.

Intervention

Control group

According to the new nurse training program, a 6-month novice adaptation period was conducted before starting the job. The training utilized clinical pathway teaching methods and a combination of online and offline instruction to gradually impart theoretical knowledge, operational skills, work processes, job responsibilities, rules and regulations, and emergency response plans.

Gratitude Intervention Group

The gratitude intervention group carried out gratitude intervention for 2 months on the basis of the six-month novice adaptation period training for new nurses. To foster a sense of gratitude among new nurses and thereby alleviate professional burnout, we have established a gratitude intervention team composed of the chief nurse, co-chief nurse, supervisor nurse, and two senior nurses. The chief nurse was responsible for the formulation of the intervention plan and the evaluation index; the co-chief nurse and supervisor nurse were responsible for the implementation of intervention contents; the senior nurses cooperated with the implementation of the intervention and the distribution of questionnaires. To ensure all team members can effectively lead and participate in intervention activities, they have all undergone comprehensive training on gratitude-related knowledge and skills.

Based on the gratitude intervention of Emmons³³ and Heckendorf,³⁴ a gratitude program suitable for the nursing field was designed. This combined the intervention content with Chinese filial piety culture, emphasizing gratitude towards family members and colleagues. When introducing gratitude therapy, we integrate the concepts of gratitude and benevolence from Confucian culture. We use Chinese historical stories, idioms, or fables to convey messages of gratitude, such as "a drop of water received, repaid with a spring of water," emphasizing the importance of gratitude and reciprocity. When translating and designing materials, we pay attention to Chinese expression habits and linguistic characteristics, using humble and respectful language to express gratitude, consistent with politeness and respect in Chinese culture. At the same time, we respect the boundaries of personal privacy and emotional expression in Chinese culture, avoiding forcing the sharing of information that individuals are unwilling to disclose.

The intervention method was a combination of online and offline. The online intervention was realized by establishing "WeChat" groups, and the intervention content was mainly gratitude video and audio. More videos and songs related to gratitude, such as "Grateful Family", "Grateful Society" and "Grateful Medical Workers", to be regularly released in the "WeChat" every week. The offline intervention includes knowledge lectures, cognitive training and emotional experience training. Among them, knowledge lectures help new nurses to understand the source and concept of gratitude, connotation and life examples. Further activities included application of gratitude to specific medical situations, carrying out thanks-themed activities, writing a negative emotion letter to colleagues, patients and leaders every week, responding from the other side's perspective, conducting emotional experience training, and keeping a gratitude diary for cognitive training every day". Detailed in Table 1, the intervention was divided into 4 times, once every 2 weeks, 1.5 h each time for 2 months.

Table 1.

Summary of the sessions content in gratitude intervention.

Time	Content
The first intervention	Introduce gratitude therapy
	Sources and concepts of gratitude. (10 min) The meaning and function of gratitude. (10 min) Content of gratitude. (15 min) Group discussion on the connotation of gratitude and life examples. (25 min) How to be grateful. (30 min)
The second intervention	Capture gratitude in life, establish gratitude consciousness
	Recognize and capture gratitude from specific medical situations. (35 min) (cognitive training) Discuss feelings from specific medical negative emotional situations. (40 min) (Cognitive training) Keep a daily gratitude journal. (5 min) Write letters to colleagues, patients and leaders with negative emotions every week, and reply letters from the perspective of the other person to change their cognition in the letters. (10 min, once a week)
The third intervention	Carry out themed activities related to gratitude
	Chorus and sign language performance of "Grateful Heart". (15 min) Watch the gratitude video "Turning Point". (20 min) Invite the second session of Chinese moral model-Tian Xiuying to give a speech. (40 min) Keep a daily gratitude journal. (5 min) Write letters to colleagues, patients and leaders with negative emotions every week, and reply letters from the perspective of the other person to change their cognition in the letters. (10 min, once a week)
The fourth intervention	Carry out themed activities related to gratitude
	Perform the sketch "Thank You for Having You". (20 min) Conduct gratitude game Destiny Card. (Gratitude emotion experience training) (20 min) Music and gratitude meditation sentences evoke gratitude. (gratitude emotion experience training) (40 min) Summarize and strengthen gratitude therapy. (10 min)

Statistical analysis

Sample size

The final evaluation index of this study was the score of job involvement. According to the results of the preliminary experiment, suppose the type I error is two-sided α = 0.05，the type II error is β = 0.2, finally, a minimum of 110 participants were required. Given the 20% loss of follow-up rate, increase to 132.

