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Forty-five good things: a prospective pilot study of the Three Good Things well-being intervention in the USA for healthcare worker emotional exhaustion, depression, work–life balance and happiness

Objectives High rates of healthcare worker (HCW) burn-out have led many to label it an ‘epidemic’ urgently requiring interventions. This prospective pilot study examined the efficacy, feasibility and evaluation of the ‘Three Good Things’ (3GT) intervention for HCWs, and added burn-out and work–life balance to the set of well-being metrics. Methods 228 HCWs participated in a prospective, repeated measures study of a web-based 15-day long 3GT intervention. Assessments were collected at baseline and 1, 6 and 12-month post-intervention. The primary measure of efficacy was a derivative of the emotional exhaustion subscale of the Maslach Burnout Inventory. The secondary measures were validated instruments assessing depression symptoms, subjective happiness, and work–life balance. Paired samples t-tests and Cohen’s d effect sizes for correlated samples were used to examine the efficacy of the intervention. Results 3GT participants exhibited significant improvements from baseline in emotional exhaustion, depression symptoms and happiness at 1 month, 6 months and 12 months, and in work–life balance at 1 month and 6 months (effect sizes 0.16–0.52). Exploratory subgroup analyses of participants meeting ‘concerning’ criteria at baseline revealed even larger effects at all assessment points (0.55–1.57). Attrition rates were similar to prior 3GT interventions. Conclusion 3GT appears a promising low-cost and brief intervention for improving HCW well-being. Ethics and dissemination This study is approved by the Institutional Review Board of Duke University Health System (Pro00063703). All participants are required to give their informed consent prior to any study procedure.


Article Summary
Strengths and limitations of this study • This pilot study examines the efficacy of a brief intervention (Three good Things) for healthcare worker well-being over four time points and across four measures: burnout, depression symptoms, improving subjective well-being and work-life balance.
• The Three Good Things intervention is low cost, low time investment, and simple intervention.
• This pilot study is limited by not having a randomized control group. Results are limited to those who completed assessments.
• Attrition was high (only half of those who started went on to complete the 1 month post assessments) but similar to rates found in other comparable interventions.

Good Things: A Prospective Pilot Study of the Three Good Things Intervention for Enduring Improvements in Healthcare Worker Resilience
Healthcare worker (HCW) burnout has reached a critical level. In the USA, over half of physicians, and a third of nurses, report feeling burned out from their work. 1,2 In recent years HCWs have faced a staggering number of increasing demands, including complex electronic medical records, new regulatory requirements, higher rates of student loan debt and increased production pressure. Simultaneously, HCWs are often not given the resources (or worse, are having their resources taken away) that are needed to meet these new demands. 3 They report having less autonomy, less control over decision-making, and less time to have meaningful interactions with patients. As demands increase and resources decrease, the result on any system or individual is strain, and that strain is what drives the increasing prevalence of burnout. 4 The increase is evident in the careful study by Shannefeldt et al., detailing a 9 percent increase in physician burnout between 2011 and 2014. 1 Maslach characterized burnout as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment, that can occur among those who do "people work" of some kind. 5 Of particular interest to HCWs is emotional exhaustion, which refers to feelings of being overextended and exhausted by the emotional demands of one's work. Burnout has severe negative consequences for both HCWs and patients. Burnout has been linked to higher rates of HCW depression, substance abuse, anxiety, and suicidal ideation, decreased immune system function, reduced marital satisfaction, and greater risk of motor vehicle accidents. [6][7][8][9][10][11] At an organizational level, burnout has been connected to poorer relationships with patients and staff, higher rates of job turnover, earlier retirements, and reduced productivity. [12][13][14] Importantly, provider burnout is also linked to serious patient safety outcomes, including higher rates of infection, increased medication errors, lower patient satisfaction, worse safety culture, and higher standardized mortality ratios. [15][16][17][18][19] To date, the literature has predominately focused on describing the prevalence of burnout rather than testing interventions to reduce it. The most successful exception to this has been training in meditation called Mindfulness-based Stress Reduction (MBSR), and similar meditation programs that garner modest effect sizes. [20][21][22] These programs appear to be fairly effective, but they require a significant time commitment of approximately 8-10 weeks, 2.5 hours per week, and 45-60 minutes of homework a day. Another promising intervention is the "Colleagues Meeting to Promote and Sustain Satisfaction" or COMPASS program. 23 It offers physicians 1 hour of protected time every two weeks to discuss the "virtues and challenges of being a physician" over a meal paid for by the hospital (i.e., this is not a low cost intervention).
A randomized clinical trial of COMPASS found that it lead to sustained improvements in burnout and finding meaning in one's work. 23,24 A recent meta-analysis of HCW interventions for burnout revealed that, on average, interventions lead to small but significant improvements in burnout. 25 Interventions can be categorized as either aimed at helping individuals improve their burnout, or organizational activities aimed to reduce perceived demands and/or increase resources. Organizational-level interventions, which tend to focus on improving workload, scheduling, communication, teamwork and changes in workflow, are generally more effective than individual-level interventions, which, to date, largely involve meditation training. 25 Rather than ask busy and burned out HCWs to commit additional time and effort to learn a new skill like meditation during this intense time in their lives, or assume that hospital administration can be convinced to provide significant funding for well-being, we selected a Good Things (3GT). 26,27 3GT is one of a family of positive interventions used as intentional activities aimed at cultivating positive cognitions and emotions. 28 In other words, 3GT is thought to enhance participants' ability to notice genuinely positive things around them, and these can be the same things that were already present, but went unnoticed prior to the intervention.
3GT appears well suited for use with burned out populations due to research showing that burnout reduces one's ability to notice and attend to positive stimuli. 29 Moreover, 3GT has improved happiness and depressive symptoms in previous research. 26 Burnout and depression have been empirically and conceptually linked 30 and share symptoms such as extreme exhaustion, feeling down, and reduced performance. The 3GT intervention, however, has not been empirically evaluated with HCWs. 3GT involves a brief explanation, takes only a couple of minutes to complete, and requires relatively little time or resources. In the resource restricted environment of healthcare, quick and low-cost strategies are welcome.
The current pilot study tested the efficacy of 3GT for HCW well-being through four key metrics: burnout, depression, work-life balance, and subjective happiness. Exploratory sub-group analyses examined whether those who met "percent concerning" criteria at baseline exhibited stronger intervention effects. Additionally, baseline levels of well-being were examined as a predictor of completing or failing to complete follow-up assessments. Finally, feasibility and evaluation of the program were assessed through attrition and participant evaluation. therapists, pharmacists, respiratory therapists, technologists/technicians, administrative support, other managers, and students. Neither patients nor the public were involved in the current study.

Measures
To assess changes in burnout and wellbeing hypothesized to result from 3GT, validated metrics included a burnout scale, a depression scale, and two measures of resilience (i.e., worklife balance, and subjective happiness; see Table 1 for Chronbach alphas). Demographic questions and open ended items were also included. Participants completed assessments at baseline, at 1-month (i.e., 1 month after the last day of 3GT), 6-months, and 12 months followup. 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," and "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. These "percent concerning" scores can be found in Table 1. Burnout: The Maslach Burnout Inventory, which is the gold standard tool in the field of burnout, has been used extensively with healthcare workers. We used a truncated 5-item version 31 of the original 9-item emotional exhaustion scale. 32 Emotional exhaustion can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to ICD-10 criteria). 32 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 5 items was converted to a 0-100 point scale, with higher scores representative of more severe burnout. A threshold of above 50 for mild burnout was used to demonstrate prevalence and was used for grouping participants as "percent concerning". 32 Depressive Symptoms: The Center for Epidemiological Studies Depression Scale-10-item version (CES-D10) is a psychometrically sound tool for screening respondents for clinical depression 33 . All items are prefaced with, "during the past week, how often did this occur and include 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 "percent concerning". 34 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 35 , Work-life balance items elicit behavioral 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 or fewer days as "percent positive," so we adapted the reciprocal of this such that the percent of respondents with a mean over 2 was considered the "percent concerning". 35 Subjective Happiness: Lyubomirsky and Lepper's subjective happiness scale (SHS) is a valid, psychometrically sound, and internationally used scale of global happiness. 36,37 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 4 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 "percent concerning". 37

Good Things Intervention
The original 3GT intervention encouraged participants to keep a log of things that go well for 7 days . 26 We adapted 3GT to our HCW population to be simple and quick, but we modified it in several ways. First, we extended the length of the intervention to last 2 weeks (15 days), starting and ending on a Monday. In pilot testing, we found that more people complete the full two weeks if they start on a Monday. Second, using Qualtrics survey software, we sent daily email reminders to share "What went well today, and what was your role in making it happen?" in three text boxes. Third, to induce a brief savoring period, they were instructed to select a positive emotion that best fit how they felt about their good thing, from a drop-down list of 10 positive emotions (e.g., Joy, Gratitude, Hope, etc.) with options for "not applicable" and "other". 38 Prior to submitting their responses, participants could select to anonymously share their good things with other participants in the following night's log. All participants, upon completion of their log, were automatically redirected to the log of good things participants submitted and approved for sharing the day before. This exposure to shared good things was another opportunity for savoring. At the 1-month follow-up we also examined the feasibility of 3GT with HCWs through participant evaluation.

