58 l Nursing2022 l Volume 52, Number 12 www.Nursing2022.com

Abstract: With nursing burnout on the rise,
effective self-care interventions such as
gratitude journals are needed to help nurses
cope with symptoms of burnout. Gratitude
journals can support nurses’ emotional
health by improving stress management and
offering an opportunity for overall self-
reflection.

Keywords: gratitude journal, journaling,
mental health, positivity, self-care

BY KELLY CUMELLA, MSN, RN, FNP-C

Gratitude journals can
improve nurses’ mental

well-being

SH
U

TT
ER

ST
O

C
K
/P

LA
TE

R
ES

C
A

Since the onset of the pandemic,
nurses throughout the US have been
feeling the effects of work burnout.
The World Health Organization de-
fines burnout as a syndrome that
results from chronic workplace stress
that has not been effectively man-
aged.1 Burnout symptoms can range
from physical feelings of exhaustion
and low energy to reduced profes-
sional efficacy.1 A 2021 study that
surveyed 1,834 nurses found that
54% of the respondents were experi-
encing burnout.2 The study also re-

vealed a strong correlation between
burnout and nursing turnover.2 With
high rates of nursing turnover, care is
more disjointed and teamwork for
best patient outcomes becomes more
difficult.2 Effective interventions are
needed to help support mental
health practices among nurses to
mitigate high levels of burnout. Oth-
erwise, not only are individual nurs-
es at risk but the healthcare system
may also be compromised.

When nurses reflect on their rea-
sons to pursue this career path, often

NSG1222_Feature_GratitudeJournal_Deepak.indd 58 29/10/22 3:26 PM

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

www.Nursing2022.com December l Nursing2022 l 59

risk factors for a stroke or myocardial
infarction. Long-term elevated corti-
sol levels can increase the likelihood
of obesity and the amounts of depos-
ited adipose tissue.5 This means that
the body is in a constant state of
flight-or-fight mode, which can be
physically and mentally overwhelm-
ing. This constant state of chronic
stress causes increased fatigue and
eventually, burnout.5

Impact of burnout on nurses
Burnout negatively affects nurses and
also team morale, patient satisfac-
tion, patient outcomes, and even pa-
tient mortality.5 Symptoms such as
reduced physical and emotional en-
ergy, fatigue, headache, and insomnia
have been shown to increase absen-
teeism and turnover rates.2 Nurses
with poor mental and physical health
are up to 71% more likely to report
making a medical error compared
with those in better health.2 These
issues make burnout a costly prob-
lem for healthcare organizations as
well. Of note, organizations that im-
plement burnout interventions have
reported increased nursing retention,
reduced turnover rates, and higher
levels of patient satisfaction.3

Benefits of gratitude
intervention
In the past decade, there has been
growing research on positive psycho-
logical interventions as a strategy to
improve mental health, with the most
well-known being a gratitude inter-
vention.6 Gratitude is the quality of
being thankful, the readiness to show
appreciation, and to then return that
kindness.7 When the burden of pa-
tients who are critically ill, endless
tasks, lack of staff, and inadequate
pay cloud a nurse’s mind, it can be
challenging to find aspects of work to
be thankful for. Gratitude journaling
has been used to improve a grateful
disposition among nursing students,
and even encourages the adoption of
a positive viewpoint during stressful

situations.4 Journaling allows for re-
connection with various thoughts
and a comprehensive review of new
experiences, both positive and nega-
tive. By reviewing these lived experi-
ences, one gains new insights, often
developing a new perspective and a
way to reevaluate a difficult experi-
ence.2

Gratitude journals come in many
shapes and sizes, including written
and electronic formats. The basic in-
troduction to keeping a gratitude jour-
nal is to write down two to five things
you are grateful for, two to three times
per week. When working on this
practice, try to express gratitude for
both small and big things and experi-
ences.8 Prompts can also help stimu-
late reflection on different aspects of
life—to allow for a broader reflection.

Do gratitude journals work?
Various studies on the impact of
gratitude journals have found that
this practice helps provide perspec-
tive, stress management, and self-re-
flection.9 In a study involving
healthcare practitioners, the use of
gratitude journals as little as twice
per week has resulted in lower re-
ported stress levels and depressive
symptoms after 1 month and were
maintained at the 3-month follow-
up after intervention.10 In a study
conducted in Korea in 2020, 4th-year
nursing students who kept a grati-
tude journal for 8 weeks reported a
more balanced effect both profes-
sionally as well as academically.4

Other findings included the ability
to observe daily life more closely,
and an increased ability to intention-
ally remember to be more grateful.4