Data processing

Data processing used SPSS 26.0. Chi-square test was used for binary variables. After the continuous variable was tested by Shaprio-Wilk test, independent sample t test was performed on the normally distributed data, and it was expressed as the mean ± SD. Data conversion was performed on data with non-normal distribution. After conversion, data with normal distribution adopted independent sample t test, and data with non-normal distribution after conversion adopted Mann-Whitney U test, which was expressed as the median (IQR (range)).

Statistical tests

Repeated measures ANOVA was employed to compare multiple measurements at different time points. A two-tailed calculation test with a significance level (P-value) of less than 0.05 indicated statistically significant differences.

Results

New nurses characteristics and flow

Figure 1 shows the detailed flowchart of new nurses enrollment and randomization. A total of 132 participants were included in the study according to the inclusion and exclusion criteria, including 66 new nurses in the gratitude group and 66 new nurses in the control group. In the gratitude group, 5 new nurses were lost to follow-up, and 2 new nurses discontinued participation in the study. In the control group, 4 new nurses were transferred to other positions and 3 new nurses discontinued participation in the study. In the end, a total of 118 new nurses were retained in the study. (59 in the gratitude group and 59 in the control group). A total of 118 new nurses were included, with an average age of 22 years. Most of the participants > 90% were female, and the proportion of the participants with Bachelor degree or higher level was 49.2% (Table 2).

Figure 1.

The detailed enrollment, randomization flow diagram of the new nurses.

Table 2.

Baseline demographic characteristics of the study participant.

	Gratitude group	Control group	T/χ²	P value
Male/Female	<5*	6/53	2.145	0.272
Age (years)	22.3 ± 1.4	22.1 ± 1.2	0.923	0.358
Marital status
Unmarried,	56	57	0.209	1.000
Married	<5*	<5*
Educational level (%)
College degree	33(55.9)	34(57.6)	1.015	0.602
Bachelor degree	25(42.4)	25(42.4)
Master degree or above	<5*	<5*
Professional title
None	58	57	0.342	1.000
Primary	<5*	<5*

* Participant count less than 5, exact number not reported to maintain confidentiality.

Outcome measures

Tables 3 and 4 show that the 4 scales of UWES-9, GQ-6, PSS and MBI are comparable at T1(P > 0.05), and the UWES-9 scores, PSS scores, MBI-EE scores, MBI-DP scores and MBI-PA scores in gratitude group and control group have significant differences at T2, T3 and T4 (P < 0.05); GQ-6 scores are different between two group at T2 and T3 (P > 0.05), however, there was no difference at T4 (P > 0.05).

Table 3.

Changes over time in each indicators between the two groups.

