The Effect of Gratitude on the Mental Health of Healthcare Workers as Measured by Burnout and Depression

Abstract

Burnout and depression have been considered long-standing issues among healthcare workers worldwide. Current interventions for managing poor mental health include exercise, medical treatments, mindfulness, and workplace changes. The practice of gratitude has shown significant improvements in mental health in the general population, and it has been proposed as a potential intervention for healthcare workers. This scoping review aimed to assess the effect of gratitude on the mental health of healthcare workers as measured by burnout and depression. The Cumulative Index to Nursing and Allied Health Literature and Medical Literature Analysis and Retrieval System Online databases were searched using medical subject headings (e.g., gratitude journaling and burnout). Studies that were not published in a peer-reviewed journal, included non-healthcare workers, did not implement gratitude interventions, or had outcomes unrelated to burnout and/or depression were excluded. Twelve studies met the inclusion criteria. The practice of gratitude resulted in improvements in burnout and depression in the heterogeneous populations of healthcare workers. Practicing gratitude, alone or in combination with another practice, has been shown to potentially improve and/or prevent burnout and depression among healthcare workers.

INTRODUCTION

Mental health concerns among healthcare workers include work-related stress, burnout, depression, anxiety, substance use disorders, and suicidal behavior [1]. The Centers for Disease Control and Prevention states there has been an increase in symptoms of poor mental health and negative workplace conditions among healthcare workers compared to other worker groups from 2018 to 2022 [2]. During this time, the percentage of healthcare workers who felt burnt out increased from 32% to 46% [2].

The World Health Organization defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed [3]. Burnout is characterized by three dimensions: emotional exhaustion (EE), depersonalization, and diminished sense of personal accomplishment [3]. EE is characterized by feeling energy depleted, worn out, or drained from an accumulation of personal and/or work-related stress [4]. Depersonalization is characterized by a lack of empathy for, detachment from, or negative attitudes towards oneself, others, or one’s environment [4,5]. It may occur when healthcare workers develop negative attitudes towards patients, colleagues, and their profession [4]. Personal accomplishment, or personal fulfillment, is characterized by a sense of satisfaction and enjoyment that comes from work and serves as a protective factor against burnout. Believing that the work being done matters and/or is making a difference may enhance an individual’s sense of personal accomplishment [4]. Burnout is often associated with increased rates of depression, anxiety, suicidal ideation, and sleep problems, among other negative physical and mental changes [6]. If not managed appropriately and in a timely manner, healthcare worker burnout may progress into or worsen depression, and possibly lead to suicide [6].

Depression is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [7]. It is characterized by anhedonia, depressed mood, fatigue or loss of energy, impaired concentration, feelings of worthlessness, decreased or increased appetite, sleep problems, and suicidal ideation [7]. Similar to burnout, depressive symptoms may be attributed to one’s job. Despite having overlap in terms of symptoms and inciting factors, in addition to often coexisting, burnout and depression are two different constructs. Depression may be caused by factors unrelated to work and impact all aspects of one's life, while burnout is predominantly work related [7]. In other words, burnout results from chronic work-related stress and leads to development of a negative and apathetic attitude towards one’s work and the people one works with [7]. Further research is needed to determine the causal relationship between burnout and depression [7].

Current interventions to improve the mental health of healthcare workers include both individual and organizational interventions. Individual-focused interventions include self-care (e.g., exercise, regular health maintenance exams), yoga, mindfulness (i.e., techniques that build coping mechanisms to deal with stress), meditation, and communication skills training [6,8]. Organizational-focused interventions include increasing participation in workplace decisions, work schedule flexibility, time allotted to complete tasks, and trust between management and workers [6,8].

Practicing gratitude has been shown to have a positive effect on both the mental and physical health of the general population and, thus, has been proposed to improve the mental health of healthcare workers [8]. Practicing gratitude can be defined as appreciating the things one has in life [9]. Self-reflecting on things one is grateful for, listing good things that occurred throughout one’s day, journaling work events one is grateful for, and writing letters to thank someone are ways in which gratitude may be practiced. Existing research suggests that practicing gratitude is associated with improved sleep, blood pressure, and glycemic control, as well as decreased levels of stress, anxiety, and depression, as assessed in the general population [9].

