Reflective Tasks With Healthcare Workers During COVID-19
Condition: Wellbeing; Psychological Distress; Emotional Distress; Depression; Happiness; Affect
MeSH terms: Depression
Study type: Interventional

Summary: 
      The healthcare workforce is amongst the most stressed in the United Kingdom (UK). The
      Coronavirus (COVID-19) health pandemic has increased depression, anxiety, insomnia and
      distress in this population. Gratitude interventions have been shown to improve wellbeing,
      alongside reducing risk factors associated with the aforementioned mental health conditions.
      This online Randomised Control Trial of 219 healthcare staff, will investigate the effects of
      a gratitude intervention on wellbeing (gratitude, positive affect, happiness) and
      psychological distress (depression and negative affect). Means of pre- and post-outcome
      measures of two groups (gratitude journal and control) will be assessed for differences
      utilising t-tests.
    

Detailed description: 
      The healthcare workforce is amongst the most stressed in the UK, with 40.3% of staff feeling
      unwell as a result of work-related stress in the past year. This is steadily increasing each
      year, rising 3.5% from 36.8% since 2016. Chronic stress can cause psychological health
      problems, including low mood, anxiety and insomnia. Unfortunately, only 29.3% of staff across
      the NHS felt their trust took positive action on health and wellbeing, which may contribute
      to and prolong this continued rise in work-related stress.

      With the COVID-19 health pandemic adding additional pressure to the NHS, healthcare workers
      (HCWs) are at further risk of mental health problems, including post-traumatic stress
      disorder, depression and substance misuse, as evident from historical health pandemics.
      Furthermore, preliminary data from China during the COVID-19 health pandemic indicated
      frontline HCWs experienced depression (50.4%), anxiety (44.6%), insomnia (34%) and distress
      (71.5%). A systematic review identified risk factors for increased psychological distress of
      HCWs during a health pandemic: being female, a nurse and experiencing stigmatised attitudes
      from the general public, as well as being quarantined. Perceived control and social support
      were associated with lower distress. Recommendations were made, to encourage a sense of
      autonomy (with information and resources), increase social support and to initiate public
      health campaigns with accurate facts, to reduce stigma and distress.

      Positive Psychology Interventions (PPIs) are one approach for promoting autonomy and reducing
      distress, by increasing positive emotions, behaviours, and/or thoughts, thereby increasing
      the wellbeing of an individual. Positive psychology focuses on optimism, positive attitude
      and gratitude, to encourage creativity, improve happiness and reduce mental barriers to
      productivity, as opposed to focusing on 'problems'. PPIs include gratitude journals, using
      affirmations, strength focussing exercises and mindful meditations. PPIs in workplaces have
      improved performance, job wellbeing, engagement and other areas, whilst reducing negative
      performance and negative job wellbeing.

      PPIs have focused on gratitude as a target for improving wellbeing, due to the inverse
      relationship found between gratitude and burnout. Burnout is a state of emotional and
      physical exhaustion, cynicism and detachment from work, caused by prolonged stress. Gratitude
      is a positive, social emotion, similar to appreciation, which can either be state (of being)
      or trait (dispositional). State gratitude is experienced when undeserved acts of kindness or
      generosity are given freely by another person. Whereas trait gratitude is viewed as a
      characteristic of a person, that varies in intensity and frequency throughout their daily
      life. Gratitude interventions have found improvements (with a small to medium effect size) in
      quality of relationships, wellbeing and optimism, alongside job satisfaction . Furthermore, a
      reduction in anxiety, depression and negative affect is also evident.

      Gratitude interventions utilise both expression and self-reflection as their methodological
      properties. Expression includes giving small tokens of appreciation or paying gratitude
      visits. Self-reflection includes writing personal gratitude lists or journals. Gratitude
      lists were as effective as clinical therapies when working with excessive worry. Whereas,
      sharing a gratitude letter was not as effective at improving gratitude, furthermore
      expression of gratitude immediately induced feelings of embarrassment and discomfort.
      However, increases in elevation were noted here, namely improved job performance,
      connectedness, empowerment and autonomy. The reduced effectiveness of this expressive
      gratitude intervention, may be due to barriers in engagement with the intervention, including
      the expected awkwardness of the situation and the 'gratitude expresser's' mood.

      Effectiveness of gratitude interventions in improving gratitude is likely to be affected by
      both traits of participants and specificities of the intervention, such as length. Research
      found trait gratitude moderated the effectiveness of the gratitude intervention in increasing
      gratitude. This supports the resistance hypothesis, suggesting that those who are predisposed
      to experience gratitude will not benefit from a gratitude intervention. Irrespective of
      gratitude moderation, wellbeing significantly improved. The duration of the intervention may
      also have an impact on effectiveness. Research found higher life satisfaction, more gratitude
      and an improved positive affect in HCWs, after writing a gratitude diary bi-weekly over
      4-weeks. Whereas a shorter 5-day intervention in the workplace, using a similar journaling
      methodology, was not effective at improving gratitude. This may be explained by research,
      which found a cumulative improvement in gratitude and happiness over 8-weeks of grateful
      letter writing, indicating gratitude interventions are required to be of a reasonable length
      in order to be effective.

      HCWs are suffering from psychological distress as a result of the COVID-19 health pandemic.
      It is vital interventions are offered to support their wellbeing. Gratitude interventions are
      effective at improving wellbeing and reducing psychological distress, namely the risk factors
      associated with psychological distress in HCWs at present. Self-reflective gratitude
      interventions, over a period of weeks are effective at improving gratitude with HCWs, without
      inducing embarrassment, discomfort or barriers to engagement. However, it is not clear if
      there are differences in effectiveness dependent upon the methodological properties of the
      intervention.

      This study will aim to investigate the effects of a gratitude intervention with HCWs, with a
      view to increasing state gratitude and psychological wellbeing (subjective happiness and
      positive affect), whilst reducing psychological distress (negative affect and depression).

      Objectives

        1. To investigate if gratitude interventions are effective at increasing state gratitude in
           HCWs

        2. To investigate if gratitude interventions are effective at reducing psychological
           distress and improving wellbeing in HCWs

        3. To investigate if high baseline trait gratitude is a moderator of changes in state
           gratitude, psychological distress and wellbeing after a gratitude intervention

      Hypotheses

        1. A gratitude intervention will increase state gratitude in HCWs

        2. A gratitude intervention will improve wellbeing (positive affect and subjective
           happiness) and reduce psychological distress (depression and negative affect) in HCWs

        3. High levels of trait gratitude will moderate the outcomes
    

Intervention name(s): Gratitude
Intervention type(s): Behavioral
Intervention description(s): A positive psychology intervention using expressions of gratitude
Other intervention name(s): Gratitude Letter; Gratitude Diary; Gratitude Journal; Appreciation Letter; expressing gratitude; positive psychology intervention
Allocation: Randomized
Intervention model: Factorial Assignment
Intervention model description: T-tests compare the mean differences between groups split across the two IVs (intervention & time), due to the between factors and within factors levels of the two IVs.
Descriptive Statistics & t-tests will be used to compare and assess cumulative gratitude week-by-week
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Gratitude