Statistical Analysis
Cronbach's alpha was used to assess the internal reliability of the scales (values above 0.70 are considered acceptable, 0.80 good, and 0.90 very good. 39 Feasibility of 3GT for HCWs was assessed through attrition (uptake) and participant evaluations. Independent samples t-tests examined whether baseline levels of the well-being metrics predicted dropping out of the study at the 1, 6, and 12 month follow-ups. Paired samples t-tests were used to test for improvement in the resilience variables across the baseline and 1, 6, and 12-month follow-ups. For all analyses, p-values < 0.05 were considered significant and all tests were two-tailed. Analyses were performed using IBM SPSS software version 23. This study was approved by our Institutional Review Board (Study Protocol ID: Pro00038083).

Respondent Demographics
Two hundred and twenty-eight HCWs (81% female) participated in at least day 1 of the 3GT intervention, and 55 (24.6%) of them identified as registered nurses. See Table 1 Figure 1 illustrates mean rates of all scales at each time point. Table 1 shows the means and percent of respondents reporting concerning levels of each resilience metric at each assessment point.
Independent t-tests assessed whether baseline well-being metrics predicted dropping out at each follow-up assessment. At the 1 month follow-up, baseline levels of burnout did not predict dropping out, (See Table 2), however, participants higher in problems with work-life balance, depression, and lower in happiness, were less likely to complete 1 month assessments.
None of the baseline measures predicted dropping out at the 6 or 12 month mark.
Paired t-tests revealed significant improvement from baseline across all four well-being measures at the 1, 6, and 12-month post assessments, ps < .05, and small to medium effect sizes.
(See Table 3). Exploratory sub-group analyses on participants who met "percent concerning" criteria at baseline also revealed significant improvement across assessments, ps < .05, as well as medium to large effect sizes.   a Means and SDs provided are those used in the paired t-test analyses. Sample sizes in parentheses denote the total number of participants who provided data at that time point. b Cohen's D effect sizes were computed with the means, SD, and N, of participants who remained in the sample at each assessment point. c The following cut-offs were used for the percent concerning sub-groups: Burnout scores > 50; Depression scores > =10; Problems with Work-life Balance scores > 2; Subjective Happiness scores < 5.

HCW 3GT Feasibility and Participant Experience
Two hundred and twenty-eight participants engaged in day 1 of 3GT. 74.4% of participants selected "share my responses" of their 3GT with other participants at least once.
3GT submissions included a wide variety of good things that happened both in and outside of work. A sample of de-identified 3GT submissions can be found in the Appendix. Participant evaluations of 3GT were overwhelmingly positive: 95.8% agreed with "I would recommend the 3 Good Things exercise to a friend." 85.3% agreed with "I have encouraged others to try 3 Good Things." And 92.7% agreed with "I would like to participate in 3 Good Things again next year." For more evaluation results, see the Appendix.
Some participants also offered feedback in an open-ended text box. Representative comments can be found in the Appendix, and included: "Some nights I really felt as if I didn't have a good day. Three good things helped me focus on the fact that even if the day wasn't my best there were still good things about it." "I love this format. It is so obstacle-free, yet just enough to really REGISTER and acknowledge tangible good things each day. Reading others' good things makes me realize how many of those things (or similar) also happened to me, and feels like it amplifies my good feelings and sense of contentment, gratitude, happiness." "Pushes you to look for the good all day long!"

Discussion
The current pilot study adapted and tested the 3GT intervention for use by HCWs.
Participants of our nightly web-based intervention exhibited significant improvement across all four of our resilience metrics: burnout, depression, problems with work-life balance, and happiness. Three of these metrics showed significant improvement a full year later, and the fourth metric, problems with work-life balance, showed improvement at 1 and 6 months, but not 12. 3GT is a relatively easy, quick, and low cost intervention. To our knowledge, this is the first Similar to previous work, half of our sample reported being burned out at baseline, and 41.7% reported symptoms of depression 1 . Rates of burnout and depression in our sample were significantly lower after participating in 3GT and a full year later. Of note is the percentage of those who met the threshold for depression was cut in half at 1 month, remained approximately halved at 6 and 12-months. In fact, participants who met the concerning thresholds at baseline for each of the well-being metrics exhibited particularly strong improvements. Cohen's d effect sizes for all measures across the whole sample ranged from .16 to .52, and from .26 to 1.57 in the percent concerning at baseline group. Generally, effect sizes around .2 are considered small, .5 are considered medium, .8 large, 1.2 very large, and 2.0 huge. 40 Given how quick and simple it is to participate in a 3GT intervention, these effect sizes are both relatively impressive and surprising. A meta-analysis of Selective Serotonin Reuptake Inhibitors (SSRIs) revealed a relatively small effect size, 41 whereas the effect sizes in the current study approach those found by Krasner and colleagues, in their widely cited study of MBSR for HCWs (.62 for burnout, .55 for depression). This is notable considering the differential time commitment involved in participating in 3GT compared to meditation training or an MBSR course. There may be a high return on investment in brief, simple, and accessible interventions like 3GT.
The study also tested whether baseline levels of well-being predicted completion of the follow-up assessments. Baseline levels of burnout did not predict dropping out of any of the follow-up assessments; however those who dropped out at the 1-month assessment mark had higher levels of depression, problems with work-life balance, and lower levels of happiness at baseline. Baseline wellbeing did not predict completing or dropping out of the 6 or 12 month assessments. These results indicate that at least some wellness indices appear have short-term predictive power for who is at risk of dropping out. However, in concert with the "percent concerning" findings, these results suggest that if someone who is really struggling at baseline is able to power through and complete the intervention, he/she is likely to experience an even greater benefit than those with relatively higher wellbeing at baseline. These findings compliment prior work indicating that those with worse wellbeing (i.e., lower positive affect, clinically depressed) appear to benefit the most from positive psychology interventions. 28,42 Relieving HCW burnout is a national imperative. Not only is burnout associated with devastating provider outcomes like substance abuse and suicidal ideation, 7,8 it's also linked to consequential patient safety outcomes, including medication errors and standardized mortality ratios. 16,19 Existing interventions for burnout largely center on learning mindfulness-based meditation. Meditation training appears helpful for HCW burnout 20 , however, in addition to the time commitment required, it is not broadly appealing to many providers due to religious, logistical or personal reasons. In other words, MBSR is good, it just isn't the right fit for many.
Since 2001, the Job Demands-Resources Model has accurately and repeatedly demonstrated that increasing demands while decreasing resources creates strain on the workforce. 43,43 This strain has been called burnout, low engagement, compassion fatigue, low safety culture and other similar monikers. Rigorous psychological research has consistently shown that the experience positive emotion is associated with the ability to recover after emotional upheavals. 44 45 When access to these little positive emotion engines is interrupted, through new or increasing demands, we end up going to work each day with weaker and weaker batteries.
This isn't weakness on the part of the person, it is the failure of our healthcare systems to create environments that promote well-being in the workforce.
By merging the well supported theories of positive emotion 46  Based on this theory, when we are burned out we focus on immediate challenges and threats, at the expense of not noticing positive events occurring around us. By having HCWs report nightly on three good things that happened that day, they apparently re-calibrate their emotional well-being through more frequent experiences of positive emotions, as well as expanding awareness of positive events. Although the mechanisms of action of this tool have yet to be definitively examined, anecdotal evidence suggests two possibilities. The first is that at the moment of reporting, there is savoring of positive emotion, whereby participants re-experience the positive emotions that accompanied the good thing that happened to them, perhaps also with a broader appreciation for that experience and what it involved. This can occur while entering the good thing, or selecting the positive emotion that goes with it, or when reading the good things in the shared logs. The second possible mechanism is that by knowing that they will be reporting on three good things each evening, participants become more aware of the good things happening around them, even at times thinking, "This can be one of my three good things I'll write about tonight!" 3GT as a resiliency tool has several strengths. The first is that the tool itself has little to no costs to deploy. We utilized a web-based format, but it is effective when administered as a paper based intervention 26,27 . Further, completion of the tool requires minimal time commitment from the participants; it takes approximately 2-3 minutes to complete each day. The tool is incredibly straightforward as well, requiring no additional skills training, and is applicable to everyone regardless of work-place role. Participants submit a wide variety of "good" things each night, including events that occurred inside and outside of the workplace. The wide variety of 3GTsubmissions have been identified by qualitative researchers as generally fitting under one of three overarching themes: having a good day at work, having supportive relationships, and making meaningful use of self-directed time 47 . The low cost, minimal time and effort commitment, and widely enjoyable nature of 3GT certainly are attractive features for burned out providers and organizations looking for ways to address the urgent need to improve resiliency.
Our study has several limitations. First, the study was not randomized and there was not a control group, which precludes any discussion of causality. Rather, we can only say that participants who signed up for 3GT and completed follow-up assessments reported significant improvements across all outcomes. It is possible that participants who engaged in 3GT but did not complete post assessments did not benefit to the same degree as those who did complete post assessments. Without a control group, we also cannot say that the results we found were not due, in part or in whole, to expectancy or placebo effects. Second, our study also suffered from attrition in that only 56%, 52%, and 53% of those who completed day 1 3GT completed the 1, 6, and 12-month assessments, respectively. This rate of attrition is similar to other comparable studies 27,48,49 . In a study by Gander and colleagues, only 67.3% of those assigned to an intervention carried out the intervention, and only 38.9% completed all follow-up assessments. 27 In light of these attrition rates, it should be noted that people are notoriously bad at maintaining self-improvement goals. For example, only 46% of new year's resolutions are still on course 6 months later, and only 20% of overweight dieters are able to maintain their weight loss for more than one year. 50,51 Nevertheless, it is unclear from our study whether the effects observed were the result of the intervention alone. It is possible that there were intrinsic characteristics of the cohort that completed follow-up assessments that predisposed them to improvement in burnout and depression. However, multiple prior randomized controlled studies of 3GT for one week (a smaller dose) have demonstrated improvement with this intervention, which we believe extends to our results 49 .
Third, 3GT is an intervention designed to help individuals build their resilience resources, but does not address the demands placed upon them personally or professionally. The pace and intensity of contemporary healthcare are what causes the strain that leads to impaired resilience.
3GT, while promising as one simple tool that should be part of a much larger toolkit, does not prevent future sources of strain. In the long term, a family of valid and accessible interventions need to be targeted at both facilitating individual resilience ("levers that I can pull for myself right now") and preventing problems of strain ("levers that my institution/work setting pull for me to provide additional resources that prevent and alleviate strain").
Despite these limitations, this pilot study expands on previous research by demonstrating that a modification of 3GT for HCW is a simple and effective intervention to improve emotional well-being, decrease burnout, and increase resiliency. Current research is underway to evaluate the efficacy of 3GT with respect to the endurance of the improvements, to examine mechanisms of action, and to use control groups.