A 2019 study investigated the
GRACE training program (a health-
care professional support program),
which included journaling and
mindfulness components to improve
healthcare workers’ well-being and
stress response.11 This study found
that the participants who attended
the training for over 2 years had

they recall positive moments when
they were able to be present and help
a patient through a very difficult time
or a time when they formed a deep
connection with a patient’s family.3

However, less reflection occurs about
the moments of witnessing horrific
deaths, complicated family grieving,
and the personal burden taken on by
the loss of a patient.3 Though these
events can be initially challenging to
process, through reflecting and jour-
naling, nurses as well as nursing stu-
dents may identify what they did
well professionally at this moment or
what they may change in the future.
This allows for closure and can bring
a positive perspective to a difficult
situation.4

This article discusses the benefits
of gratitude journaling to support
nurses and healthcare organizations
in promoting meaningful mental
health practices for nurses.

Endocrine stress response
Stress has a major impact on our en-
docrine system, specifically hormon-
al changes that can have a long-term
effect on an individual’s overall
health (see Hypothalamic-pituitary axis
and stress). If the brain perceives
something as a stressor, the hypo-
thalamus releases corticotropin-
releasing hormone (CRH), which
travels to the pituitary gland, trigger-
ing the release of adrenocorticotropic
hormone (ACTH). This hormone
travels to the adrenal glands,
prompting the release of cortisol.5

When the threat passes, cortisol lev-
els then fall. The parasympathetic
nervous system then will decrease
the stress response in the body. But
what happens if the parasympathetic
system is unable to lessen the stress
response? Chronic low-level stress
keeps the hypothalamic-pituitary
axis running; this is not healthy for
the body long term.5 Persistent epi-
nephrine release can damage blood
vessels and arteries, increasing BP
and consequently increasing cardiac

NSG1222_Feature_GratitudeJournal_Deepak.indd 59 29/10/22 3:26 PM

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

60 l Nursing2022 l Volume 52, Number 12 www.Nursing2022.com

significantly increased Hospital Con-
sumer Assessment of Healthcare
Providers and Systems (HCAHPS)
scores compared with the units that
did not receive the GRACE train-
ing.11 The study reported that higher
levels of healthcare professional
stress and burnout are associated
with a decrease in effective patient-
centered care and reduced effective
communication with both other
members of the healthcare team and
patients.11 Another qualitative study
that examined nursing students’ ex-
periences of journaling during the
pandemic found gratitude to be a
common theme of reflection. Many
found that sharing experiences in-
creased their overall feelings of grati-
tude and allowed for increased feel-
ings of gratitude toward coworkers.
The sharing of journals allowed for
the fostering of social and profes-

sional bonds.4,6 The benefits of grati-
tude journals have also extended
past the emotional realm. Physical
benefits such as improved sleep
quality, increased motivation for
physical exercise, and decreased
physical symptoms of stress such as
fatigue have also been reported.4

Starting a gratitude journal
Gratitude journals can be imple-
mented to help nurses develop im-
proved stress management tech-
niques, promote overall happiness,
and provide an outlet for nurses to
express their feelings. It is low-cost
and requires a low time commitment,
with an average journaling session
requiring 10-15 minutes, and a jour-
naling frequency of about as little as
twice per week.8 Initiating the reflec-
tion process and starting a gratitude
journal effectively can be difficult.7

Nurses should consider their per-
sonal preferences and try different
journaling methods, such as using
guided questions or an electronic
journal format. Nurses are encour-
aged to take a moment to reflect on
simple everyday pleasures, the peo-
ple in their lives, their strengths or
talents, or experiences of kindness.7

Consider this example written by a
nurse after a long day in the ED with
an eight-patient assignment includ-
ing a patient with a gunshot wound
and an older adult at the end of life.
The nurse used a prompted gratitude
journal specifically for nurses that
asked her to identify three things to
be grateful for that day:

Although there were many challenges
during this grueling shift, there are mo-
ments where the gifts of today shine.
• I am thankful for being able to contact
my older patient’s husband and help co-
ordinate with social work to allow him to
be at her bedside as she passed. He ex-
pressed that this was his wife’s wish, and
I am so happy I could help fulfill this for
them both.
• I am grateful for having a technician to
help me with vital signs today, this is not
always the case.
• I am grateful to have a strong trauma
team alongside me today to help stabilize
the patient with a gunshot wound quickly.

Being able to clearly identify three
things that she was grateful for helped
shift the nurse’s focus to the positive
parts of her day and reminded her of
the good she was able to accomplish
and how she was a part of an impor-
tant team.