The current exacerbation of poor mental health among healthcare workers accentuates the need to develop interventions that address the current state of healthcare workers’ mental health, mitigate progression of poor mental health, and prevent the development of poor mental health in both current and future healthcare workers. Since gratitude interventions tend to be low in cost and flexible to fit various lifestyles, practicing gratitude can be a practical means of improving the mental health of healthcare workers [9]. The research question guiding this scoping review is the following: can gratitude practices reduce burnout and depression in healthcare workers?

MATERIALS AND METHODS

Cumulative Index to Nursing and Allied Health Literature (CINAHL) with Full Text and Medical Literature Analysis and Retrieval System Online (MEDLINE) electronic databases were searched between February 2, 2024, through January 31, 2025. The following medical subject headings were searched: gratitude, gratitude journaling, healthcare workers, healthcare professionals, physician, doctor, nurse, depression, and burnout.

Table 1 presents the medical subject heading combinations and Boolean operators (e.g., and, or) utilized in the search strategy for this review.

Table 1.

Search strategy utilizing keyword combinations and identified articles

Medical subject headings	Identified	Determined to be potentially relevant	Included in scoping review
Gratitude AND Healthcare workers	81	6	6
Gratitude AND Healthcare professionals	95	1	0
Gratitude AND Physicians OR Doctors	334	-	-
Gratitude AND Physicians OR Doctors AND Burnout	39	5	4
Gratitude AND Physicians OR Doctors AND Depression	14	3	0
Gratitude AND Nurse OR Doctors AND Depression	14	2	0
Gratitude AND Nurse OR Doctors AND Burnout	49	4	1
Gratitude journaling AND Burnout	8	4	1

Articles were screened initially by title. The abstract of an article was evaluated if the subject or intervention of a study was unclear from the title. Identified articles were excluded if the study was not published in a peer-reviewed journal, participants were not healthcare workers, the intervention did not involve gratitude, or outcomes were not related to depression and/or burnout (Fig. 1). It was determined that a scoping review would be the appropriate study design to identify all forms of evidence related to this topic and to identify potential gaps in knowledge [10]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist was used to guide the performance of this review. This scoping review was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/2689P).

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

RESULTS

Of the 638 articles identified, 12 were included in this review [11-22]. This scoping review consists of three randomized controlled trials, one quasi-experimental study, one longitudinal cross-lagged study, one longitudinal cross-sectional study, one cohort study, one cross-sectional study, and four pilot studies. The study designs of the four pilot studies were randomized parallel repeated measures study [14], pre-test/post-test single group intervention design with longitudinal follow up [22], a non-randomized controlled study [18], and a quasi-experimental one-group pre-test/post-test study [19]. Details of the study population, location, intervention, comparison, limitation(s), outcome measure(s), and main outcomes are summarized in Table 2 [11-22].

Table 2.