Conclusions
Given the relationship between healthcare worker resilience and healthcare quality, current findings that resilience can be taught in a way that HCWs enjoy and utilize, are encouraging. 3GT has now been demonstrated as an effective, low-cost strategy to combat burnout and improve resiliency, and the refinement and extension of this type of intervention to other HCWs is warranted.
Funding: This work was supported by NIH grant number R01 HD084679-01.
 I made it to the gym and had a great workout.
 The surgeon I work with is always a pleasure to be around.
 I saw another friend from high school today and was really nice to be together and laugh.
 I am grateful for a positive response I received from a colleague after I allowed myself to be vulnerable by reaching out.
 It was NOT snowing today.
 Busy night at work, but had really great teamwork.
Conclusion 3GT appears a promising low-cost and brief intervention for improving HCW wellbeing.

Ethics and dissemination This study is approved by the Institutional Review Board of Duke
University Health System (Pro00038083). All participants are required to give their informed consent prior to any study procedure.

Strengths and limitations of this study
• This pilot study examined the efficacy of the Three Good Things intervention for healthcare worker well-being over four time points: at baseline and three postintervention follow-ups (1 month, 6 months, 12 months).
• Efficacy was assessed with four well-being measures: emotional exhaustion, depression symptoms, subjective happiness, and work-life balance.
• This pilot study is limited by not having a randomized control group. Results are limited to those who completed assessments.
• Attrition was high (only half of those who started went on to complete the 1 month post assessments) but similar to rates found in other comparable interventions. Healthcare worker (HCW) burnout has reached a critical level. In the USA, over half of physicians, and a third of nurses, report feeling burned out from their work. 1,2 In recent years HCWs have faced a staggering number of increasing demands, including complex electronic medical records, new regulatory requirements, higher rates of student loan debt and increased production pressure. Simultaneously, HCWs are often not given the resources (or worse, are having their resources taken away) that are needed to meet these new demands. 3 They report having less autonomy, less control over decision-making, and less time to have meaningful interactions with patients. As demands increase and resources decrease, the result on any system or individual is strain, and that strain is what drives the increasing prevalence of burnout. 4 The increase is evident in the careful study by Shannefeldt et al., detailing a 9 percent increase in physician burnout between 2011 and 2014. 1 Maslach characterized burnout as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment, that can occur among those who do "people work" of some kind. 5 Of particular interest to HCWs is emotional exhaustion, which refers to feelings of being overextended and exhausted by the emotional demands of one's work. Burnout has severe negative consequences for both HCWs and patients. Burnout has been linked to higher rates of HCW depression, substance abuse, anxiety, and suicidal ideation, decreased immune system function, reduced marital satisfaction, and greater risk of motor vehicle accidents. [6][7][8][9][10][11] At an organizational level, burnout has been connected to poorer relationships with patients and staff, higher rates of job turnover, earlier retirements, and reduced productivity. [12][13][14] Importantly, provider burnout is also linked to serious patient safety outcomes, including higher rates of infection, increased medication errors, lower patient satisfaction, worse safety culture, and higher standardized mortality ratios. [15][16][17][18][19] To date, the literature has predominately focused on describing the prevalence of burnout rather than testing interventions to reduce it. The most successful exception to this has been training in meditation called Mindfulness-based Stress Reduction (MBSR), and similar meditation programs that garner modest effect sizes. [20][21][22] These programs appear to be fairly effective, but they require a significant time commitment of approximately 8-10 weeks, 2.5 hours per week, and 45-60 minutes of homework a day. Another promising intervention is the "Colleagues Meeting to Promote and Sustain Satisfaction" or COMPASS program. 23 It offers physicians 1 hour of protected time every two weeks to discuss the "virtues and challenges of being a physician" over a meal paid for by the hospital (i.e., this is not a low cost intervention).
A randomized clinical trial of COMPASS found that it lead to sustained improvements in burnout and finding meaning in one's work. 23,24 A recent meta-analysis of HCW interventions for burnout revealed that, on average, interventions lead to small but significant improvements in burnout. 25 Interventions can be categorized as either aimed at helping individuals improve their burnout, or organizational activities aimed to reduce perceived demands and/or increase resources. Organizational-level interventions, which tend to focus on improving workload, scheduling, communication, teamwork and changes in workflow, are generally more effective than individual-level interventions, which, to date, largely involve meditation training. 25 Rather than ask busy and burned out HCWs to commit additional time and effort to learn a new skill like meditation during this intense time in their lives, or assume that hospital administration can be convinced to provide significant funding for well-being, we selected a Good Things (3GT). 26,27 3GT is one of a family of positive interventions used as intentional activities aimed at cultivating positive cognitions and emotions. 28 In other words, 3GT is thought to enhance participants' ability to notice genuinely positive things around them, and these can be the same things that were already present, but went unnoticed prior to the intervention.
3GT appears well suited for use with burned out populations due to research showing that burnout reduces one's ability to notice and attend to positive stimuli. 29 Moreover, 3GT has improved happiness and depressive symptoms in previous research. 26 Burnout and depression have been empirically and conceptually linked 30 and share symptoms such as extreme exhaustion, feeling down, and reduced performance. The 3GT intervention, however, has not been empirically evaluated with HCWs. 3GT involves a brief explanation, takes only a couple of minutes to complete, and requires relatively little time or resources. In the resource restricted environment of healthcare, quick and low-cost strategies are welcome.
The primary aim of the current before-after prospective pilot study was to test the efficacy of 3GT for HCW well-being through four metrics: burnout (specifically, the emotional exhaustion component), which is the primary outcome of interest, as well as depression symptoms, subjective happiness, and work-life balance, which are secondary outcomes of interest. We hypothesized that 3GT participants would report reductions in emotional exhaustion and depressive symptoms, as well as improvements in subjective happiness and work-life balance, between baseline assessments and all three follow-up assessments.
Exploratory secondary aims of the study were to 1) test whether those who met "percent concerning" criteria at baseline exhibited stronger intervention effects, 2) examine whether baseline well-being was a predictor of completing or failing to complete follow-up assessments, and 3) assess the feasibility and evaluation of the program through attrition rates and participant evaluation.

Design and Patient Population
This is a non-randomized repeated measures before-after trial of 3GT, conducted between pharmacists, respiratory therapists, technologists/technicians, administrative support, other managers, and students. Participants completed assessments at baseline, at 1-month (i.e., 1 month after the last day of 3GT), 6-months, and 12 months follow-up. Links to online assessments were sent to participants via email.

