To assess changes in well-being, we used four validated scales (EE, depression symptoms, subjective happiness and work–life balance) at each assessment point (see table 1 for Cronbach’s alphas). These four metrics were selected a priori and they were the only metrics administered. Demographic questions were included at baseline and open-ended items were also included at the 1-month follow-up. In the 1-month assessment, we also asked for evaluation feedback on a 1–5 scale, (‘strongly agree’ to ‘strongly disagree’) through questions such as, ‘I would recommend the 3 Good Things exercise to a friend,’ ‘I have encouraged others to try 3 Good Things,’ ‘I would like to participate in 3 Good Things again next year,’ and with an open-ended comments text box.
In addition to using scale scores to examine change following 3GT, we also report the percentage of participants whose scores fell below well-being thresholds established by prior literature.
Burn-out EE Subscale: The Maslach Burnout Inventory, which is the gold-standard tool in the field of burn-out, has been used extensively with HCWs. A meta-analysis has revealed that of the three subscales (EE, depersonalisation and personal accomplishment), EE consistently produces the largest and most consistent coefficient alpha estimates, while depersonalisation and personal accomplishment were both lower and less consistent than EE.31 (link) In addition to being more psychometrically robust, EE can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to criteria outlined in the International Statistical Classification of Diseases and Related Health Problems - 10th Revision).32 (link) We used a 5-item derivative33 (link) of the original 9-item EE scale.32 (link) Example items include ‘I feel frustrated by my job’ and ‘Events at work affect my life in an emotionally unhealthy way’. Participants respond using a 5-point Likert scale (1=disagree strongly; 5=agree strongly). Each participant’s mean of the five items was converted to a 0–100 point scale, with higher scores representative of more severe EE. A score of 50 or higher indicates that the respondent is not disagreeing with the EE statements, and is the first threshold for per cent concerning because it indicates at least mild EE.34 (link) These ‘per cent concerning’ thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a given metric. The per cent concerning threshold can be grasped quickly, providing an anchor for interpretation and offering a way of communicating something about the distribution of the data within a single number. For EE, internal consistency in the current study was good (Cronbach’s alpha=0.85)
Depressive symptoms: The Center for Epidemiological Studies Depression Scale-10-item version is a psychometrically sound tool for screening respondents for clinical depression.35 (link) All items are prefaced with, ‘during the past week, how often did this occur’ and includes items such as ‘I could not ‘get going’ and ‘my sleep was restless’. Responses are answered on a 4-point scale (0=rarely or none; 3=all of the time). Each participant’s responses are summed together to achieve a 0–30 point scale. A score of 10 or higher is considered a positive screen, and was the threshold we used to group participants by depressive symptom severity as ‘per cent concerning’.36 (link) Internal consistency in the current study was good (Cronbach’s alpha=0.85)
Subjective Happiness: Lyubomirsky and Lepper’s Subjective Happiness Scale (SHS) is a valid, psychometrically sound and internationally used scale of global happiness.37 38 (link) Example items include ‘In general I consider myself (1=not a very happy person to 7=a very happy person)’ and ‘Compared to most of my peers I consider myself (1=less happy to 7=more happy)’. All four items of the SHS are answered using a 7-point scale, and each participant’s responses were averaged, with higher scores representative of higher subjective happiness. Benchmarking data in diverse populations demonstrate mean SHS scores consistently flank a value of 5 on therefore a threshold of below 5 was used to group participants as the ‘per cent concerning’.38 (link) Internal consistency in the current study was very good (Cronbach’s alpha=0.86).
Work–life balance: Work–life balance items are from the work–life climate scale, which has been shown to have good psychometrics when used on HCWs,39 Work–life balance items elicit behavioural work–life infractions by asking: During the past week, how often did this occur? Followed by phrases such as: Skipped a meal, arrived home late from work or slept less than 5 hours in a night. The response scale for the work–life climate items ranged from: rarely or none of the time (less than 1 day); some or a little of the time (1–2 days); occasionally or a moderate amount of time (3–4 days); all of the time (5–7 days) and not applicable. Work–life climate scale scores were computed by taking the mean of the items. Previous research has used 2 or fewer days as ‘per cent positive,’ referring to scores greater than 2 as work–life imbalance. We use the imbalance designation (per cent of respondents with a mean over 2) as the ‘per cent concerning’.39 Internal consistency in the current study was good (Cronbach’s alpha=0.81).
