Using a Shared Gratitude Experience to Support Well-Being among Health Informatics Students during a Crisis

Abstract

Objectives This study explores the results of a rapidly implemented no-cost gratitude intervention designed to address student distress during the coronavirus disease 2019 (COVID-19) pandemic. This intervention focused on shared gratitude journaling with a postimplementation survey of well-being using elements of Seligman's PERMA (Positive emotion, Engagement, Relationships, Meaning, and Accomplishment) model of well-being.

Methods Journaling took place from November 2020 to April 2021 using a convenience sample (N = 57) from the Master of Science in Health Informatics program at the University of Alabama at Birmingham. An online postimplementation survey was conducted to evaluate students' perceptions of how the intervention influenced their well-being. Quantitative analysis was conducted to understand student well-being after two semesters of using an online shared gratitude board. Qualitative analysis was conducted to identify themes in the content of the student posts.

Results Relative to the PERMA elements, the majority of students agreed or strongly agreed that posting to the gratitude board led to improvements in Positive Emotion (85.72%), Engagement (77.2%), Relationships (67.7%), Meaning (77.2%), and Accomplishment (60%). Students who would recommend the board outweighed the number of students who would not by over 25%.

Discussion The gratitude board represented an opportunity to rapidly implement a no-cost opportunity based on the science of gratitude and well-being to support students' mental health and wellness. Meta-inferences gleaned from the quantitative and qualitative findings suggest that students found gratitude in different areas, that having things to do was helpful, that being able to connect with people was important, that students derived purpose from effort, and that they felt a sense of accomplishment by completing objectives.

Conclusion Our findings suggest that adopting an attitude of gratitude helps stimulate positive emotion to facilitate growth and learning. While this study was conducted with students in a graduate Health Informatics program, it has widespread generalizability to other programs and in other environments, especially at times when there is emotional distress.

Keywords

resilience - happiness - psychological well-being

Background and Significance

As one of the greatest crises to impact the United States in a century, the coronavirus disease 2019 (COVID-19) pandemic brought a constellation of stressors to both students and faculty alike. Specifically in the university setting, a large survey of faculty found that 87% believed that student mental health had worsened during the pandemic.[1] Additionally, faculty were grappling with their own stressors such as sudden changes to an online format of teaching, fatigue, emotional well-being, and work- and family-related stress.[2] [3] Faculty members often became the unofficial gatekeepers of student well-being, as their regular interactions with isolated students during lockdown opened the window to changes in student well-being and performance. Nearly 80% of faculty reported having one-on-one interactions with students regarding their mental health and wellness.[1] This dynamic led to an opportunity for faculty to consider opportunities for improving the well-being of their students. This could take the form of one-on-one discussions, group huddles or check-ins, or directing students to existing well-being resources within the university or community. Other tools that have been shown to support overall well-being and resilience include practices such as mindfulness, journaling, exercise, and gratitude.[4] [5] [6] [7] [8] [9] [10]

Graduate education is a highly personal decision, and many would agree that the central motivation is to invest in one's own learning, education, and growth. Even prior to COVID-19, literature suggests increasing mental health issues among graduate students.[11] However, the emotional stressors of social isolation, death, and overall uncertainty (personal, family, community, and national) brought on during the 2020 pandemic added layers of stress that caught many people ill-equipped to handle the volume and velocity—it was simply too much too quickly and mental health compromises emerged and overall well-being was threatened.[1] [12] [13] Well-being can be thought of from two different perspectives: positive experiences balanced on positive affect[9] [14] or moral and self-realization.[15] [16] While scientific experts in this field have clear supporting arguments for each perspective and multiple models for understanding well-being, there is agreement that the Well-being theory, also called the PERMA model of well-being provides a useful framework for understanding and evaluating well-being.[17]

PERMA refers to five components of well-being: (P) Positive emotion, (E) Engagement, (R) Relationships, (M) Meaning, and (A) Achievement. Positive emotion can be defined as positive feelings of happiness, optimism, joy, or hope. Gratitude has been shown to reduce negative emotions and increase positive affect.[18] Engagement refers to being immersed or absorbed in one's activities or achieving a state of flow. Healthy Relationships are essential for well-being and can be cultivated among family, friends, classmates, mentors, and others. Meaning generally refers to feeling a sense of purpose in life. Achievement is felt when one sees the acquisition of a goal based on their own effort.[17]