Patient and Public Involvement
Neither patients nor the public were involved in the current study. To assess changes in well-being, we used four validated scales (emotional exhaustion, depression symptoms, subjective happiness, and work-life balance) at each assessment point (see Table 1 for Chronbach alphas). These four metrics were selected a prioi 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.

Measures
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.

Burnout (Emotional Exhaustion (EE) Sub-scale):
The Maslach Burnout Inventory, which is the gold standard tool in the field of burnout, has been used extensively with healthcare workers. A meta-analysis has revealed that of the three sub-scales (emotional exhaustion, depersonalization, and personal accomplishment), emotional exhaustion consistently produces the largest and most consistent coefficient alpha estimates, while depersonalization and personal accomplishment were both lower and less consistent than emotional exhaustion. 31 In addition to being more psychometrically robust, emotional exhaustion can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to ICD-10 criteria). 32 We used a 5-item derivative 33 of the original 9-item emotional exhaustion scale. 32 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 5 items was converted to a 0-100 or higher indicates that the respondent is not disagreeing with the emotional exhaustion statements, and is the first threshold for percent concerning because it indicates at least mild emotional exhaustion. 34 These "percent concerning" thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a 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 "percent concerning". 36 Internal consistency in the current study was good  fewer days as "percent positive," referring to scores greater than 2 as work-life imbalance. We use the imbalance designation (percent of respondents with a mean over 2) as the "percent concerning". 39 Internal consistency in the current study was good (Cronbach's alpha = .81).

Good Things Intervention
The original 3GT intervention encouraged participants to keep a log of things that go well for 7 days . 26 We adapted 3GT to our HCW population to be simple and quick, but we modified it in several ways. First, we extended the length of the intervention to last 2 weeks (15 days), starting and ending on a Monday. In pilot testing, we found that more people complete the full two weeks if they start on a Monday. Second, using Qualtrics survey software, we sent nightly email reminders to enter "What went well today, and what was your role in making it happen?" in three text boxes. Third, to induce a brief savoring period, they were instructed to select a positive emotion that best fit how they felt about their good thing, from a drop-down list of 10 positive emotions (e.g., Joy, Gratitude, Hope, etc.) with options for "not applicable" and "other". 40 Prior to submitting their responses, participants could select to anonymously share their good things with other participants in the following night's log. All participants, upon completion of their log, were automatically redirected to the log of good things participants submitted and approved for sharing the day before. This exposure to shared good things was another opportunity for savoring. At the 1-month follow-up we also examined the feasibility of 3GT with HCWs through participant evaluation.

Statistical Analysis
Cronbach's alpha was used to assess the internal reliability of the scales (values above 0.70 are considered acceptable, 0.80 good, and 0.90 very good. 41 Feasibility of 3GT for HCWs was assessed through attrition (uptake) and participant evaluations. Independent samples t-tests examined whether baseline levels of the well-being metrics predicted dropping out of the study at the 1, 6, and 12 month follow-ups. Paired samples t-tests were used to test for improvement in the well-being variables across the baseline and 1, 6, and 12-month follow-ups. These analyses used list-wise deletion for missing data. Participants who were lost to follow up were still included in any analysis for which they had provided data. For all analyses, p-values < 0.05 were considered significant and all tests were two-tailed. A power analysis indicated that our sample size provided high power (1-β) > .9 to detect relatively small effect sizes (Cohen's d = . 3).
Cohen's d effect sizes for correlated samples were computed using the formula d = M diff /SD pooled .
Generally, effect sizes around .2 are considered small, .5 are considered medium, .8 large, 1.2 very large, and 2.0 huge. 42 Analyses were performed using IBM SPSS software version 24. This study was approved by our Institutional Review Board (Study Protocol ID: Pro00038083). Of those who participated, 48.2% reported 21 or more years of experience in their profession. The most common response for number of years in current position was 1-4 years.

Well-being Metrics over Time
Internal reliabilities are reported at the bottom of Table 1. Internal consistency for each metric was good at each time point, with Cronbach alphas ranging from .79 to .87. All participant well-being metrics were relatively highly correlated with themselves across time, especially Subjective Happiness, with correlations between .74 and .80. Figure 1 illustrates mean rates of all scales at each time point.
Independent t-tests assessed whether baseline well-being metrics predicted dropping out or not at each follow-up assessment. At the 1 month follow-up, baseline levels of emotional exhaustion did not predict dropping out, (See Table 2), however, participants higher in problems with work-life balance, depression, and lower in happiness, were less likely to complete 1 month assessments. None of the baseline measures predicted dropping out at the 6 or 12 month mark. Table 3 shows the means and results of the analyses across the whole sample, as well as the sub-group of respondents reporting concerning levels of each well-being metric at each assessment point. Paired t-tests conducted on the entire sample revealed significant improvement, ps < .05, in emotional exhaustion, depression symptoms, and happiness at 1, 6, and 12-months, and in work-life balance at 1 and 6 months. Effect sizes across all four metrics were small to medium ranging from .16 to .52 . Exploratory sub-group analyses on participants who met "percent concerning" criteria at baseline also revealed significant improvement across assessments, ps < .05, as well as moderate to very large effect sizes (.55 -1.57).
Finally, we examined whether the number of days participants completed 3GTs predicted changes in well-being across the study. We computed well-being change scores for all metrics between baseline and follow-up assessments, and used spearman correlations to detect   good things makes me realize how many of those things (or similar) also happened to me, and feels like it amplifies my good feelings and sense of contentment, gratitude, happiness." "Pushes you to look for the good all day long!"