Studies reporting gratitude in healthcare workers

Author/year	Study design	Subjects	Geographical location	Intervention	Main outcomes	Limitations
Cheng et al. [13] (2015)	RCT	102 Full-time healthcare practitioners Specialties: Physicians, nurses, physiotherapist, occupational therapists	Hong Kong, China	Duration: 4 weeks, 3-month follow-up post-treatment Intervention: Gratitude diary – write down work-related events one is grateful for 2 times/week Comparison: Hassle diary–write down bothersome work-related events 2 times/week Control: No diary Outcomes: Depression, perceived stress Outcome measures: Chinese version of the 10-item version of the CES-D and PSS-10	Depression: Gratitude group reported significantly lower depressive symptoms in comparison to control group at the 3-month follow-up (–1.50 points; 95% CI [–2.98, –0.01], p = 0.048) and hassle group at post-treatment (–2.71 points; 95% CI [–1.31, –4.11], p < 0.001) and the 3-month follow-up (–3.9 points; 95% CI [–2.51, –5.29], p < 0.001) Other: Gratitude group reported significantly less perceived stress than the control group at post-treatment (–2.26 points; 95% CI [–3.79, –0.72], p = 0.004) control group at 3-month follow-up (–2.65 points; 95% CI [–4.00, –1.30]; p < 0.001), hassle group at post-treatment (–3.91 points; 95% CI [–2.33, –5.50], p < 0.001), and hassle group at 3-month follow-up (–4.41 points, 95% CI [–3.00, –5.82], p < 0.001)	Longer follow-up period is needed to determine the long-term effects of the gratitude intervention
Roche et al. [14] (2023)	Pilot randomized parallel repeated measures design	59 Pediatric healthcare workers Specialties: NPs, physicians	Northeast United States	Duration: 2 weeks, follow-up 2 weeks and 6 months post-treatment Intervention: Gratitude journaling – write down 3 things one is grateful for at the beginning of each day; 3 things that went well throughout the day at the end of each day Comparison: Cognitive Strategies – receive instruction and guided practice in cognitive restructuring skills via three 30-minute live zoom sessions Outcomes: Depression, anxiety, meaning and purpose, feasibility, and acceptability Outcome measures: PHQ-9, Generalized Anxiety Disorder-7, National Institute of Health Toolbox Meaning and Purpose Fixed Form, Assessment of Intervention, Sustenance of Intervention	Depression: Insignificant decrease in depressive scores in both the intervention and comparison groups Other: Insignificant decrease in anxiety scores in the intervention and comparison group; subjects reported high acceptability; feasibility of the intervention revealed a significantly higher reported use of cognitive strategies 6 months after the intervention	Low study enrollment and poor study attrition
Hao et al. [15] (2022)	Longitudinal cross-lagged study	393 Hospital nurses Specialty: Nurses	Hubei Province, China	Duration: 4 months Intervention: Online gratitude questionnaire assessing gratitude and depressive symptoms – administered at baseline and after 4 months Outcomes: Gratitude, depressive symptoms, general positive and negative affect Outcome measures: GQ-6, DASS-21, Chinese version of the Scale of Positive and Negative Experience	Depression: Gratitude at baseline could predict depressive symptoms at 4 months, and depressive symptoms at baseline could predict gratitude at four months	Limited external validity to populations with severe or moderate depressive symptoms, belong to non-Chinese cultures, and are non-nursing healthcare workers
Ricker et al. [11] (2020)	Longitudinal study	251 Family medicine resident physicians Specialty: Residents	United States (Tucson, Arizona; New York City, New York; Minneapolis, Minnesota; August, Maine; Portland, Maine; Hartford, Connecticut; Galveston, Texas)	Duration: Residency (3-5 years) Intervention: 10 online assessments administered at the start of residency, the start of the second year, and at graduation Outcomes: Burnout, depression, well-being (perceived stress, satisfaction with life, positive and negative affect), protective factors (emotional intelligence, mindfulness, gratitude) Outcome measures: MBI, CES-D, PSS-10, Satisfaction with Life Scale, Positive and Negative Affect Scale, Interpersonal Reactivity Index, Trait Meta-Mood, 6-item scale designed to assess individual differences in the proneness to experience gratitude in daily life, Freiburg Mindfulness Inventory	Burnout: Emotional exhaustion and depersonalization peaked after the first year of residency and remained elevated through graduation; risk of burnout at graduation was inversely proportional with protective factors Depression: Depression, mindfulness, and gratitude remained stable throughout residency Other: Improvements in well-being seen from year two start until graduation; emotional intelligence was lower at graduation than at the start of residency	Lack of external validity to healthcare workers today due to data collection occurring in 2011-2013