	Gratitude Group (59)	Control Group (59)	Group^a
UWES-9
T1	31.1 ± 6.3	31.3 ± 6.1	0.836
T2	38.4 ± 6.2	32.2 ± 5.7	<0.001**
T3	37.5 ± 6.6	31.7 ± 5.5	<0.001**
T4	35.6 ± 5.0	29.0 ± 6.6	<0.001**
GQ-6
T1	30.1 ± 5.0	29.3 ± 4.7	0.379
T2	33.5 ± 3.8	30.2 ± 4.3	<0.001**
T3	33.3 ± 3.8	29.6 ± 4.3	<0.001**
T4	31.7 ± 4.4	30.7 ± 4.1	0.211
PSS
T1	18.8 ± 5.2	19.4 ± 4.4	0.506
T2	15.1 ± 5.4	19.7 ± 4.1	<0.001**
T3	15.9 ± 5.0	20.3 ± 5.3	<0.001**
T4	16.5 ± 4.8	19.4 ± 5.2	0.002**
MBI-EE
T1	23.8 ± 9.5	23.2 ± 7.1	0.677
T2	16.8 ± 7.2	24.6 ± 6.9	<0.001**
T3	18.7 ± 6.8	23.7 ± 5.5	<0.001**
T4	18.4 ± 5.8	23.2 ± 4.8	<0.001**
MBI-DP
T1	8.0 ± 3.3	7.7 ± 3.8	0.659
T2	3.9 ± 1.9	7.6 ± 3.1	<0.001**
T3	4.1 ± 2.1	7.3 ± 4.0	<0.001**
T4	4.4 ± 2.0	7.5 ± 4.0	<0.001**
MBI-PA
T1	30.2 ± 9.2	29.9 ± 7.0	0.858
T2	34.9 ± 5.6	30.1 ± 5.5	<0.001**
T3	33.2 ± 6.4	30.5 ± 6.4	0.024**
T4	33.2 ± 5.8	30.2 ± 7.0	0.013**

Abbreviation: UWES-9, the Utrecht Work Engagement Scale-9; T1, Baseline; T2, Immediate Postintervention; T3, 3 months Postintervention; T4, 6 months Postintervention;

**, have significance; GQ-6, Gratitude Questionnaire-6; PSS, The Perceived Stress Scale; MBI-EE, Maslach Burnout Inventory- Emotional Exhaustion; MBI-DP, Maslach Burnout Inventory- Depersonalization; MBI-PA, Maslach Burnout Inventory- Reduced Personal Accomplishment, ^a Independent t-test/chi-squared test between groups.

Table 4.

Comparison of each scale scores of new nurses in the same group at different time points.

	P ¹⁾	P ²⁾	P ³⁾	P ⁴⁾	P ⁵⁾	P ⁶⁾
UWES-9
gratitude group	<0.001**	<0.001**	0.001**	0.929	0.049	0.339
control group	0.969	1.000	0.232	0.998	0.021**	0.057
GQ-6
gratitude group	<0.001**	0.002**	0.348	1.000	0.096	0.164
control group	0.808	0.999	0.491	0.954	0.990	0.629
PSS
gratitude group	0.001**	0.014**	0.090	0.930	0.429	0.989
control group	1.000	0.901	1.000	0.982	1.000	0.922
MBI-EE
gratitude group	<0.001**	0.001**	<0.001**	0.507	0.685	1.000
control group	0.927	0.999	1.000	0.971	0.747	0.996
MBI-DP
gratitude group	<0.001**	<0.001**	<0.001**	0.999	0.895	0.995
control group	1.000	0.995	1.000	0.999	1.000	1.000
MBI-PA
gratitude group	0.004**	0.167	0.142	0.523	0.599	1.000
control group	1.000	0.999	1.000	1.000	1.000	1.000

Abbreviation: UWES-9, the Utrecht Work Engagement Scale-9; **, have significance; GQ-6, Gratitude Questionnaire-6; PSS, The Perceived Stress Scale; MBI-EE, Maslach Burnout Inventory- Emotional Exhaustion; MBI-DP, Maslach Burnout Inventory- Depersonalization; MBI-PA, Maslach Burnout Inventory- Reduced Personal Accomplishment. P¹⁾: Comparison Baseline (T1) and Immediate after intervention (T2). P²⁾: Comparison baseline (T1) and 3 month after intervention (T3). P³⁾: Comparison baseline (T1) and 6 months after intervention (T4). P⁴⁾: Comparison between immediate after intervention (T2) and 3 month after intervention (T3). P⁵⁾: Comparison between immediate after intervention (T2) and 6 months after intervention (T4). P⁶⁾: Comparison between 3 month after intervention (T3) and 6 months after intervention (T4).