Discussion
The current pilot study adapted and tested the 3GT intervention for use by HCWs.
Participants of our nightly web-based intervention exhibited improvement across all four of our well-being metrics: burnout (EE), depression, problems with work-life balance, and happiness. Three of these metrics showed significant improvement between baseline and the 12 month follow-up, and the fourth metric, problems with work-life balance, showed improvement between baseline and the 1 and 6 month follow-ups. 3GT is a relatively simple, brief, and lowcost intervention. To our knowledge, this is the first study demonstrating the efficacy of 3GT in HCWs across variety of well-being measures, including emotional exhaustion.
Similar to previous work, half of our sample reported at least emotional exhaustion at baseline, and 37.2% reported symptoms of depression 1 . Rates of emotional exhaustion and depression in our sample were significantly lower a full year after participating in 3GT. Of note is the percentage of those who met the threshold for a positive screen for depression was cut approximately in half at 1 month (from 37.2% to 19.1%). In fact, participants who met the concerning thresholds at baseline for each of the well-being metrics exhibited particularly strong improvements. Cohen's d effect sizes for all measures across the whole sample ranged from .16 to .52, and from .55 to 1.57 in the percent concerning at baseline group.
Given how brief and simple it is to participate in a 3GT intervention, these effect sizes are notable in comparison to current psychological interventions. A meta-analysis of Selective Serotonin Reuptake Inhibitors (SSRIs) revealed a relatively small effect size (d= .32 between SSRIs and a placebo), 43 whereas the effect sizes in the current study approach those found by Krasner and colleagues, in their widely cited study of MBSR for HCWs (.62 for emotional exhaustion, .55 for depression). This is notable considering the differential time commitment involved in participating in 3GT compared to meditation training or an MBSR course. There may be a high return on investment in brief, simple, and accessible interventions like 3GT.
The study also tested whether baseline levels of well-being predicted completion of the follow-up assessments. Baseline levels of emotional exhaustion did not predict dropping out of any of the follow-up assessments; however those who dropped out at the 1-month assessment mark had higher levels of depression, problems with work-life balance, and lower levels of happiness at baseline. Baseline wellbeing did not predict completing or dropping out of the 6 or 12 month assessments. These results indicate that at least some wellness indices appear to have short-term predictive power for who is at risk of dropping out. However, in concert with the "percent concerning" findings, these results suggest that if someone who is really struggling at baseline is able to power through and complete the intervention, he/she is likely to experience an even greater benefit than those with relatively higher wellbeing at baseline. These findings compliment prior work indicating that those with worse wellbeing (i.e., lower positive affect, clinically depressed) appear to benefit the most from positive psychology interventions. 28,44 Relieving HCW burnout is a national imperative. Not only is burnout associated with devastating provider outcomes like substance abuse and suicidal ideation, 7,8 it's also linked to consequential patient safety outcomes, including medication errors and standardized mortality ratios. 16,19 Existing interventions for burnout largely center on learning mindfulness-based meditation. Meditation training appears helpful for HCW burnout 20 , however, in addition to the time commitment required, it is not broadly appealing to many providers due to religious, logistical or personal reasons. In other words, MBSR appears beneficial, it just isn't the right fit for many.
Since 2001, the Job Demands-Resources Model has accurately and repeatedly demonstrated that increasing demands while decreasing resources creates strain on the workforce. 45 This strain has been called burnout, low engagement, compassion fatigue, low safety culture and other similar monikers. Rigorous psychological research has consistently shown that experiencing positive emotions is associated with the ability to recover after  46 Positive emotions, like hope, gratitude and serenity, help people build personal resources, such as social bonds, intellectual skills, and motivation for personal growth. 45 Positive emotions also have the ability to recharge our self-regulation when we are feeling depleted 47 and to undo the cardiovascular aftereffects of an emotional upheaval, relative to negative emotions and control groups. 48 When access to positive emotion "engines" is interrupted, through new or increasing demands, we end up going to work each day with weaker and weaker batteries. This isn't weakness on the part of the person, it is the failure of our healthcare systems to create environments that promote well-being in the workforce.
By merging the well supported theories of positive emotion 49  Prior research has found that those experiencing burnout are more likely to attend to negative stimuli, even at the expense of not attending to positive stimuli, which could improve ones' mood. 29 By having HCWs report nightly on three good things that happened that day, they might be re-calibrating their emotional well-being through more frequent experiences of positive emotions, as well as expanding their awareness of positive events. Although the mechanisms of action of this tool have yet to be definitively examined, anecdotal evidence suggests two possibilities. The first is that at the moment of reporting, there is savoring of positive emotion, whereby participants re-experience the positive emotions that accompanied the good thing that happened to them, perhaps also with a broader appreciation for that experience and what it involved. This can occur while entering the good thing, or selecting the positive emotion that goes with it, or when reading the good things in the shared logs. The second possible mechanism is that by knowing that they will be reporting on three good things each evening, participants become more aware of the good things happening around them. A few participants commented that this was their experience, even at times thinking, "This can be one of my three good things 3GT as a resiliency tool has several strengths. The first is that the tool itself has little to no costs to deploy. We utilized a web-based format, but it is effective when administered as a paper based intervention 26,27 . Further, completion of the tool requires minimal time commitment from the participants; it takes approximately 2-3 minutes to complete each day. The tool is straightforward as well, requiring no additional skills training, and is applicable to everyone regardless of work-place role. Participants submit a wide variety of "good" things each night, including events that occurred inside and outside of the workplace. The wide variety of 3GTsubmissions have been identified by qualitative researchers as generally fitting under one of three overarching themes: having a good day at work, having supportive relationships, and making meaningful use of self-directed time 50 . The low cost, minimal time and effort commitment, and widely enjoyable nature of 3GT are attractive features for burned out providers and organizations looking for ways to address the urgent need to improve well-being. The current pilot study has several strengths. The study examined the efficacy of a the Three Good Things intervention for healthcare workers across a wide variety of roles in healthcare. Well-being metrics were assessed across four time points: at baseline and three postintervention follow-ups (1 month, 6 months, 12 months). The efficacy of 3GT was assessed with four validated measures of well-being, which specifically assessed the emotional exhaustion element of burnout, depression symptoms, subjective well-being, and work-life balance.
Our study has several limitations. First, the study was not randomized and there was not a control group, which precludes any discussion of causality. Rather, we can only say that participants who signed up for 3GT and completed follow-up assessments reported significant improvements across all outcomes. It is possible that participants who engaged in 3GT but did not complete post assessments did not benefit to the same degree as those who did complete post assessments. Without a control group, we also cannot say that the results we found were not due, in part or in whole, to expectancy or placebo effects. We note also that our sample is comprised largely of women (81% of participants at baseline), however this is generally in line with base rates of women working in healthcare in the US (in 2017, 75% of healthcare workers were female). 51 Future research should oversample for men and examine whether 3GT is equally effective across genders.
Second, our study also suffered from attrition in that only 56%, 52%, and 53% of those who completed day 1 3GT completed the 1, 6, and 12-month assessments, respectively. This rate of attrition is similar to other comparable studies 27,52,53 . In a study by Gander and colleagues, only 67.3% of those assigned to an intervention carried out the intervention, and only 38.9% completed all follow-up assessments. 27 In light of these attrition rates, it should be noted that people are notoriously bad at maintaining self-improvement goals. For example, only 46% of Third, 3GT is an intervention designed to help individuals build their well-being resources, but does not address the demands placed upon them personally or professionally. The pace and intensity of contemporary healthcare are what causes the strain that leads to impaired well-being. 3GT, while promising as one simple tool that should be part of a much larger toolkit, does not prevent future sources of strain. In the long term, a family of valid and accessible interventions need to be targeted at both facilitating individual well-being ("levers that I can pull for myself right now") and preventing problems of strain ("levers that my institution/work setting pull for me to provide additional resources that prevent and alleviate strain").
Despite these limitations, this pilot study expands on previous research by demonstrating that a modification of 3GT for HCW appears to offer a simple and effective intervention to improve emotional well-being, and decrease emotional exhaustion. Current research is underway to evaluate the efficacy of 3GT with respect to the endurance of the improvements, to examine mechanisms of action, and to use control groups.

Conclusions
Given the relationship between healthcare worker well-being and healthcare quality, current findings that well-being metrics appear to improve across repeated measures are encouraging. 3GT has now been demonstrated as a low-cost strategy to potentially improve well-being, such that refinement and extension of this type of intervention is warranted.
Funding: This work was supported by NIH grant number R01 HD084679-01.
Contributorship Statement: JBS developed the procedure, collected the data, contributed to analyses, and co-wrote the paper. KCA contributed to analyses and co-wrote the paper.
Competing interests: None declared.

Data Sharing Statement:
The authors will share survey data from the study upon reasonable request to the first author. x My husband thanked me for helping make supper.
x Talked with several people from my hospital that I had never had the chance to get to know before.
x I had extra time to enjoy my morning coffee.
x I completed a project that I had been needing to get done for a few weeks.
x I made it to the gym and had a great workout.
x The surgeon I work with is always a pleasure to be around.
x I saw another friend from high school today and was really nice to be together and laugh.
x I am grateful for a positive response I received from a colleague after I allowed myself to be vulnerable by reaching out.
x It was NOT snowing today.
x Busy night at work, but had really great teamwork.

3) Representative Comments from participants about their experience of Three Good
Things: x I enjoyed the participation in this exercise. At first it was challenging but after the first couple of days it became easier to think of positive things going on in my life. It was a good experience for me to realize how positive my life really is vs. always thinking of the things that are negative.
x I wish it were ongoing. I don't feel like doing it myself but I was instantly struck by the power of being part of group of people who were asked to see their lives through this positive filter.
x I thought it was very well organized and liked how it made me focus on the positive.
x I like the idea of it -but I don't like having to do one more task each and every day!
x Am still trying to note 3 good things a day, & believe it helped "reroute" my thinking.
x I appreciated stepping back to recognize all the things I take for granted that are good in my life x When thinking about my 3 good things all day long, I was amazed how they changed by the time I was ready to put them down. x Registering what was good, by typing it and sending it in, makes a really big difference in my mood (that day and afterward). Just thinking about it aloud, or even talking about it, is not as impactful.
x On some days, especially early on, I felt that the good things I shared were small, relatively insignificant, things I did not value as greatly, but shared simply because they were the only things in my day I could think of that I and others would identify as x I will miss my daily reminder email!
x It was actually something I did just for myself, taking time for myself. I think that led to taking time for myself in other ways ( i.e. breaks at work, exercising in the a.m. before work -I have NEVER done that before and it feels good!) It really changed my outlook at the end of the day to the good things instead of dwelling on the negative. eventually I was looking for good things and making good things happen.
x I was skeptical, but have realllllllly realllllly enjoyed the change in my outlook and I cannot thank you all enough :) x It motivated me to follow suit after reading others' activities. x It is a positive exercise that reinforces positive thoughts which lead to more positive behaviors. I feel better about life.
x It helped me live in the moment and take each day as it comes. I feel that my sleep is improved. I even went back to sleep after waking up at 3.45 am. This never happens if I have to work that day. Overall, I feel that I can make even more time for myself to maintain the work life balance. Thank you for allowing me participate in this exercise.
x I was prompted to build a routine of thinking about my day differently.
x I really like hearing from so many people and learning how we are more alike than different.
x I looked forward to it popping up on my email each evening.
x I enjoyed it very much! By day 3 I was already looking back on my day with a more positive attitude x I enjoyed finding good things -especially on hard days. I looked forward to completing them. I sometimes told people that I was including them in my 3 good things (after explaining the exercise). It helped me appreciate the small and big things, think about how they made me feel and usually it was my favorite people in my life that I included.
x I did the same exercise with my family and the email reminded me to ask my kids what 3 great things happened to them right before bed.
x I did learn to look forward to it, although the first couple of days were difficult. I liked how it would make me stop during the day, and mentally bookmark events for my three good things. x I did enjoy it. I liked reading through everyone's responses --the good kind of rubs off! It was interesting to see people turn something negative into something positive, i.e. see the silver lining or put a positive spin on things.
x I became tuned into the present and what I was feeling.
x Pushing myself to take a minute (or two) for me to think, look back, look ahead.
It seriously helped me get through my mother's death the week before and the family dynamics/calisthenics that ensued the in the surrounding time. We conducted exploratory analyses on participants whose scores were concerning at baseline on our wellbeing metrics. The results of these analyses can be found in Table 3 and are briefly described in the results section, pg. 14. We carefully describe and interpret the results of the study in the discussion section, particularly since this was a non-randomized pilot study. We were mindful not to overstate the impact of these findings, and rather present them as a promising first step in evaluating 3GT with healthcare workers.

