Cultivating a Culture of Gratitude and Recognition Among Nurses and Staff on a Blood and Marrow Transplantation Unit

During a time of increasing nursing burnout, innovative strategies are being sought by nursing leadership to improve the work environment. Cultivating a positive work environment, focused on meaningful recognition and gratitude, may be one strategy to address this issue.

Background

Gratitude can motivate individuals to make positive changes in their lives to strengthen the network of support, become healthier and more productive at work, practice humility, and increase levels of generosity by learning to “pay it forward” when shown kindness and appreciation (Dulko & Kohal, 2022). When applied in the workplace, it can promote well-being and prosocial behavior (Youssef-Morgan et al., 2022). Gratitude can energize, heal, and bring hope—characteristics that are invaluable to a worn-out workforce emerging from a pandemic (Fishman, 2020). This is an important concept to explore to help address the heightened nursing turnover rate of about 18% in 2023, in addition to the overall hospital turnover rate of about 21% (NSI Nursing Solutions, 2024).

Meaningful recognition, including showing gratitude, is one of the six evidence-based standards to create a healthy work environment for nurses according to the American Association of Critical-Care Nurses (n.d.). Research shows that expressions of gratitude toward healthcare staff from patients, families, and fellow healthcare providers have demonstrated improved job satisfaction and increased resiliency (Aparicio et al., 2019; Dulko & Kohal, 2022). This expression of gratitude can have personal and professional effects on healthcare professionals that extend beyond the care of individual patients. It increases motivation to continue caring for others, contributes to staff retention, fosters a healthy work environment, and leads to improved personal health and well-being (Aparicio et al., 2019; Starkey et al., 2019). Gratitude also strengthens relationships among health professionals, thereby increasing teamwork effectiveness (Aparicio et al., 2019). Within the setting of oncology units, gratitude expressed by patients to healthcare staff was found to be highly supportive and contributed to reduced work-related psychological demands and lower levels of burnout (Converso et al., 2015). Lower reported burnout in nursing and heightened job satisfaction are predictive of increased intention to stay employed within an organization (Al Sabei et al., 2019; de Cordova et al., 2022). Expressed gratitude from patients often focuses on technical, hands-on skills, as well as interpersonal and communication skills (Aparicio et al., 2019). Despite the well-documented psychological and physiologic benefits of actively practicing gratitude, there are few published studies that evaluate nurse-driven gratitude interventions involving patients and staff in the hospital setting.

The primary goal of this pilot study was to develop and evaluate an easily modifiable intervention focused on meaningful workplace recognition and expression of gratitude during a period of increased turnover within the profession. It was designed to foster a positive healthcare work environment within the hospital setting. The aims of this study were to (a) measure baseline work gratitude among nurses and staff; (b) evaluate the impact of a positive workplace recognition intervention on overall work gratitude, sense of belonging and community, and job satisfaction; and (c) explore the relationships among work gratitude, sense of belonging and community, and job satisfaction among nurses and staff.

Methods and Variables

Sample and Setting

From April to July 2023, a prospective pilot study was implemented on a blood and marrow transplantation unit at University of Florida Health Shands Hospital in Gainesville, a large academic hospital. An initial target sample size was 23 participants, or roughly 50% of the target population, with the aim of including the majority of the unit staff in the final evaluation. The surveys were sent to full-time RNs, patient care assistants (PCAs), and support technicians on the unit. Prior to the intervention, 24 nurses and staff (representing 52% of unit staff) completed study measures. Three months later, 16 (representing 35% of unit staff) postintervention surveys were received. Nurses comprised the largest group of participants (n = 16), followed by PCAs (n = 6) and support technicians (n = 2).

Intervention

Public-facing digital signage was installed on a wall near the nurses’ station on the unit. Installation was delayed by about four months because of supply chain issues. A digital signage software, Xibo, was used for updating the board, with training from information technology support. Slides were designed by the principal investigators using Canva, a free-to-use online graphic design tool. For the duration of the study, the principal investigators wirelessly updated the board weekly with slides about unit-/facility-based accomplishments, calendar events, life events as submitted by staff (e.g., birth of children), professional development opportunities, staff introductions, and quotes from expressions of gratitude submitted by staff, nurses, and patients. These cycled on-screen during a one- to two-week period. The investigators met weekly to check in, review submissions, and generate new ideas for slides.