Acknowledging that there are multiple methods and tools to reduce stress, the literature is replete with the benefits of showing gratitude, journaling, and gratitude journaling. As such, we focused our intervention on gratitude journaling with an aim to incorporate as many elements of PERMA as possible. For Positive emotion, the practice of gratitude has been specifically recommended as a mechanism for increasing feelings of happiness.[17] For Engagement, one way to increase engagement is to practice living in the moment, even during mundane or routine tasks.[17] By reflecting on the simple pleasures each day, this intervention encouraged students to find benefits even during routine or normal days. For Relationships, we wanted the intervention to serve as a mechanism for students to feel connected to each other and connected to faculty, especially during a season where social isolation was a significant stressor. For Meaning, we wanted the intervention to help students focus on the things in their lives that were meaningful and important, rather than the daily onslaught of negative news and the many challenges during the pandemic. By directing students to focus on the good things in their lives, we hoped to cultivate a deeper sense of meaning. For the Achievement element of well-being, Seligman[17] suggests reflecting on past successes as a mechanism to improve this element.

The sudden, compounding, and sustained stressors experienced by both our faculty and our students, including one student death and several suicide attempts, the Health Informatics program administration felt the need to provide a safe space for focusing on positive events, no matter how incidental they might have seemed—basically finding the good in each day. The intervention provided an opportunity for students to share their successes, large or small, with their peers and faculty. Based on positive results from other socially oriented gratitude interventions,[7] we opted to create a shared electronic online gratitude board that was visible to all students and faculty within the program. This paper reports on a postimplementation survey of a course-based gratitude intervention called “Find the Good,” a name chosen by the Program Director as it was consistent with Siegelman's Engagement pillar to practice living in the moment. We use the PERMA model of well-being as a means to understand and evaluate the gratitude intervention.

Methods

In response to increased student stress, mental health issues, one student death, and several suicide attempts among Health Informatics students, “Find the Good” was launched on November 6, 2020, and remains active, but not monitored, as of this paper. Padlet.com was used as the gratitude board vehicle. Padlet.com was chosen because it was easily accessible, easy to use, and free. The account was created by the Program Director with a link shared out to all participants. Although many of the students were aware of the student's death, most were not aware of the suicide attempts and other mental health struggles endured by their fellow classmates. It is helpful to reflect on these days back in 2020—everyone was reactive and implementing whatever they thought would help. So, too, was “Find the Good.” Other than knowing that gratitude journaling is helpful to create positive emotions and that positive emotions have a positive impact on learning,[19] “Find the Good” was a reactive attempt to salvage our students during a time of generalized chaos. A mass email with a link was sent out by the Program Director to all program students letting them know about “Find the Good” and each instructor continually mentioned it in class and amended their syllabi to include a link. In an attempt to draw students into the practice of posting, the syllabi also included that all students were awarded two extra credit points for consistent posting throughout the mid-fall 2020 (November 2020 through December 2020) and spring 2021 semesters (January 2021 through April 2021).

From a quantitative perspective, a convenience sample of unique participants (N = 57) from the Master of Science in Health Informatics program at the University of Alabama at Birmingham were invited via email to participate in the “Find the Good” postimplementation survey. The survey was conducted using the online Qualtrics platform. There were 39 usable surveys resulting in a 66% response rate. The survey was open from June 22, 2021, through June 30, 2021, with reminders sent at 3 and 7 days. The purpose of the survey was to understand students' perceptions of the role of the gratitude board, “Find the Good,” in improving their well-being along the dimensions of PERMA, including changes in positive emotions, engagement, relationships, meaning, and accomplishment. We also asked questions relative to relationship status, gender, and children living at home. We also included a question that would result in a Net Promoter Score (NPS) to understand how likely someone would be to recommend “Find the Good.” The quantitative data were analyzed in SPSS Statistics for Windows version 27 (SPSS Inc., Chicago, IL).

A qualitative review of the postings revealed 2,315 records of student perceptions posted to the “Find the Good” gratitude board. These records were downloaded from the shared gratitude platform, padlet.com, and uploaded into NVivo20 for thematic coding and analysis. Thematic coding of the noted student perceptions produced 19 primary themes with over 400 combined subthemes and sub/subthemes. A stemmed word query was run using the NVivo software and a word map was created to visualize findings.

Results

Quantitative

Out of the 39 respondents, 35 reported posting regularly to the gratitude board. In terms of gender, respondents were each 9% from the center with males at 41% and females at 59% (If the center is 50%, then 9% lower would be 41% and 9% higher would be 59%). A majority of the respondents did not have children (69.2%) and about two-thirds (64.1%) indicated being in a relationship where they are living with someone. Relative to the PERMA elements, the majority of students agreed or strongly agreed that posting to the “Find the Good” gratitude board led to improvements in Positive Emotion (85.72%), Engagement (77.2%), Relationships (67.7%), Meaning (77.2%) and Accomplishment (60%). When asked whether students would recommend posting on the gratitude board to a classmate on a scale of 1 to 10, the mean score was 7.95. The results of the NPS indicated that approximately 43% of students were promoters, 40% of students were passive, and 17% were detractors, resulting in an NPS of 25.71. NPSs from 0 to 30 are considered good, while over 30 are considered great (see [Table 1]).