Discussion
Generalisability 21 Discuss the generalisability (external validity) of the study results Generalisability is conveyed in the end of the discussion, and the conclusion section.  Conclusion 3GT appears a promising low-cost and brief intervention for improving HCW wellbeing.

Ethics and dissemination This study is approved by the Institutional Review Board of Duke
University Health System (Pro00038083). All participants are required to give their informed consent prior to any study procedure.  This pilot study is limited by not having a randomized control group. Results are limited to those who completed assessments.
 Attrition was high (only half of those who started went on to complete the 1 month post assessments) but similar to rates found in other comparable interventions. Maslach characterized burnout as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment, that can occur among those who do "people work" of some kind. 5 Of particular interest to HCWs is emotional exhaustion, which refers to feelings of being overextended and exhausted by the emotional demands of one's work. Burnout has severe negative consequences for both HCWs and patients. Burnout has been linked to higher rates of HCW depression, substance abuse, anxiety, and suicidal ideation, decreased immune system function, reduced marital satisfaction, and greater risk of motor vehicle accidents. [6][7][8][9][10][11] At an organizational level, burnout has been connected to poorer relationships with patients and staff, higher rates of job turnover, earlier retirements, and reduced productivity. [12][13][14] Importantly, provider burnout is also linked to serious patient safety outcomes, including higher rates of infection, increased medication errors, lower patient satisfaction, worse safety culture, and higher standardized mortality ratios. [15][16][17][18][19] To date, the literature has predominately focused on describing the prevalence of burnout rather than testing interventions to reduce it. The most successful exception to this has been training in meditation called Mindfulness-based Stress Reduction (MBSR), and similar meditation programs that garner modest effect sizes. [20][21][22] These programs appear to be fairly effective, but they require a significant time commitment of approximately 8-10 weeks, 2.5 hours per week, and 45-60 minutes of homework a day. Another promising intervention is the "Colleagues Meeting to Promote and Sustain Satisfaction" or COMPASS program. 23 It offers physicians 1 hour of protected time every two weeks to discuss the "virtues and challenges of being a physician" over a meal paid for by the hospital (i.e., this is not a low cost intervention).
A randomized clinical trial of COMPASS found that it lead to sustained improvements in burnout and finding meaning in one's work. 23,24 A recent meta-analysis of HCW interventions for burnout revealed that, on average, interventions lead to small but significant improvements in burnout. 25 Interventions can be categorized as either aimed at helping individuals improve their burnout, or organizational activities aimed to reduce perceived demands and/or increase resources. Organizational-level interventions, which tend to focus on improving workload, scheduling, communication, teamwork and changes in workflow, are generally more effective than individual-level interventions, which, to date, largely involve meditation training. 25 Rather than ask busy and burned out HCWs to commit additional time and effort to learn a new skill like meditation during this intense time in their lives, or assume that hospital administration can be convinced to provide significant funding for well-being, we selected a Good Things (3GT). 26,27 3GT is one of a family of positive interventions used as intentional activities aimed at cultivating positive cognitions and emotions. 28 In other words, 3GT is thought to enhance participants' ability to notice genuinely positive things around them, and these can be the same things that were already present, but went unnoticed prior to the intervention.
3GT appears well suited for use with burned out populations due to research showing that burnout reduces one's ability to notice and attend to positive stimuli. 29 Moreover, 3GT has improved happiness and depressive symptoms in previous research. 26 Burnout and depression have been empirically and conceptually linked 30 and share symptoms such as extreme exhaustion, feeling down, and reduced performance. The 3GT intervention, however, has not been empirically evaluated with HCWs. 3GT involves a brief explanation, takes only a couple of minutes to complete, and requires relatively little time or resources. In the resource restricted environment of healthcare, such quick and low-cost strategies are welcome.
The primary aim of the current study was to test the efficacy of 3GT for HCW well-being through four metrics: burnout (specifically, the emotional exhaustion component), which is the primary outcome of interest, as well as depression symptoms, subjective happiness, and worklife balance. We hypothesized that 3GT participants would report reductions in emotional exhaustion and depressive symptoms, as well as improvements in subjective happiness and work-life balance, between baseline assessments and all three follow-up assessments.
Exploratory secondary aims of the study were to 1) test whether those who met "percent concerning" criteria at baseline exhibited stronger intervention effects, 2) examine whether baseline well-being was a predictor of completing or failing to complete follow-up assessments,  pharmacists, respiratory therapists, technologists/technicians, administrative support, other managers, and students. Participants completed assessments at baseline, at 1-month (i.e., 1 month after the last day of 3GT), 6-months, and 12 months follow-up. Links to online assessments were sent to participants via email.

Patient and Public Involvement
Neither patients nor the public were involved in the current study.

Measures
To assess changes in well-being, we used four validated scales (emotional exhaustion, depression symptoms, subjective happiness, and work-life balance) at each assessment point (see  Table 1 for Chronbach alphas). These four metrics were selected a prioi 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.

Burnout (Emotional Exhaustion (EE) Sub-scale): The Maslach Burnout Inventory, which
is the gold standard tool in the field of burnout, has been used extensively with healthcare workers. A meta-analysis has revealed that of the three sub-scales (emotional exhaustion, depersonalization, and personal accomplishment), emotional exhaustion consistently produces the largest and most consistent coefficient alpha estimates, while depersonalization and personal accomplishment were both lower and less consistent than emotional exhaustion. 31 In addition to being more psychometrically robust, emotional exhaustion can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to ICD-10 criteria). 32 We used a 5-item derivative 33   statements, and is the first threshold for percent concerning because it indicates at least mild emotional exhaustion. 34 These "percent concerning" thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a Benchmarking data in diverse populations demonstrate mean SHS scores consistently flank a  fewer days as "percent positive," referring to scores greater than 2 as work-life imbalance. We use the imbalance designation (percent of respondents with a mean over 2) as the "percent concerning". 39 Internal consistency in the current study was good (Cronbach's alpha = .81).

Good Things Intervention
The original 3GT intervention encouraged participants to keep a log of things that go well for 7 days . 26 We adapted 3GT to our HCW population to be simple and quick, but we modified it in several ways. First, we extended the length of the intervention to last 2 weeks (15 days), starting and ending on a Monday. In pilot testing, we found that more people complete the full two weeks if they start on a Monday. Second, using Qualtrics survey software, we sent nightly email reminders to enter "What went well today, and what was your role in making it happen?" in three text boxes. Third, to induce a brief savoring period, they were instructed to select a positive emotion that best fit how they felt about their good thing, from a drop-down list of 10 positive emotions (e.g., Joy, Gratitude, Hope, etc.) with options for "not applicable" and "other". 40 Prior to submitting their responses, participants could chose to anonymously share their good things with other participants in the following night's log. All participants, upon completion of their log, were automatically redirected to the log of good things participants submitted and approved for sharing the day before. This exposure to shared good things was another opportunity for savoring.

Statistical Analysis
Cronbach's alpha was used to assess the internal reliability of the scales (values above 0.70 are considered acceptable, 0.80 good, and 0.90 very good. 41 Feasibility of 3GT for HCWs was assessed through attrition (uptake) and participant evaluations. Independent samples t-tests examined whether baseline levels of the well-being metrics predicted dropping out of the study at the 1, 6, and 12 month follow-ups. Paired samples t-tests were used to test for improvement in the well-being variables across the baseline and 1, 6, and 12-month follow-ups. These analyses used list-wise deletion for missing data. Participants who were lost to follow up were still included in any analysis for which they had provided data. For all analyses, p-values < 0.05 were considered significant and all tests were two-tailed. A power analysis indicated that our sample size provided high power (1-β) > .9 to detect relatively small effect sizes (Cohen's d = . 3).
Cohen's d effect sizes for correlated samples were computed using the formula d = M diff /SD pooled .
Generally, effect sizes around .2 are considered small, .5 are considered medium, .8 large, 1.2 very large, and 2.0 huge. 42 Analyses were performed using IBM SPSS software version 24. This study was approved by our Institutional Review Board (Study Protocol ID: Pro00038083).

Respondent Demographics
Two hundred and twenty-eight HCWs (81% female, 76.3% day shift) participated in at least day 1 of the 3GT intervention, and 55 (24.6%) of them identified as registered nurses. See Table 1 for demographic information. Of these, 127 participants completed the 1-month follow- Of those who participated, 48.2% reported 21 or more years of experience in their profession. The most common response for number of years in current position was 1-4 years.