Professional organization
support
Professional organizations offer tools,
programs, and resources to support
nurses and healthcare facilities in the
development of self-care programs for
their nursing staff. The American
Nurses Association (ANA), for ex-
ample, recognizes the strain nurses
are putting on not only their physical
but mental health, especially during

Hypothalamic-pituitary axis and stress

The hypothalamic-pituitary axis is a neuroendocrine pathway that mediates a response to stressors. Dysregu-
lation of the system can result in an unrelieved stress response and stress-related disorders. Source: Donnelly-
Moreno LA, Moseley B. Timby’s Introductory Medical-Surgical Nursing. Philadelphia, PA: Wolters Kluwer
Health; 2021.

NSG1222_Feature_GratitudeJournal_Deepak.indd 60 29/10/22 3:26 PM

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

www.Nursing2022.com December l Nursing2022 l 61

the COVID-19 pandemic. The phil-
anthropic arm of the ANA, the Ameri-
can Nurses Foundation, launched a
national well-being initiative that in-
cludes Narrative Expressive Writing.12

Writing is a proven and effective tool
for building resilience, improving
mindfulness, and reducing psycho-
logical distress. In this 5-week pro-
gram, nurses respond anonymously
to COVID-19-related writing prompts.
A certified responder reads individu-
al’s submissions and provides confi-
dential feedback.12 The American
Association of Nurse Practitioners
and the American Nurses Holistic
Association also recognize journaling
as a proven tool to improve mindful-
ness and reduce stress.12

Conclusion
Gratitude journals have been shown
to be an effective, low-cost tool to
support self-care and reduce the ef-
fects of burnout for healthcare profes-

sionals. With its low time commit-
ment, it is also a realistic intervention
for busy nurses. Gratitude practice
has been shown to benefit healthcare
organizations as well. To effectively
care for patients, nurses must also
ensure their physical and mental
well-being, and using gratitude jour-
nals can be a positive step toward
doing just that. ■

REFERENCES

1. World Health Organization. Burn-out an
“occupational phenomenon”: International
Classification of Diseases. 2019. www.who.int/
news/item/28-05-2019-burn-out-an-occupational-
phenomenon-international-classification-of-diseases.

2. Melnyk BM, Kelly SA, Stephens J, et al. Interventions
to improve mental health, well-being, physical
health, and lifestyle behaviors in physicians and
nurses: a systematic review.a Am J Health Promot.
2020;34(8):929-941. doi:10.1177/0890117120920451.

3. Henry BJ. Nursing burnout interventions: what
is being done? Clin J Oncol Nurs. 2014;18(2):211-214.

4. Ko H, Kim S, Kim E. Nursing students’ experiences
of gratitude journaling during the COVID-19 pandemic.
Healthcare (Basel). 2021;9(11):1473. doi:10.3390/
healthcare9111473.

5. Harvard Health. Understanding the stress response.
2020. www.health.harvard.edu/staying-healthy/
understanding-the-stress-response.

6. O’Connell BH, O’Shea D, Gallagher S. Feeling
thanks and saying thanks: a randomized controlled
trial examining if and how socially oriented gratitude
journals work. J Clin Psychol. 2017;73(10):1280-1300.

7. Definition of gratitude. In: Oxford Dictionary. Oxford
University Press. www.oxfordlearnersdictionaries.
com/us/definition/english/gratitude.

8. Suttie J. How practicing gratitude helps nurses
avoid burnout. Am Nurse J. 2021;16(8):48.

9. Moon H, Jung M. The relationship between a
disposition of gratitude, clinical stress, and clinical
satisfaction in nursing students. Perspect Psychiatr
Care. 2020;56(4):768-776.

10. Cheng S-T, Tsui PK, Lam JHM. Improving mental
health in health care practitioners: randomized
controlled trial of a gratitude intervention. J Consult Clin
Psychol. 2015;83(1):177-186. doi:10.1037/a0037895.

11. Victorson D, Sauer C, Horowitz B, Wolf-
Beadle J. Development and implementation of a
brief healthcare professional support program
based in gratitude, mindfulness, self-compassion,
and empathy. J Nurs Adm. 2021;51(4):212-219.
doi:10.1097/NNA.0000000000001000.

12. ANA. American Nurses Foundation launches
national well-being initiative for nurses. 2020.
www.nursingworld.org/news/news-releases/2020/
american-nurses-foundation-launches-national-
well-being-initiative-for-nurses/.

Kelly Cumella is an instructor of nursing at SUNY
Brockport in Brockport, N.Y. She also works as an NP
in primary care and the geriatric care setting.

The author has disclosed no potential conflicts of
interest, financial or otherwise.

DOI-10.1097/01.NURSE.0000884760.97338.8b

NSG1222_Feature_GratitudeJournal_Deepak.indd 61 29/10/22 3:26 PM

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.