Table 1 PERMA domain questions

PERMA domain/survey question			Frequencies (percentage)
Please rate the effect of posting to the gratitude board on the following dimensions of well-being. Posting to the gratitude board IMPROVED:	n	Mean (SD) 1–5	Agree or strongly agree	Neither agree nor disagree	Disagree or strongly disagree
P, Positive emotion—my feeling of positive emotions such as contentment, hope, or joy	35	4.14 (0.72)	30 (85.72%)	4 (11.4%)	1 (2.9%)
E, Engagement—my engagement with my program	35	4.03 (0.94)	27 (77.2%)	6 (17.1%)	2 (5.8%)
R, Relationships—my relationships with faculty and students	34	4.00 (0.87)	13 (67.7)	10 (29.4%)	1 (2.9%)
M, Meaning—my sense of meaning and purpose	35	4.03 (0.77)	27 (77.2%)	7 (20%)	1 (2.9%)
A, Accomplishment—my feelings of achievement and mastery	35	3.69 (1.0)	21 (60%)	10 (28.6%)	4 (11.5)
On a scale from 0 to 10, how likely are you to recommend posting to the gratitude board to a classmate?	35	7.95 (2.01)

Abbreviations: PERMA, Positive emotion, Engagement, Relationships, Meaning, and Accomplishment; SD, standard deviation.

Qualitative

A word frequency query using NVivo20 with a specific search for stemmed words was run. Results with a frequency greater than 1.0% are shown in [Table 2] where results are also aligned to the best-fitting PERMA domain. Stemmed words are derivatives of a word, for example, “thank” may have also appeared as thank, thanks, or thankful. Students used 963 words in their perceptions of gratitude on the gratitude board. The stemmed word frequency results showed “grateful” to have the greatest use frequency of 15.17%. Other words less frequently used, yet popular were, thankful at 2.04%, today at 1.93%, days at 1.78%, family at 1.37%, working at 1.23%, friends at 1.18%, weekend at 1.08%, and time at 1.05%.

Table 2 Common themes (>1.0%)

Word	Similar words	PERMA domain	Saturation (%)
grateful	grateful	P	15.17
thankful	thank, thankful, thanks	P	2.04
today	today	E	1.93
days	day, days	E	1.78
working	work, worked, working, works	E	1.23
weekend	weekend, weekends	E	1.08
family	families, families', family	R	1.37
friends	friend, friendly, friends	R	1.18
time	time, times	M	1.05

Abbreviation: PERMA, Positive emotion, Engagement, Relationships, Meaning, and Accomplishment.

To provide a visual representation of text density, we put all words into a word cloud (see [Fig. 1]). The benefit of doing so helps to quickly convey the most prominent words used on the gratitude board. The word cloud does not, however, provide detailed insights into the PERMA domain or the actual saturation of the word as detailed in [Table 2].

Fig. 1 Word cloud.

Discussion

This paper used quantitative and qualitative methods to report on a shared gratitude board intervention for Master of Science Health Informatics students during the COVID-19 pandemic. The shared gratitude board, called “Find the Good,” was implemented as a mechanism to help students feel connected to each other and to decrease feelings of isolation.

A joint display table helps to display quantitative and qualitative findings together in a unified format. This helps to identify relationships to develop meta-inferences.[20] The quantitative and qualitative findings are displayed in [Table 3] relative to the PERMA domains.

Table 3 Joint table display

Domain	Quantitative findings	Qualitative themes	Saturation	Meta-inferences
(P) Positive emotion	85.7%	thankful, grateful, great, good, beautiful, wonderful	17.2%	Students were able to find gratitude in many different areas
(E) Engagement	77.2%	weekend, getting, working, today	6.0%	Having things to do provides substance
(R) Relationships	67.7%	support, family, friends, team, home	2.6%	Students appreciated being able to connect to people close to them
(M) Meaning	77.2%	time, final, semester	1.1%	Students derived a sense of purpose from their effort
(A) Achievement	60.0%	semester, job, program, health, opportunity	<1.0%	A sense of accomplishment was felt by completing one or more objectives