Job involvement

The UWES-9 scale was the main result of our study. It can be seen from Figure 2, the scores of UWES-9 scale of gratitude group showed a trend of first markedly rising and then slightly declining. The score increased at T2, and gradually decreased at T3 and T4. The scores of UWES-9 scale of control group had an initial small rise, followed by a marked decline to well below baseline. The scores of UWES-9 in gratitude group were higher than those in control group at three time points after intervention (P < 0.05).

Figure 2.

The UWES-9 scale scores curve of new nurses between the two groups.

Tables 3 and 4 intra-group comparison shows that the UWES-9 scores of the gratitude group showed a trend of first increasing and then slightly decreasing, while the change trend of the control group was not obvious. That is, the UWES-9 scores of the gratitude group at T2, T3 and T4 were higher than those at T1(P¹),(P²), (P³) (P < 0.05). However, the UWES-9 scores of the gratitude group at T2 and T3 (P⁴), UWES-9 scores of the gratitude group at T2 and T4 (P⁵), UWES-9 scores of the gratitude group at T3 and T4 (P⁶) had no statistical difference (P > 0.05). In the control group, a few time points (such as P⁵ in UWES-9) showed statistical differences, while other time points showed no statistical significance (P > 0.05).

Gratitude

Tables 3 and 4 intra-group comparison shows that the GQ-6 score of the gratitude group showed a trend of first increasing and then slightly decreasing, while the change trend of the control group was not obvious. That is, the GQ-6 scores in the gratitude group at T2 and T3 higher than those at T1(P¹),(P²) (P < 0.05); however, the GQ-6 scores of the gratitude group at T1 and T4 (P³), GQ-6 scores of the gratitude group at T2 and T3 (P⁴), GQ-6 scores of the gratitude group at T2 and T4 (P⁵), GQ-6 scores of the gratitude group at T3 and T4 (P⁶) had no statistical difference (P > 0.05). There was no statistical significance of GQ-6 scores in the control group at each time point (P > 0.05).

Perceived stress

Tables 3 and 4 intra-group comparison shows that the PSS scores of the gratitude group showed a trend of first decreasing and then slightly increasing, while the change trend of the control group was not obvious. That is, the PSS scores in the gratitude group at T2 and T3 were lower than those at T1(P¹),(P²) (P < 0.05). However, the PSS scores of the gratitude group at T1 and T4 (P³), PSS scores of the gratitude group at T2 and T3 (P⁴), PSS scores of the gratitude group at T2 and T4 (P⁵), PSS scores of the gratitude group at T3 and T4 (P⁶) had no statistical difference (P > 0.05). There was no statistical significance of PSS scores in the control group at each time point (P > 0.05).

Burnout

Tables 3 and 4 intra-group comparison shows that the MBI-EE scores and the MBI-DP scores of the gratitude group showed a trend of first decreasing and then slightly increasing, while the change trend of the control group was not obvious. That is, the MBI-EE scores and the MBI-DP scores in the gratitude group at T2, T3 and T4 were lower than those at T1(P¹),(P²), (P³) (P < 0.05); However, the MBI-EE scores and the MBI-DP scores of the gratitude group at T2 and T3 (P⁴), the MBI-EE scores and the MBI-DP scores of the gratitude group at T2 and T4 (P⁵), the MBI-EE scores and the MBI-DP scores of the gratitude group at T3 and T4 (P⁶) had no statistical difference (P > 0.05). There was no statistical significance of the MBI-EE scores and the MBI-DP scores in the control group at each time point (P > 0.05).

Tables 3 and 4 intra-group comparison shows that the MBI-PA scores of the gratitude group showed a trend of first increasing and then slightly decreasing, while the change trend of the control group was not obvious. That is, the MBI-PA scores in the gratitude group at T2 were higher than those at T1 (P¹) (P < 0.05); there was no statistical significance in MBI-PA scores of gratitude group and control group at other points (P > 0.05).