Adair et al. [17] (2020)	Prospective cohort study	1,575 Healthcare workers Specialties: Attending physicians, resident physicians, PAs, NPs, nurses, pharmacists, and therapists	United States	Duration: Single exposure intervention with 1-week follow-up Intervention: Gratitude letter-writing – write a gratitude letter per assigned condition (self- or others-focused), and complete a well-being assessment at baseline and 1 week later Outcomes: Well-being (emotional exhaustion, subjective happiness, work-life balance), tool engagement Outcome Measures: MBI, Lyubomirsky and Lepper’s Subjective Happiness Scale, work-life climate scale, five questions to assess participants’ experience with the tool	Burnout: Participants in both writing conditions reported significant improvement in emotional exhaustion at the 1-week follow-up (p < 0.001) Other: Participants in both writing conditions reported significant improvement in happiness and work-life balance at the 1-week follow-up (p < 0.001); no significant differences in well-being measures between the self- and other-focused prompt groups; tool engagement was high; 75.4% of participants reported greater ease thinking about things to be grateful for since writing the letter	Lack of nonintervention control group; duration of effectiveness is unknown beyond one week
Caragol et al. [22] (2022)	Pilot study pre-test/post-test single group intervention design with longitudinal follow-up	30 Clinicians Specialties: Physicians, NPs, PAs	United States	Duration: 8 weeks with 4- and 8-week follow-up post-treatment Intervention: In-person 90-minute group psychoeducation and skills-building workshop followed by an 8-week daily gratitude journal entry consisting of 3 things one is grateful for and why those things are meaningful Outcomes: Resilience (coping self-efficacy, clinician autonomy, self-care behaviors), feasibility and acceptability of the intervention, career satisfaction, gratitude Outcome Measures: GQ-6, 13-item Coping Self-Efficacy scale, survey on Activities for Promoting Self Care, Robert Wood Johnson Foundation Survey of Young Physicians	Other: Intervention was brief, feasible, and of interest to clinicians; statistically significant improvements were seen in coping self-efficacy, clinician autonomy, self-care, and practice satisfaction at both 4- and 8-weeks follow-up; gratitude journal entries mentioned most frequently were support platforms at work (47%) and sense of competence (42%)	No control group; decreased response rate for follow-up surveys over time; too many variables to determine which contributed most to the positive outcomes
Lee et al. [12] (2021)	Cross-sectional survey	646 Nurses Specialty: Nurses	Gwangju, South Korea	Duration: Time spent filling out questionnaire Intervention: One-time self-administered questionnaire Outcomes: Perceived stress, gratitude disposition, depression, anxiety, burnout Outcome measures: PSS-10, K-GQ-6, PHQ-9, GAD-7, and MBI-GS	Burnout: MBI-GS-Exhaustion is positively associated with PSS-10 (r = 0.587) and negatively associated with K-GQ-6 (r = –0.283); MBI-GS-Cynicism is negatively associated with K-GQ-6 (r = –0.452); MBI-GS-Professional efficacy is positively associated with K-GQ-6 (r = 0.320) Depression: PHQ-9 is positively associated with PSS-10 (r = 0.486), MBI-GS-Exhaustion (r = 0.479), and MBI-GS-Cynicisms (r = 0.508); and negatively associated with K-GQ-6 (r = –0.310) Other: GAD-7 scores were positively associated with PSS-10 (r = 0.426) and MBI-GS-Cynicism (r = 0.406); K-GQ-6 is negatively associated with PSS-10 (r = –0.419) and GAD-7 (r = –0.273)	Nature of study limits ability to determine causality among variables; possibility of multicollinearity among variables
Gold et al. [16] (2023)	RCT	223 Members of an academic medicine department Specialties: Administrative staff, clinical staff, faculty, fellows, residents	Ann Arbor, Michigan, United States	Duration: 3 weeks, follow-up at 1 and 3 months Intervention: Three Good Things – list 3 good things that occurred that day via a survey link sent via text message 3 days/week Control: Delayed intervention Outcomes: Depression, positive affect, gratitude, and life satisfaction Outcome measures: PHQ-9, 10-item positive affect subscale from the Positive and Negative Affect Schedule-Short Form, GAC, 5-item Satisfaction with Life Questionnaire	Depression: Intervention group had insignificant decrease in PHQ-9 scores 1-month after starting the intervention (–0.5 points, 95% CI [–1.06, 0.6]) and increase in PHQ-9 scores 3 months after starting the intervention (0.27 points, 95% CI [–0.31, 0.86]) Other: Positive affect in the intervention group improved slightly at 1 month, then declined slightly, and remained significantly improved at 3 months; gratitude and life satisfaction showed a similar trend to positive affect without significant improvement; high retention rate	Limited external validity to people outside of the academic center surveyed