Relative to the PERMA framework, all elements showed a positive association with Positive Emotion (85.72%), Engagement (77.2%), and Meaning (77.2%) being the strongest. The PERMA elements of Relationships (67.7%) and Accomplishment (60%), while still positive, were not quite as strong. These findings, Positive Emotion and Meaning especially, align with the qualitative analysis showing “grateful” as the word used most often in the posts (n = 2,064, 15.17%). The extent to which “grateful” was used to exhibit perceptions of gratitude may be indicative of expressing feelings of gratitude, its derivative, and the nature of the board. The lower results for Relationships may be due to the widespread isolation that a lot of people were feeling during this time and taking this into consideration, the Relationship score may have been even lower had students not had the opportunity to participate in the “Find the Good” shared gratitude board. During the pandemic, health care workers, who represent many in our program, were stretched thin and questioning whether they were impacting progress.[21] This feeling of helplessness could explain the lower Accomplishment results.

Consistent with the literature, the “Find the Good” shared gratitude board created a low-cost and immediately implementable environment to support overall well-being.[4] [6] [8] While we do not know the impact that the “Find the Good” gratitude board had on rising mental health issues among graduate students, faculty reported, anecdotally, that students were confiding in them more often and on deeper issues than ever before.[1] [9] While supporting student mental health during times of crisis requires a multifaceted approach at multiple levels of the academic institution, the “Find the Good” intervention is a simple, low-cost tool that is easy for any faculty member to incorporate into their coursework. Given the positive perceptions of participating students, this represents a potential high impact in the quest to support student well-being and to improve student engagement.

Initial faculty concerns around adding extra credit points are aligned with the literature in that students will become relaxed on coursework because they are counting on the extra credit[22]; however, in the end, these points did not actually lead to a letter grade increase and we did not find coursework relaxation to be the case. To the authors' knowledge, there is no literature available on extra credit points to motivate students during a pandemic.

While this assessment of a rapidly developed gratitude intervention yielded positive results, there are a few notable limitations. First of all, given the urgent need to mitigate stress during the pandemic, we did not capture baseline data on student well-being. Therefore, we cannot measure the actual effects of the intervention on students' well-being but only their perceptions of such. Secondly, the majority of survey respondents were those who were actively engaged with the board, leading to a possible response bias. Opportunities for future research include a randomized study design and applications to other student populations. Lastly, as we are reporting on students' perceptions, we do not establish any correlations between the use of a gratitude board and well-being using the PERMA framework, but rather this study helps us to understand the potential impact of an online shared gratitude board to well-being and lays the foundation for a broader, more rigorous, and less urgently implemented study.

Conclusion

This study reports on the findings of an online gratitude board that was implemented, rather urgently, during the chaos of the COVID-19 pandemic. The “Find the Good” gratitude board was implemented specifically after the death of a student and others expressing suicidal ideation during COVID-19. Mental health counselors were overwhelmed during this time and faculty became the de facto counselors for students. We align our findings to the PERMA framework suggesting that adopting an attitude of gratitude helps stimulate positive emotion to facilitate growth and learning through enhanced attention, positive emotions, and overall motivation to learn.[19] While this study was conducted with students in a graduate Health Informatics program, it has widespread generalizability to other programs and in other environments, especially at times when there is emotional distress.

Clinical Relevance Statement

Clinical environments can be very stressful and while many are filled with joy, such as the birth of a healthy baby, many are also filled with profound sorrow. These emotions are compounded by overburdened clinicians. Gratitude journaling within clinical practice holds impactful relevance in promoting psychological well-being and contributing to empathy. By encouraging individuals to regularly reflect on and document moments of gratitude, this intervention fosters a positive shift in cognitive patterns, emotional regulation, and interpersonal relationships.

Multiple-Choice Questions

1. What is the PERMA framework?

   • Five elements in the model of well-being

   • Five elements in the model of gratitude journaling

   • Five elements in the framework of positive thinking

   • Five elements in the framework of empathy

   Correct Answer: The correct answer is option a.

2. What is the benefit of gratitude journaling?

   • Promotes psychological well-being

   • Stimulates a positive shift in the way we think about things

   • Contributes to interpersonal relationships

   • All of the above.

   Correct Answer: The correct answer is option d.

Conflict of Interest

None declared.

Acknowledgments

The authors acknowledge the students who contributed to the “Find the Good” gratitude board and thank them for taking the time to enrich their own lives and the lives of others around them during such difficult and emotionally fragile times. Additionally, we thank the reviewer for their thoughtful review of this manuscript.

Protection of Human Subjects

This study was conducted under IRB #300007440 as exempt from the University of Alabama at Birmingham.

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Publication History

Received: 16 April 2024

Accepted: 21 August 2024

Article published online:
20 November 2024