Discussion

The current reports on the impact of gratitude interventions on job involvement were limited and the results were mixed.³⁵ Komase et al.³⁶ conducted a three-week gratitude intervention program for 835 workers, and the results showed that there was no significant improvement in job involvement. The present study shows that gratitude intervention may be effective in improving the job involvement of new nurses, which may be due to the increased intensity of the gratitude intervention. The present study shows that gratitude intervention may be effective in improving the job involvement of new nurses, which may be due to the greater frequency and duration of the gratitude intervention compared to previous studies.³⁵ In order to clarify the benefits of gratitude intervention on nurses’ job involvement, we conducted a two-month gratitude intervention during which participants were asked to record gratitude journal activities every day and participate in gratitude-related activities every two weeks. We increased the frequency of intervention and this intensity level is more comparable with previous studies¹³ that successfully found significant gratitude effects.

Gratitude is a pleasurable psychological state, and gratitude practices can provide a way to retrieve treasures from the trove of memories and turn them into tangible benefits.³⁷ When individuals have gratitude in daily affairs, they will have the motivation to repay others, and gratitude will promote the improvement of individual behavior.³⁸ This study cultivated gratitude mentality of new nurses through daily recording of gratitude diary and correspondence, improved their understanding of gratitude, guided new nurses to work with gratitude, internalized gratitude into a conscious behavior norm, improved their professional identity, and improved the level of job involvement of new nurses.

This study may be effective in improving the gratitude level of participants, which is consistent with the findings of Komase et al..³⁶ The GQ-6 score at baseline in our study was similar to the findings of Lee et al..³⁹ Studies have shown that individuals with high levels of gratitude are able to find positive aspects in a variety of contexts, identify objects of gratitude, and find and reinterpret positive features even in negative perceptual situations.⁴⁰

Newly recruited nurses are in the transition from school to work and face a series of stressful situations such as adjusting to clinical work, maintaining relationships with colleagues, often being separated from parents and living independently. In addition, they also face the professional learning pressure of standardized training and intensive curriculum arrangement. In recent years, with the COVID-19 pandemic raging around the world, the proportion of online courses has increased. In order to adapt to the new learning environment, new nurses are under more pressure. Through the practice of gratitude, new nurses focus on the positive aspects of their work situation, avoid negative thinking that often leads to psychological distress, broaden their horizons, deepen their focus on future well-being, develop gratitude for neglected things in daily life, and then form positive emotions. However, this effect did not persist at 6 months of follow-up, possibly because the new nurses gradually stopped recalling gratitude or the cumulative effects of these stressors may have overwhelmed their capabilities for generating gratitude. For future research, it is imperative to consider a more holistic approach that not only includes gratitude interventions but also addresses the objective work stressors that new nurses encounter. Documenting and analyzing the work conditions of these nurses could provide valuable insights. This includes gathering data on the length of work shifts, the number of shifts per week, the frequency and scheduling of night shifts, the availability of free time after night work, the provision of rest breaks, the quality of office conditions, the percentage of emergency work, the care of patients with incurable or end-stage diseases, patient load, staffing and supply shortages, the adequacy of personal protective equipment, the possibility of taking time off when needed, and the expectation to perform non-clinical tasks such as administrative work that could be delegated to other staff. By addressing both the internal practice of gratitude and the external factors that contribute to nurse stress, researchers and healthcare institutions can work towards creating a more supportive and sustainable work environment for new nurses, ultimately improving their well-being and patient care outcomes.