Gratitude submissions were accepted via QR codes posted on flyers placed around the unit in staff- and patient-facing areas. This facilitated anonymous submissions of gratitude and/or positive recognition for unit staff members. Individuals who elected to submit were notified that their responses may be selected for posting on the public-facing board and used for research purposes. Responses were screened by the investigators and posted to the electronic screen within 72 hours of submission.

For two weeks before and after implementation, electronic surveys were sent via email to PCAs, RNs, and support technicians employed on the unit. The nurse manager, who served as a coprincipal investigator, was intentionally not involved with the recruitment process. Participation was voluntary, and a waiver of informed consent was completed prior to survey completion. A LISTSERV provided by nursing leadership, which included nurses and staff employed at the times of survey collection, was used. Flyers inviting participation and providing QR codes were also posted in high-traffic areas for staff. Reminder emails were sent weekly during the survey period.

There was no monetary compensation for completing the surveys or gratitude submissions, and participation was voluntary. Approval from the University of Florida Institutional Review Board was obtained prior to implementing the study.

Measures

Work Gratitude Scale: This scale was used to measure nurses’ sense of gratitude at work (Youssef-Morgan et al., 2022). This scale has demonstrated reliability and validity within the educational workplace but has not been previously used in the healthcare setting. It was selected because of its concurrent validity in relation to the Gratitude Questionnaire and the Gratitude Resentment and Appreciation Scale, with a notable adaption to apply this concept to the workplace. Work gratitude is defined as “the intentional choice to engage in positive appraisals and feelings of thankfulness and appreciation toward the characteristics, situations, and people currently present in one’s work context” (Youssef-Morgan et al., 2022, p. 3). Scores ranged from 1 (strongly disagree) to 7 (strongly agree). A mean score for gratitude at work was computed across all 10 questions, with higher scores indicating higher levels of work gratitude.

Demographic and staff perception survey: An anonymized survey developed by the investigators was used to assess age, unit role, number of years in current role, prior work experience in the current role within and outside the organization, and shift worked. The survey also assessed self-reported job satisfaction, perceived sense of belonging and community on the unit, and perceived strength of social support, with scores ranging from 1 to 5 (1 = never, 2 = sometimes, 3 = neutral, 4 = usually, and 5 = always).

Statistical Analysis

Statistical analysis was performed in R, version 4.3.1. Descriptive statistics were reported as mean and SD for continuous variables and as frequency and percentage for categorical variables. Spearman’s rank correlation coefficients were calculated to examine the relationships between job satisfaction, sense of belonging and community, and work gratitude. Wilcoxon rank-sum tests were used to compare the level of job satisfaction, sense of belonging and community, and work gratitude before and after the intervention. Nonparametric statistical methods were chosen because of the non-normality of the collected data. Although the initial plan was to analyze paired data, this was not an option because of challenges of respondents in recalling their self-selected unique identification number on the final survey.

Results

Table 1 presents sample characteristics and descriptive statistics for key study variables. Baseline levels of job satisfaction, sense of belonging and community, and work gratitude were positive on the unit. The average level of job satisfaction reported was 3.5 of 5 (SD = 1). In response to the statement “I feel a sense of belonging and community on my unit,” participants scored 3.8 of 5 (SD = 1.1). The average baseline work gratitude score was 5.2 (SD = 0.8) of a total of 7.

Impact of Intervention

There were no statistically significant changes in the scores for job satisfaction (p = 0.26), sense of belonging and community (p = 0.74), and work gratitude (p = 0.43) before and after the intervention. These conclusions were unchanged when only RN responses were evaluated. For descriptive purposes, the authors also calculated the average level of job satisfaction, sense of belonging and community, and work gratitude after the intervention (see Figure 1).

Relationships Among the Variables

Statistically significant relationships were noted between some of the attributes investigated. Staff who reported higher levels of work gratitude also reported higher job satisfaction (p = 0.001) and greater sense of belonging and community (p = 0.034). There was no significant correlation between job satisfaction and sense of belonging and community (p = 0.052).

Gratitude Submissions

A total of 21 gratitude submissions were received during the study period, of which 90% were generated by nursing staff. Submissions were directed toward nurses (n = 17), support staff (n = 1), and PCAs (n = 3). No negative feedback or rude comments were received during this study period.