McGinness et al. [18] (2022)	Nonrandomized controlled pilot	41 Pediatric residents Specialty: Residents	Oakland, California, United States	Duration: 4 weeks, up to 6 months follow-up Intervention: Journaling group – listed 3 things they were grateful for and 3 good things daily via an app; completed a survey before, after and 6 months after intervention Control: No journaling, surveys as per intervention group Outcomes: Burnout, feasibility, gratitude, and life satisfaction Outcome measures: OLBI, PWLS, Feasibility as adherence to journaling at least 5 days per week of the intervention period, GQ-6, Satisfaction with Life Scale	Burnout: Journaling group had a statistically significant decrease in OLBI-Exhaustion (p = 0.025) compared to the control group that persisted up to 6 months after the end of the intervention; no statistically significant changes in OLBI-Disengagement (p = 0.055) and PWLS single question burnout questionnaire (p = 0.201) Other: No statistically significant change in life satisfaction (p = 0.446) or gratitude (p = 0.939); journaling adherence was 85% throughout the intervention, 31% at 1-month post-intervention, and 7% at 6 months post intervention	Extrinsic incentive bias could have impacted results as intervention participants were offered a greater amount of financial incentive than the control group; nonrandomized study
Camero and Carrico [19] (2022)	Quasi-experimental one-group pretest-posttest pilot	29 Healthcare personnel at a long-term care facility Specialty: Nurses	Midwestern United States	Duration: 21 days, follow-up within 1-week post-treatment Intervention: Gratitude journaling and receipt of a daily gratitude quote via text message – write 3 things one is grateful for each day, encouraged to write a thank you note to 1 person each week Outcomes: Burnout, qualitative measures Outcome measures: MBI	Burnout: slight improvement with no statistical significance within the 3 subscales of the MBI (emotional exhaustion, depersonalization, and personal accomplishment) between the pre- (1 week before) and post- (1 week after) gratitude journal intervention Other: 88% of participants endorsed feeling there is a benefit to gratitude journaling; 85% intended to continue daily gratitude journaling	Limited external validity to healthcare workers in other healthcare facilities; small sample size
Desai et al. [20] (2024)	RCT	81 Healthcare workers Specialties: Nurses, allied healthcare professionals, physicians	United States	Duration: 6 weeks Intervention: Podcast-based self-guided gratitude practice group – 50-minute podcast once a week, participants were encouraged to practice a gratitude practice technique discussed in the podcast Comparison: Trainer-guided virtual heartfulness meditation program – listen to audio file consisting of relaxation techniques followed by 15-30 minutes of meditation guided by a trainer in the morning and at night right before bed Outcomes: Compassion satisfaction, burnout, secondary traumatic stress, vigor, dedication, absorption at work, qualitative measures Outcome measures: ProQOL-5, Utrecht Work Engagement Scale, qualitative questions regarding the experience of learning and practicing	Burnout: Significant improvement in burnout for the Heartfulness group between Week 0 and Week 6 (p = 0.002), significant mean difference in burnout between the two intervention groups between Week 0 and Week 6 (–4.42 points, 95% CI [–8.03, –0.82]) Other: Both groups reported reduced stress, feelings of calm, feeling less reactive, and a deeper appreciation of self, family, and others; increased empathy and patience; difficulty finding time to complete the interventions	Small sample size; high attrition rates in both groups
Christensen et al. [21] (2023)	Quasi experimental	90 Healthcare workers Specialties: Physicians, doctor of osteopathy, NPs, PAs, nurses, technicians, administrative, ancillary staff	South Texas, United States	Duration: 4 months Intervention: Mindfulness-Based Stress Reduction toolkit – 45-minute introduction and 4 biweekly voluntary 15-minute mindfulness sessions focused on acupressure, meditation, gratitude journaling, or self-compassion Outcomes: SRSL, burnout, job satisfaction, work-place stress, health record proficiency Outcome measures: MZBS	Burnout: Significant changes in answers to the following questions after completing one 15-minute in-person session: “Using your own definition of burnout, circle the answer” (p = 0.045), “I feel a great deal of stress because of my job” (p = 0.018), and “My proficiency with electronic health record use” (p = 0.033) Other: SRSL remained the same or elevated in participants who did not participate; highest attended program was meditation, followed by self-compassion and gratitude journaling	“High tempo of daily clinic workflow:” inability to track individual daily mindfulness practices; small participant size and high attrition rate