The stress and burnout of new nurses were reduced in this study, which is consistent with the findings of Cheng et al.⁴¹ and Caragol et al..⁴² The PSS-10 scores in our baseline survey were similar to those of Lee et al.⁴³ and nurses treating COVID-19 in Wuhan, China. New nurses working for a short time, with less experience, may be more easily affected by the environment. New nurses need to receive professional training and assessment after completing daily nursing work, and they may not know how to release stress. Research has shown that gratitude practices reduce negative emotions, lower stress levels, and may act as a buffer against the harmful psychological consequences of stressful life events.^44,45 The present study conducted gratitude intervention through knowledge lectures, cognitive training and emotional experience training. First, inculcating knowledge about gratitude lays the foundation for subsequent cognitive training and emotional experience training. Then, through the specific medical situation and negative emotional situation, the sensitivity of new nurses to gratitude is improved, the motivation of accidents is understood from the situation, the positive significance of accidents is explored, and the gratitude treatment of new nurses is guided. This mechanism of improving resilience through cultivating positive emotions is supported by Fredrickson's " broaden-and-build " theory.⁴⁶ Positive emotions can temporarily extend our consciousness, leading to a flexible, innovative thinking process and action, elastic for individuals to make a long-term contribution. To reconstruct the cognitive processes of new nurses, it is essential to cultivate positive cognitive habits. This involves encouraging them to adopt new approaches in their daily lives, actively seeking out things to appreciate, and broadening their perspective. By doing so, they can enhance their cognitive flexibility, which is the ability to think about situations in different ways and adapt to change more effectively.

Previous research has shown that keeping a gratitude journal can work by intentionally shifting attention to what is going on, and participants may recalibrate their perceptions to notice more positive experiences.¹⁵ For example, we hold gratitude theme activities to enhance the gratitude awareness of new nurses and increase the gratitude experience. The new nurses began to look more closely at things in their daily lives that they had previously ignored or not noticed, and they deliberately tried to remember pleasant things, and set up "wechat" groups to share their personal experiences, encourage each other to keep regular gratitude diaries and share their gratitude stories with each other. The findings of the present study suggest that gratitude interventions can provide nurses with new perspectives, alleviate stress, and find positive meaning in setbacks, thereby changing their professional attitudes, reducing burnout, and enhancing job involvement. These results have certain reference significance for guiding future research directions in this area.

The present study excluded new nurses who were pregnant, nursing, or ill from the gratitude intervention research to ensure the safety and well-being of these specific groups and to avoid potential confounding factors in the research results. However, the impact of gratitude interventions on these nurses is indeed worth noting, as they face unique challenges in their careers and personal lives that could benefit from strategies that promote positive psychological states.

Furthermore, in addition to the risk of nurse burnout and the challenges already mentioned, another significant issue affecting the health and well-being of nurses is the high prevalence of smoking, which has been linked to the psychological burden of nursing work.⁴⁷ The stressful nature of nursing roles, along with the demands of patient care and the emotional toll of witnessing illness and suffering, can lead to coping mechanisms such as smoking. Understanding how gratitude interventions might help reduce the psychological burden and potentially lower the incidence of smoking among nurses is an important area for future research.

By studying the effects of gratitude interventions on all new nurses, including those who are pregnant, nursing, or ill, researchers can gain a more comprehensive understanding of how such interventions can support the well-being of healthcare professionals. Additionally, addressing the high prevalence of smoking and other health behaviors influenced by work-related stress could significantly improve the overall health outcomes and quality of life for nurses. Integrating gratitude practices into broader wellness programs may offer a multifaceted approach to help nurses cope with the complex demands of their profession.

Conclusion

This study combined gratitude intervention programs from both domestic and international sources. Compared to new nurses who did not participate in the gratitude interventions, reduced stress and burnout of new nurses, and improved level of job involvement were found. This study has some limitations. In the current study, the samples were all from one hospital, and the proportion of female was too high, so the results cannot be generalized to the general population. In addition, the study did not control for past habits, such as meditation or journaling. In the future, therefore, multicenter trials may be conducted, and more male participants will need to be recruited.

Footnotes

Acknowledgements

This research was performed thanks to the staff of Xuzhou Central Hospital for their contributions to this study.

Ethical approval

The trial has been approved by the Ethics Committee of Xuzhou Central Hospital (Approval number:XZXY-LK-202221201-114).

Informed consent

This study has obtained informed consent from all participants.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Jiangsu Provincial Hospital Association Project (Project Number: JSYGY-3-2021-183), Xuzhou Medical Key Talent Project (Project Number: XWRCHT20220051) and Xuzhou Science and Technology Project (Project Number: KC21221).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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