Well-being Metrics over Time
Internal reliabilities are reported at the bottom of Table 1. Internal consistency for each metric was good at each time point, with Cronbach alphas ranging from .77 to .87. All participant well-being metrics were relatively highly correlated with themselves across time, especially Subjective Happiness, with correlations between .74 and .80. Figure 1 illustrates mean rates of all scales at each time point.

Independent t-tests assessed whether baseline well-being metrics predicted dropping out
or not at each follow-up assessment. At the 1 month follow-up, baseline levels of emotional exhaustion did not predict dropping out, (See Table 2), however, participants higher in problems with work-life balance, depression, and lower in happiness, were less likely to complete 1 month assessments. None of the baseline measures predicted dropping out at the 6 or 12 month mark. Table 3 shows the means and results of the analyses across the whole sample, as well as the sub-group of respondents reporting concerning levels of each well-being metric at each assessment point. Paired t-tests conducted on the entire sample revealed significant improvement, ps < .05, in emotional exhaustion, depression symptoms, and happiness at 1, 6, and 12-months, and in work-life balance at 1 and 6 months. Effect sizes across all four metrics were small to medium ranging from .16 to .52. Exploratory sub-group analyses on participants who met "percent concerning" criteria at baseline also revealed significant improvement across assessments, ps < .05, as well as moderate to very large effect sizes (.55 -1.57). Finally, we examined whether the number of completed 3GTs days predicted changes in well-being across the study. We computed well-being change scores for all metrics between baseline and follow-up assessments, and used spearman correlations to detect associations between change scores and number of completed 3GTs days. No significant associations were found, ps > .05.    good things makes me realize how many of those things (or similar) also happened to me, and feels like it amplifies my good feelings and sense of contentment, gratitude, happiness." "Pushes you to look for the good all day long!"

Discussion
The current pilot study adapted and tested the 3GT intervention for use by HCWs.
Participants of our nightly web-based intervention exhibited improvement across all four of our well-being metrics: burnout (EE), depression, problems with work-life balance, and happiness.
Three of these metrics showed significant improvement between baseline and the 12 month SSRIs and a placebo), 43 whereas the effect sizes in the current study approach those found by Krasner and colleagues, in their widely cited study of MBSR for HCWs (.62 for emotional exhaustion, .55 for depression). This is notable considering the differential time commitment involved in participating in 3GT compared to meditation training or an MBSR course. There may be a high return on investment in brief, simple, and accessible interventions like 3GT.
The study also tested whether baseline levels of well-being predicted completion of the follow-up assessments. Baseline levels of emotional exhaustion did not predict dropping out of any of the follow-up assessments; however those who dropped out at the 1-month assessment mark had higher levels of depression, problems with work-life balance, and lower levels of happiness at baseline. Baseline wellbeing did not predict completing or dropping out of the 6 or 12 month assessments. These results indicate that at least some wellness indices appear to have short-term predictive power for who is at risk of dropping out. However, in concert with the "percent concerning" findings, these results suggest that if someone who is really struggling at baseline is able to power through and complete the intervention, he/she is likely to experience an even greater benefit than those with relatively higher wellbeing at baseline. These findings compliment prior work indicating that those with worse wellbeing (i.e., lower positive affect, clinically depressed) appear to benefit the most from positive psychology interventions. 28,44 Relieving HCW burnout is a national imperative. Not only is burnout associated with devastating provider outcomes like substance abuse and suicidal ideation, 7,8 it's also linked to consequential patient safety outcomes, including medication errors and standardized mortality ratios. 16,19 Existing interventions for burnout largely center on learning mindfulness-based meditation. Meditation training appears helpful for HCW burnout 20 , however, in addition to the time commitment required, it is not broadly appealing to many providers due to religious, logistical or personal reasons. In other words, MBSR appears beneficial, it just isn't the right fit for many.
Since 2001, the Job Demands-Resources Model has accurately and repeatedly demonstrated that increasing demands while decreasing resources creates strain on the workforce. 45 This strain has been called burnout, low engagement, compassion fatigue, low safety culture and other similar monikers. Rigorous psychological research has consistently shown that experiencing positive emotions is associated with the ability to recover after emotional upheavals. 46 Positive emotions, like hope, gratitude and serenity, help people build personal resources, such as social bonds, intellectual skills, and motivation for personal growth. 47 Positive emotions also have the ability to recharge our self-regulation when we are feeling depleted 48 and to undo the cardiovascular aftereffects of an emotional upheaval, relative to negative emotions and control groups. 47 When access to positive emotion "engines" is interrupted, through new or increasing demands, we end up going to work each day with weaker and weaker batteries. This isn't weakness on the part of the person, it is the failure of our healthcare systems to create environments that promote well-being in the workforce.
By merging the well supported theories of positive emotion 49  Prior research has found that those experiencing burnout are more likely to attend to negative stimuli, even at the expense of not attending to positive stimuli that could improve ones' mood. 29 By having HCWs report nightly on three good things that happened that day, they might be re-calibrating their emotional well-being through more frequent experiences of positive emotions, as well as expanding their awareness of positive events. Although the mechanisms of 3GT as a resiliency tool has several strengths. The first is that the tool itself has little to no costs to deploy. We utilized a web-based format, but it is effective when administered as a paper based intervention 26,27 . Further, completion of the tool requires minimal time commitment from the participants; it takes approximately 3 minutes to complete each day. The tool is straightforward as well, requiring no additional skills training, and we found that it was applicable to everyone regardless of work-place role. Participants submit a wide variety of "good" things each night, including events that occurred inside and outside of the workplace.
The wide variety of 3GTsubmissions have been identified by qualitative researchers as generally fitting under one of three overarching themes: having a good day at work, having supportive relationships, and making meaningful use of self-directed time 50 . The low cost, minimal time and effort commitment, and widely enjoyable nature of 3GT are attractive features for burned out providers and organizations looking for ways to address the urgent need to improve wellbeing. Our study has several limitations. First, the study was a non-randomized pilot, and there was not a control group, which precludes any discussion of causality. Rather, we can only say that participants who signed up for 3GT and completed follow-up assessments reported significant improvements across all outcomes. It is possible that participants who engaged in 3GT but did not complete post assessments did not benefit to the same degree as those who did complete post assessments. Without a control group, we also cannot say that the results we found were not due, in part or in whole, to expectancy or placebo effects. Nevertheless, previous 3GT studies have used control groups (cites) to demonstrate that the 3GT intervention is responsible for the changes in well-being. 26,27 We note also that our sample is comprised largely of women (81% of participants at baseline), however this is generally in line with base rates of women working in healthcare in the US (in 2017, 75% of healthcare workers were female). 51 Future research should oversample for men and examine whether 3GT is equally effective across genders.
Second, our study also suffered from attrition in that only 56%, 52%, and 53% of those who completed day 1 3GT completed the 1, 6, and 12-month assessments, respectively. This rate of attrition is similar to other comparable studies 27,52,53 . In a methodologically rigorous study by Gander and colleagues, only 67.3% of those assigned to an intervention carried out the intervention, and only 38.9% completed all follow-up assessments. 27 In light of these attrition rates, it should be noted that people are notoriously bad at maintaining self-improvement goals.
Even among people seeking treatment for obesity using weight loss programs in medical centers, a third had to half discontinue their program and are lost to follow-up. 54,55 Similarly, over 40% of people seeking treatment through a smoking cessation clinic were lost to follow-up 56 , and another 48% of web-based smoking cessation individuals are lost to follow-up. 57 Attrition is a primary barrier to evaluating web-based interventions, with levels often reaching 60-80%. 58 It is unclear from our study whether the effects observed were the result of the intervention alone. Intrinsic characteristics of the cohort that completed follow-up assessments may have predisposed them to improvement in emotional exhaustion and depression. Still, prior randomized controlled studies of 3GT for one week (a smaller dose) have demonstrated improvement with this intervention, which we believe extends to our results. 53 We note also that those who needed this intervention the most, (i.e., those with higher burnout and depression, and worse work-life balance at baseline) were more likely to drop out of the study before the 1 month follow-up (after which time attrition did not change much does not prevent future sources of strain. In the long term, a family of valid and accessible interventions need to be targeted at both facilitating individual well-being ("levers that I can pull for myself right now") and preventing problems of strain ("levers that my institution/work setting pull for me to provide additional resources that prevent and alleviate strain").
Despite these limitations, this pilot study expands on previous research by demonstrating that a modification of 3GT for HCW appears to offer a simple and effective intervention to improve emotional well-being, and decrease emotional exhaustion. Current research is underway to evaluate the efficacy of 3GT with respect to the endurance of the improvements, to examine mechanisms of action, and to use control groups.