RCT: randomized controlled trial, CES-D: Center for Epidemiologic Studies-Depression Scale, PSS-10: Perceived Stress Scale-10, CI: confidence interval, NPs: nurse practitioners, PHQ-9: Patient Health Questionnaire, GQ-6: Gratitude-Questionnaire-Six Item Form, DASS-21: Depression, Anxiety, and Stress Scale-21, MBI-GS: Maslach Burnout Inventory-General Survey, PAs: physician assistants, GAD-7: Genralized Anxiety Disorder-7, GAC: Gratitude Adjective Checklist, OLBI: Oldenburg Burnout Inventory, PWLS: Physician Work Life Study, ProQOL-5: Professional Quality of Life Scale-5, SRSL: self-reported stress level, MZBS: Mini-Z Burnout Survey.

Subspecialties of healthcare workers represented in this review are physicians, residents, physician assistants, nurse practitioners, nurses, pharmacists, allied health professionals (e.g., physical therapists, occupational therapists, respiratory therapists), and clinic staff. The number of participants in a single study ranged from 29 to 1,575. Both primary outcomes (burnout and depression) were assessed in two studies [11,12]. Depression was assessed in a total of six studies [11-16]. Burnout was assessed in a total of seven studies [11,12,17-21]. The primary outcome measured in one study was resilience, which has been associated with decreased rates of burnout [22,23].

Nine studies utilized experimental study designs [13,14,16-22]. The duration of interventions ranged from a single exposure up to eight weeks. A form of gratitude journaling was the most commonly implemented practice utilized alone or in combination with other gratitude practices. Gratitude journaling was completed on various mediums in six studies. Four studies used physical journals [13,14,19,22], one study used a phone application [18], and one study used an online survey sent via text message [16]. The frequency of gratitude journaling ranged from twice a day to two times per week. Four of the six studies that implemented gratitude journaling had participants journal at least once daily [14,18,19,22]. Instructions for what to write in a journal varied between studies. Five studies instructed participants to list three good things, three things they were grateful for, or three things that went well throughout the day [14,16,18,19,22]. One study instructed participants to list at least one work related event they were grateful for during their time of gratitude journaling [13].

Other gratitude practices that were implemented alone or in combination with gratitude journaling included gratitude letter writing [17], a group psychoeducation and skills-building workshop [22], receipt of a gratitude quote via text message [19], and listening to a gratitude podcast [20]. Outcomes of the various gratitude interventions were compared to that of a control group [13,16,18], a non-gratitude intervention [12,13,19], and/or pretest/baseline outcome measurements [17,19,21,22]. Non-gratitude interventions that were compared to a gratitude intervention were journaling work events deemed as a “hassle” [13], cognitive restructuring [13], and instructor guided meditation [20].

Three studies utilized non-experimental study designs [11,12,15]. Hao et al. [15] performed a longitudinal cross-lagged study evaluating the causal relationship between gratitude and depression symptoms in nurses in China. The results supported a reciprocal link between gratitude and depressive symptoms as gratitude at baseline could predict depressive symptoms at four months, and depressive symptoms at baseline could predict gratitude at four months [15]. The longitudinal cross-sectional study by Ricker et al. [11] found that the risk of burnout at graduation was inversely proportional to protective factors, such as gratitude, among family medicine residents. The cross-sectional study by Lee et al. [12] found that the exhaustion and cynicism subscales of the Maslach Burnout Inventory-General Survey (MBI-GS) were negatively associated with gratitude, the professional efficacy subscale of the MBI-GS was positively associated with gratitude, and depression was negatively associated with gratitude in nurses in Korea. Lee et al. [12] also reported that the exhaustion and cynicism subscales of the MBI-GS were positively associated with depression.