Discussion

This pilot project was a viable and creative way to show appreciation toward nurses and staff and foster a positive work environment during a challenging time in the profession. Overall, it was positively received by staff and patients on the blood and marrow transplantation unit, garnering increasing engagement among nurses during the project. Although the findings evaluating the overall impact of the intervention were not statistically significant, during a time of heightened burnout and turnover, it is notable that averages for job satisfaction, belonging and community, and work gratitude increased overall following the three-month study period. Having greater job satisfaction and sense of belonging within the organization significantly decreases nurses’ turnover intention (Bai et al., 2024; Liu et al., 2023). In addition, studies show that increased gratitude levels can reduce turnover and increase well-being and resiliency among nursing staff (Aparicio et al., 2019; Bai et al., 2024; Starkey et al., 2019).

When exploring the relationships further, the authors found that nurses and staff who reported higher job satisfaction and a stronger sense of belonging and community experienced significantly higher levels of work-related gratitude. This supports prior research that demonstrates the positive relationship among job satisfaction, social support, and gratitude within the workplace (Chen et al., 2021). Healthcare organizations can improve nurses’ job satisfaction by increasing gratitude within the workplace (Bai et al., 2024). Interestingly, there was no significant correlation between job satisfaction and sense of belonging and community within this study, though prior studies have demonstrated this relationship.

Limitations

There are several limitations noted in this study. The sample size was small and was limited to one unit within the hospital setting, which affects generalizability. Challenges among staff in recalling their self-assigned eight-digit code for pre- and postintervention surveys limited matching in the final analysis. Inclusion of the nurse manager on the study team may have negatively affected the number of participants, despite the established anonymity of the survey responses. It is possible that the baseline levels of job satisfaction, sense of belonging and community, and work gratitude may be elevated because of the type of specialty unit. There were a limited number of gratitude submissions received during the study period, which limits the interpretation of themes of gratitude among nurses, staff, and patients. In addition, the time frame for implementation may not have been long enough to capture a shift in overall unit culture.

Conclusion

Finding creative and innovative strategies to improve the workplace for nurses and staff is beneficial for supporting the nursing profession. Organizations should prioritize interventions, spend time, and increase energy to provide meaningful recognition and expressions of gratitude toward employees to recognize nurses and staff for a job well done (Blake, 2023). Nurses are well positioned to champion these efforts because of their integral role and presence within the healthcare organization. This project represents one approach to enhancing gratitude, job satisfaction, and sense of belonging and community among nurses and staff, which can be tailored to fit the needs of individual hospital units. Future studies should continue to explore nurse-driven initiatives to increase meaningful recognition and gratitude among patients and staff.

The authors gratefully acknowledge Dean Anna McDaniel, PhD, RN, FAAN, Irene Alexaitis, DNP, RN, NEA-BC, Angela Starkweather, PhD, ACNP-BC, FAANP, FAAN, Laurie Duckworth, PhD, APRN, FNP-C, FAAN, Jennifer Pruitt, MSN, APRN, CNM, E. Mendy Dunn, MSN, RN, ACRP-CP, NE-BC, Ann Horgas, PhD, RN, FGSA, FAAN, and the UF College of Nursing’s Office of Research Support for providing the opportunity for this research and for support throughout the project.

About the Authors

Bryce Catarelli, DNP, APRN, FNP-C, is a clinical assistant professor in the College of Nursing at the University of Florida (UF) in Gainesville; Jamie Dees, MSN, RN, CNL^®, BMTCN^®, is a nurse manager at UF Health Shands Hospital in Gainesville; and Fan Yi, PhD, is an assistant professor in the Department of Mathematics and Statistical Science at the University of Idaho in Moscow. This research was funded, in part, by the UF College of Nursing “Strengthening the UF Health Nursing Academic–Practice Partnership Through Joint Demonstration Projects With College of Nursing Faculty and Shands Nurses” project (P0274409). Catarelli and Dees contributed to the conceptualization and design and completed the data collection. Dees and Yi provided statistical support. Catarelli contributed to the manuscript preparation. All authors provided the analysis. Catarelli can be reached at bcatarelli@ufl.edu, with copy to ONFEditor@ons.org. (Submitted September 2023. Accepted April 17, 2024.)