In addition to using scale scores to examine change following 3GT, we also report the percentage of participants whose scores fell below well-being thresholds established by prior literature.
Burn-out EE Subscale: The Maslach Burnout Inventory, which is the gold-standard tool in the field of burn-out, has been used extensively with HCWs. A meta-analysis has revealed that of the three subscales (EE, depersonalisation and personal accomplishment), EE consistently produces the largest and most consistent coefficient alpha estimates, while depersonalisation and personal accomplishment were both lower and less consistent than EE.31 (link) In addition to being more psychometrically robust, EE can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to criteria outlined in the International Statistical Classification of Diseases and Related Health Problems - 10th Revision).32 (link) We used a 5-item derivative33 (link) of the original 9-item EE scale.32 (link) Example items include ‘I feel frustrated by my job’ and ‘Events at work affect my life in an emotionally unhealthy way’. Participants respond using a 5-point Likert scale (1=disagree strongly; 5=agree strongly). Each participant’s mean of the five items was converted to a 0–100 point scale, with higher scores representative of more severe EE. A score of 50 or higher indicates that the respondent is not disagreeing with the EE statements, and is the first threshold for per cent concerning because it indicates at least mild EE.34 (link) These ‘per cent concerning’ thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a given metric. The per cent concerning threshold can be grasped quickly, providing an anchor for interpretation and offering a way of communicating something about the distribution of the data within a single number. For EE, internal consistency in the current study was good (Cronbach’s alpha=0.85)
Depressive symptoms: The Center for Epidemiological Studies Depression Scale-10-item version is a psychometrically sound tool for screening respondents for clinical depression.35 (link) All items are prefaced with, ‘during the past week, how often did this occur’ and includes items such as ‘I could not ‘get going’ and ‘my sleep was restless’. Responses are answered on a 4-point scale (0=rarely or none; 3=all of the time). Each participant’s responses are summed together to achieve a 0–30 point scale. A score of 10 or higher is considered a positive screen, and was the threshold we used to group participants by depressive symptom severity as ‘per cent concerning’.36 (link) Internal consistency in the current study was good (Cronbach’s alpha=0.85)
Subjective Happiness: Lyubomirsky and Lepper’s Subjective Happiness Scale (SHS) is a valid, psychometrically sound and internationally used scale of global happiness.37 38 (link) Example items include ‘In general I consider myself (1=not a very happy person to 7=a very happy person)’ and ‘Compared to most of my peers I consider myself (1=less happy to 7=more happy)’. All four items of the SHS are answered using a 7-point scale, and each participant’s responses were averaged, with higher scores representative of higher subjective happiness. Benchmarking data in diverse populations demonstrate mean SHS scores consistently flank a value of 5 on therefore a threshold of below 5 was used to group participants as the ‘per cent concerning’.38 (link) Internal consistency in the current study was very good (Cronbach’s alpha=0.86).
Work–life balance: Work–life balance items are from the work–life climate scale, which has been shown to have good psychometrics when used on HCWs,39 Work–life balance items elicit behavioural work–life infractions by asking: During the past week, how often did this occur? Followed by phrases such as: Skipped a meal, arrived home late from work or slept less than 5 hours in a night. The response scale for the work–life climate items ranged from: rarely or none of the time (less than 1 day); some or a little of the time (1–2 days); occasionally or a moderate amount of time (3–4 days); all of the time (5–7 days) and not applicable. Work–life climate scale scores were computed by taking the mean of the items. Previous research has used 2 or fewer days as ‘per cent positive,’ referring to scores greater than 2 as work–life imbalance. We use the imbalance designation (per cent of respondents with a mean over 2) as the ‘per cent concerning’.39 Internal consistency in the current study was good (Cronbach’s alpha=0.81).