Various outcome measures were used to assess depression and burnout. The Patient Health Questionnaire-9, the Chinese version of the 10-item version of the Center for Epidemiologic Studies-Depression Scale, and the depression subscale of the Depression, Anxiety, and Stress Scale-21 were used to assess depression. The MBI was the most used outcome measure to assess burnout. Other outcome measures used to assess burnout were the Oldenburg Burnout Inventory (OLBI), Professional Quality of Life Scale-5, Physician Work Life Study single-item burnout questionnaire, and the Mini-Z burnout survey.

Gratitude was measured in six studies [11,12,15,16,18,22]. The Gratitude-Questionnaire-Six Item Form (GQ-6), including the Korean version of the GQ-6, was the most used outcome measure to assess gratitude. Other outcome measures used to assess gratitude were the three-item Gratitude Adjective Checklist and a six-item scale designed to assess individual differences in the proneness to experience gratitude in daily life created by Ricker et al. [11].

Qualitative measures, such as feasibility and acceptability of the intervention, tool engagement, and interest in the intervention, were assessed by six of the studies [14,17-20,22]. Researchers reported high tool engagement (i.e., participant engagement with the intervention) [17], high adherence rates [18], and subjective feelings of benefit from practicing gratitude [19,20]. Time was a reported barrier for healthcare workers to practice gratitude [20,21]. Desai et al. [20] reported participants in both the gratitude podcast and meditation groups found it difficult to find time to complete the intervention. The meditation group was asked to listen to a relaxation technique audio file then do 15-20 minutes of trainer guided meditation every morning and evening. Christensen et al. [21] reported participation in the mindfulness intervention may have been limited by the “high tempo of daily clinic workflow”.

All studies found gratitude improved depression and/or burnout in healthcare workers, though improvements were not always significant. Significant findings were found in three studies [13,17,18]. Cheng et al. [13] found a significant decrease in depression in healthcare workers following a four-week gratitude journaling protocol, which was defined as journaling at least one work related moment of gratitude twice weekly. Adair et al. [17] found a significant improvement in the EE subscale of burnout in healthcare workers one week after writing a gratitude letter per assigned prompt. McGinness et al. [18] found a significant reduction in scores on the exhaustion subscale of the OLBI following an intervention in which participants recorded three things they were grateful for and three positive events via a mobile application daily. No study found gratitude worsened depression or burnout in healthcare workers. Gratitude was also reported to benefit anxiety [12,14], stress [12,13,20], life satisfaction [16], practice satisfaction [22], happiness [17], positive affect [16], and work-life balance [17] in healthcare workers. The positive effects of gratitude on these outcomes were not always significant [14,16,20].

DISCUSSION

The findings of the twelve studies included in this review suggest gratitude has the potential to improve burnout and depression in healthcare workers. The findings of the non-experimental studies suggest inherent gratitude is negatively associated with depression and burnout. The experimental studies found improvements in burnout and depression following a gratitude intervention, which were generally well accepted by healthcare workers. Of the studies that primarily assessed a gratitude journaling intervention, a significant decrease in either depression or burnout was reported only in two studies [13,18]. The intervention of both studies was carried out for four weeks, which was a longer duration than the other studies [14,16,19]. Of the studies that implemented a gratitude journaling intervention, there were no notable differences in the frequency of journal entries, or instructions of what to journal, between studies with statistically significant results and those without.

Desai et al. [20] was the only study that implemented a gratitude intervention involving a weekly 50-minute gratitude podcast followed by self-guided efforts to implement the gratitude practices described in the podcast. There was no significant reduction in burnout following this intervention.

Limitations identified by the authors of the studies included in this review include inability to assess longer term effects due to short term follow-up [13], low study enrollment [14,20-22], high attrition rates [14,20-22], lack of participant cultural diversity and representation of other healthcare specialties [15,16,19], data collected greater than 10 years ago [11], study design without a control group, and longitudinal study design limiting conclusions to be correlation versus causation [12,17,22]. One-fourth of the studies included in this review were pilot studies, which likely contributes to having small sample sizes and limited diversity of participants. Pilot studies were included in this review due to the limited number of existing studies evaluating the effect of gratitude on depression and burnout in healthcare workers. Roche et al. [14] and Desai et al. [20] speculate high attrition rates may have been impacted by external factors, including the state of the pandemic at the time at which the study was conducted and stress related to work and/or home situations. Adair et al. [17] attributed the reduced participation in follow-up assessments one-week post-intervention to the web-based format of the study. Web-based formats help increase accessibility to tools but make it easier for participants to ignore follow-up requests [17]. Limitations of the review process of this scoping review include risk of bias due to a single researcher screening identified articles and collecting data from selected articles, and data synthesis without use of statistical analysis tools.

