Developing a Deliberate Practice of Expressing Gratitude

Written by: Janet Serwint, M.D.

In the following post, Jan walks us through her personal journey of a building a reflective gratitude practice.   She shares her struggles and joys and offers practical ideas you can easily implement!

When the COVID pandemic began, I experienced anxiety, stress and isolation similar to what many others were experiencing.   In an attempt to address these issues, I decided to explore a practice of expressing gratitude.

Gratitude is described by Wood et al. as a “life orientation towards noting and appreciating the positive in life”.  Another definition describes gratitude as “pausing to notice and appreciate the things that we often take for granted”.  Research to date, which has been cross-sectional in design, has found that  expressing gratitude is associated with  an increase in self- esteem and empathy in addition to physiological increases in dopamine and serotonin.  Hence, expressing gratitude may physiologically make you feel good.   Understanding the positive effects prompted me to pursue this journey.

My initial interpretation of gratitude was being grateful for the relationships in my life and the many acts of kindness that others have shown me.   These encompass gratitude for family, friends and colleagues, but during the pandemic a new realization of my gratitude for front line workers who provide services essential to our community but who perhaps we had taken for granted in the past:  grocery store workers, food pantry workers, pharmacists, postal and delivery people, teachers, police and fire fighters, workers in retail stores, restaurants and many others.   I find that even though we are now at a different phase with COVID,  there were many experiences and lessons learned during the COVID pandemic for which I am grateful.

Yet I realized that my initial conceptualization of gratitude while important, was perhaps too limited and I sought additional ideas.  My continued contributions to my gratitude journal allowed me to enhance my interpretive lens of events in the world and consider additional aspects of gratitude which included the need to take time for reflection.

Conceptualizations of Gratitude

Wood et al. suggests a wider conceptualizations of gratitude to include the following: 1) a focus on what a person has which transcends relationships, mere possessions and includes one’s abilities and blessings, 2) feelings of awe when encountering beauty and nature, and 3) appreciation and gratitude arising from understanding that life is short and the importance of valuing each day.

Focus on what a person has.  This may include basic needs that we may often take for granted: a clean or safe place to live, access to food, clean water or even computer access.   We may express gratitude for the ability to use our five senses in being able to see, hear, taste, touch and smell.  I believe that the COVID pandemic made me more aware of the value of these senses:  to see the smile of a loved one,   beautiful things in nature or reading a book; hearing the laughter of a child or inspiring music (Louis Armstrong’s It’s a Wonderful World is one of my personal favorites); being able to taste your favorite foods; the gift of touch through feeling a hug, or stroking your pet, and the smell of flowers, the air after a  rainstorm or the aroma of coffee brewing.    We sometimes forget the privilege and blessings of our  human rights, spiritual freedom, being raised with good values and moral consciousness, access to an education, and gratitude for cultivating attributes such as creativity, kindness, altruism, and humanism.   Yet as I reflect on these aspects, it also makes me realize how fortunate I am and I realize that many others may not have these same privileges, emphasizing the need to advocate so that these basic needs/rights are available to everyone.

Feelings of awe when appreciating something of beauty.   This beauty can include people, things and nature; the beauty of a couple walking hand in hand, a parent hugging their child, the sight of a sunrise, of clouds, of landscapes in everyday places or awe-inspiring beauty in our national parks.   There are other countless examples of experiences that can touch our hearts and elicit powerful positive emotions such as joyous expressions of love or laughter, viewing a beautiful painting, reading a moving poem or being able to spend time in nature are just a few.    And there are probably countless other examples.

Appreciation arising from understanding life is short.   Every human being suffers at different points in life, and these experiences contribute to who we are today.  Every experience that you have had to date informs your personal and professional life today.  The concept of understanding life is short often becomes apparent after survival and recovery after a period of suffering or a traumatic event.    These events may occur to us personally or to our family, friends or colleagues yet they impact us all.  They may range from gratitude for your health (something we often take for granted until it is at risk)  near miss health scares  such as the possibility of a life altering diagnosis and further testing confirms health, a near miss accident, to the actual experience of trauma related experiences:  a life altering diagnosis such as cancer, effects from COVID, surviving harassment or abuse,  challenges of immigration, return from war, or natural disasters such as hurricanes or earthquakes.   Many who survive comment on their gratitude in “just being alive” or focusing on “good days” for which to be grateful and valuing each day.  Focus on this gratitude also reminds us to reflect on the fact that many of us may be struggling silently  and hopefully helps us to be more compassionate towards others as we may not always know what others may be experiencing.