Practicing gratitude has the potential to be a low-cost, well accepted, and feasible intervention to improve and/or prevent burnout and depression amongst current and future healthcare workers. Due to the limited amount of existing literature on the topic of gratitude, there is not a current consensus as to which gratitude intervention has the greatest impact on burnout and depression in healthcare workers. Future research is needed to identify the most effective gratitude practice across multiple healthcare worker specialties of varying cultural backgrounds, including the frequency at which gratitude must be practiced and the minimal duration of time in which gratitude must be practiced for there to be a significant outcome. Burke and O’Donovan [8] also concluded from their systematic review, which explored the impact of gratitude on burnout among healthcare workers, that there is preliminary evidence of an inverse association between gratitude and burnout; however, further research is needed to confirm this finding.

Future research may also aim to evaluate the effect of gratitude practices in combination with other non-gratitude interventions aimed at reducing and/or preventing burnout and depression in healthcare workers. Other interventions implemented in the studies evaluated in this review include instruction and guided practice in various cognitive strategies, guided meditation, and psychoeducation combined with a skills building workshop. These interventions were found to reduce burnout and/or depression in healthcare workers and were reported to be feasible and of interest. The cognitive strategies intervention even had a higher reported use six months after the end of the intervention in comparison to the gratitude journaling intervention [14]. Other interventions that may be studied in combination with gratitude practices are the individual and organizational focused interventions [6,8]. Zhang et al. [23] summarized the findings of existing literature on interventions to reduce burnout in physicians, and proposed utilization of a “bundle strategy” as an effective means of reducing burnout. The bundle strategy consists of communication skills and training, self-care workshop, stress management training, workload or schedule rotation, teamwork/transition, debriefing sessions and a focus group, and finding ways to increase resilience [23]. Resilience is the bridge from burnout to wellness according to Zhang et al. [23] given the potential link between burnout and resilience, future research may also focus on identifying interventions that improve resilience.

Future research is warranted to determine the effectiveness of gratitude practices within individual healthcare worker disciplines. There are both similar as well as unique stressors associated with various disciplines. Identifying the best gratitude practices per discipline will help clinicians (or organizations) when recommending these strategies to fellow healthcare workers (or members of their medical team). Research is also warranted to determine the optimal gratitude strategies based on country of origin. This review identified research conducted in the United States, China, and Korea. It is possible that certain strategies may be more effective based on cultural norms.

The correlation between gratitude and lower rates of depression and burnout in healthcare workers identified by Hao et al. [15], Lee et al. [12], and Ricker et al. [11] provide additional reasoning to allocate resources to future research and implementation of gratitude interventions. As Ricker et al. [11] studied family practice residents, future research may also be aimed at studying the effects of gratitude on student healthcare workers in the short-term during school, and potentially in the long-term as practicing healthcare workers. Researchers may discover the prevention of healthcare worker burnout and depression may produce more favorable outcomes than attempting to reduce burnout and depression once it has developed over months and years of practice.

CONCLUSIONS

Gratitude has been shown to have a positive effect on healthcare worker mental health as measured by burnout and depression. Gratitude journaling was the most studied gratitude intervention amongst healthcare workers in this review, though the significance of the reduction in burnout and/or depression following gratitude journaling was variable. The correlational findings further support the notion that gratitude has a positive effect on burnout and depression. Although gratitude interventions such as gratitude journaling have the potential to serve as a low-cost and practical means of addressing depression and burnout in healthcare workers, it may not be able to address poor mental health alone. Thus, further research is needed to explore and confirm the positive effects of gratitude on burnout and depression in healthcare workers, as well as to identify the most effective gratitude intervention alone or in combination with other interventions.

Funding Statement

Funding: None.