Taking time to reflect:  Making gratitude a deliberate practice

It seems to be human nature that those of us in health care tend to focus on the challenges and what didn’t go well, instead of the successes and joys.   While a focus on the challenges allows us to grow and develop strategies to improve, the concept of celebrating the joys and successes may also be important and life enriching.   There are daily successes of which we don’t take notice.  Gratitude journals may be one way to acknowledge the positive psychology of life and to make gratitude a deliberate practice.

Gratitude journals have become quite popular and may be as simple as listing 3 things each day for which one is grateful. Dr. Rachel Remen expands on this concept of gratitude journaling and is well known for encouraging people to ask 3 more specific questions each day:

 “What surprised me today?”

“What inspired me today?”

“What touched my heart today?”

I started  a gratitude journal at the beginning of the pandemic.  But completing the gratitude journal wasn’t as easy as I thought it would be.  Initially, I became frustrated because I couldn’t find answers to the questions and it felt more like an obligation as my perfectionist tendencies seemed to get in the way.  I would feel “stressed” at night before I went to bed if I hadn’t come up with answers to the 3 questions.   So initially, my gratitude journaling which was supposed to alleviate my stress was adding to it.  And initially I couldn’t “see” the examples all around me.  But I stuck with it and after about 5-6 days I  began to notice examples “real time” and heroes all around me.   A deliberate practice of gratitude became a way for me to be more “mindful” in the moment and notice so many examples of life events for which I was grateful and which prior to this I had overlooked.

Contributing to this journal made me more aware of my gratitude and prompted me to share this  gratitude with the person for whom I felt grateful; whether through spoken appreciation, a card, an email, a phone call, or adding more specifics to the thanks I might share verbally each day.   Acknowledging the random acts of kindness really improved my mood.  I also found ways to expand this concept beyond my individual journaling.   Colleagues have mentioned that while these questions are good for personal journaling, they are also good questions to share with family over dinner.   Families have enjoyed asking each other these questions and found a greater depth and discovery of experiences of each other’s lives.    I have also expanded this concept to our health care teams at work.   Asking and share the answers to these questions among colleagues at the end of hospital rounds, at the end of a clinic session,  or the end of the day.   Sharing these examples of  surprise, inspiration and touching our heart had provided more focus on a culture of caring and shared experiences within our teams.

I found another aspect of deliberate focus on gratitude is keeping examples of the gratitude that others may express to you.  Many of my colleagues share a practice that I have done throughout my career of keeping a  Smile File or a Sunshine File.  This file includes keeping letters, cards, and emails of gratitude that others have sent you that may be from patients, family, friends, learners, mentees.  It may be a hard copy or a computer file but I personally like the hard copy of the cards and mementos.   What a beautiful way to remember these people and these experiences and also to remind you of the meaning of your work and celebrate the successes you have experienced.  I loved to receive them, started to collect them and I always knew they were there.  I could refer to them during times when I was struggling, when I perceived my life wasn’t going well or when I was in a slump.  In writing this article I pulled out my Smile File which I hadn’t looked at in several years and it brought back such happy memories, reminded me of the meaning of my work and how valuable it is to have sentiments in writing, prompting me to be more proactive in sending written tokens of gratitude to others.

So, in closing, consider embracing the concept of gratitude.  There is a full circle of benefits to you and to those with whom you may share your gratitude to them.  See if developing a deliberate practice may help you to have a more positive outlook on life and your career, enhance your well-being, remind you of the meaning of the work you do and the reward of expressing gratitude to others.


Remen R.  Journaling:

Serwint JR, Stewart MT. Cultivating the joy of medicine: A focus on instrinsic factors and the meaning of our work.  Curr Probl Pediatr Adolesc Health Care. 2019 Dec;49(12):100665. doi: 10.1016/j.cppeds.2019.100665.

Wood AM, Froh JJ, Geraghty AWA.   Gratitude and well-being: a review and theoretical integration.   Clinical Psychology Review 2010; (30):890-905.