Conclusions
Given the relationship between healthcare worker well-being and healthcare quality, current findings that well-being metrics appear to improve across repeated measures are encouraging. 3GT has now been demonstrated as a low-cost strategy to potentially improve well-being, such that refinement and extension of this type of intervention is warranted.
Funding: This work was supported by NIH grant number R01 HD084679-01.
Contributorship Statement: JBS developed the procedure, collected the data, contributed to analyses, and co-wrote the paper. KCA contributed to analyses and co-wrote the paper.

Competing interests: None declared.
Data Sharing Statement: The authors will share survey data from the study upon reasonable request to the first author.        I completed a project that I had been needing to get done for a few weeks.
 I made it to the gym and had a great workout.
 The surgeon I work with is always a pleasure to be around.
 I saw another friend from high school today and was really nice to be together and laugh.
 I am grateful for a positive response I received from a colleague after I allowed myself to be vulnerable by reaching out.
 It was NOT snowing today.
 Busy night at work, but had really great teamwork.

2) Participant evaluation statistics
 95.8% agreed with "I would recommend the 3 Good Things exercise to a friend."  85.3% agreed with "I have encouraged others to try 3 Good Things."  92.7% agreed with "I would like to participate in 3 Good Things again next year."  92.8% agreed with "I would recommend the 3 Good Things exercise to a supervisor."  94.3% agreed with "My overall impression of the 3 Good Things exercise is favorable."   I like the idea of it -but I don't like having to do one more task each and every day!  Am still trying to note 3 good things a day, & believe it helped "reroute" my thinking.
 I appreciated stepping back to recognize all the things I take for granted that are good in my life  I did enjoy it. I liked reading through everyone's responses --the good kind of rubs off! It was interesting to see people turn something negative into something positive, i.e. see the silver lining or put a positive spin on things.
 I became tuned into the present and what I was feeling.
 Pushing myself to take a minute (or two) for me to think, look back, look ahead.

Gender as a Time-Invariant Covariate
To explore whether gender plays a role in in the reduction of burnout across the assessment points, we added gender (1=man, 0 = woman) as a time-invariant covariate to the model.
In the results of the fixed effects, we again find that the intercept is significant (γ 00 = 54.14, p < .001), and the model-implied mean level of burnout at baseline is 54.14 for women. The main effect of time point is also significant (γ 10 = -2.72, p < .001), reflecting that the model implied linear slope of the trajectory is significantly decreasing over time  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   10 for women. The main effect of gender is not significant (γ 01 = -2.78, p < .001), and this reflects that the model-implied intercept is not significantly different by gender (i.e., genders did not differ at baseline). The interaction between gender and time point is not significant, although it is at the level of a trend (γ 11 =.15, p = .08), indicating that the model-implied linear slopes do not differ in magnitude between men and women.
In the random effects results, we find that significant variability remains in the random intercept (τ 00 = 624.93, p < .001) and the random slope (τ 11 = 27.46, p < .001), after accounting for gender. There was not significant covariance between intercepts and slopes, after accounting for gender (τ 10 = -28.79, p = .17).
(b) Report category boundaries when continuous variables were categorized All measures were used according to the scoring and use recommendations by the scales' authors. All measures of interest produced continuous outcomes which were used in simple paired ttests.
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period N/a, this is not a risk study Other analyses 17 Report other analyses done-eg analyses of subgroups and interactions, and sensitivity analyses We conducted exploratory analyses on participants whose scores were concerning at baseline on our wellbeing metrics. The results of these analyses can be found in Table 3 and are briefly described in the results section, pg. 14.

Discussion
Key results 18 Summarise key results with reference to study objectives Achieved on pg. 17 We carefully describe and interpret the results of the study in the discussion section, particularly since this was a non-randomized pilot study. We were mindful not to overstate the impact of these findings, and rather present them as a promising first step in evaluating 3GT with healthcare workers.

Note
Conclusion 3GT appears a promising low-cost and brief intervention for improving HCW wellbeing.

Article Summary
Strengths and limitations of this study  This pilot study examined the efficacy of the Three Good Things intervention for healthcare worker well-being over four time points: at baseline and three postintervention follow-ups (1 month, 6 months, and 12 months).
 Efficacy was assessed with four well-being measures: emotional exhaustion, depression symptoms, subjective happiness, and work-life balance.
 This pilot study is limited by not having a randomized control group. Results are limited to those who completed assessments.
 Attrition was high (only half of those who started went on to complete the 1 month post assessments) but similar to rates found in other comparable interventions.

Intervention in the US for Healthcare Worker Emotional Exhaustion, Depression, Worklife Balance, and Happiness
Healthcare worker (HCW) burnout has reached a critical level. In the USA, over half of physicians, and a third of nurses, report feeling burned out from their work. 1,2 In recent years HCWs have faced a staggering number of increasing demands, including complex electronic medical records, new regulatory requirements, higher rates of student loan debt and increased production pressure. Simultaneously, HCWs are often not given the resources (or worse, are having their resources taken away) that are needed to meet these new demands. 3 They report having less autonomy, less control over decision-making, and less time to have meaningful interactions with patients. As demands increase and resources decrease, the result on any system or individual is strain, and that strain is what drives the increasing prevalence of burnout. 4 The increase is evident in the careful study by Shannefeldt et al., detailing a 9 percent increase in physician burnout between 2011 and 2014. 1 Maslach characterized burnout as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment, that can occur among those who do "people work" of some kind. 5 Of particular interest to HCWs is emotional exhaustion, which refers to feelings of being overextended and exhausted by the emotional demands of one's work. Burnout has severe negative consequences for both HCWs and patients. Burnout has been linked to higher rates of HCW depression, substance abuse, anxiety, and suicidal ideation, decreased immune system function, reduced marital satisfaction, and greater risk of motor vehicle accidents. [6][7][8][9][10][11] At an organizational level, burnout has been connected to poorer relationships with patients and staff, higher rates of job turnover, earlier retirements, and reduced productivity. [12][13][14] Importantly, provider burnout is also linked to serious patient safety outcomes, including  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   5 higher rates of infection, increased medication errors, lower patient satisfaction, worse safety culture, and higher standardized mortality ratios. [15][16][17][18][19] To date, the literature has predominately focused on describing the prevalence of burnout rather than testing interventions to reduce it. The most successful exception to this has been training in meditation called Mindfulness-based Stress Reduction (MBSR), and similar meditation programs that garner modest effect sizes. [20][21][22] These programs appear to be fairly effective, but they require a significant time commitment of approximately 8-10 weeks, 2.5 hours per week, and 45-60 minutes of homework a day. Another promising intervention is the "Colleagues Meeting to Promote and Sustain Satisfaction" or COMPASS program. 23 It offers physicians 1 hour of protected time every two weeks to discuss the "virtues and challenges of being a physician" over a meal paid for by the hospital (i.e., this is not a low cost intervention).
A randomized clinical trial of COMPASS found that it lead to sustained improvements in burnout and finding meaning in one's work. 23,24 A recent meta-analysis of HCW interventions for burnout revealed that, on average, interventions lead to small but significant improvements in burnout. 25 Interventions can be categorized as either aimed at helping individuals improve their burnout, or organizational activities aimed to reduce perceived demands and/or increase resources. Organizational-level interventions, which tend to focus on improving workload, scheduling, communication, teamwork and changes in workflow, are generally more effective than individual-level interventions, which, to date, largely involve meditation training. 25 Rather than ask busy and burned out HCWs to commit additional time and effort to learn a new skill like meditation during this intense time in their lives, or assume that hospital administration can be convinced to provide significant funding for well-being, we selected a Good Things (3GT). 26,27 3GT is one of a family of positive interventions used as intentional activities aimed at cultivating positive cognitions and emotions. 28 In other words, 3GT is thought to enhance participants' ability to notice genuinely positive things around them, and these can be the same things that were already present, but went unnoticed prior to the intervention.
3GT appears well suited for use with burned out populations due to research showing that burnout reduces one's ability to notice and attend to positive stimuli. 29 Moreover, 3GT has improved happiness and depressive symptoms in previous research. 26 Burnout and depression have been empirically and conceptually linked 30 and share symptoms such as extreme exhaustion, feeling down, and reduced performance. The 3GT intervention, however, has not been empirically evaluated with HCWs. 3GT involves a brief explanation, takes only a couple of minutes to complete, and requires relatively little time or resources. In the resource restricted environment of healthcare, such quick and low-cost strategies are welcome.
The primary aim of the current study was to test the efficacy of 3GT for HCW well-being through four metrics: burnout (specifically, the emotional exhaustion component), which is the primary outcome of interest, as well as depression symptoms, subjective happiness, and worklife balance. We hypothesized that 3GT participants would report reductions in emotional exhaustion and depressive symptoms, as well as improvements in subjective happiness and work-life balance, between baseline assessments and all three follow-up assessments.
Exploratory secondary aims of the study were to 1) test whether those who met "percent concerning" criteria at baseline exhibited stronger intervention effects, 2) examine whether baseline well-being was a predictor of completing or failing to complete follow-up assessments,  pharmacists, respiratory therapists, technologists/technicians, administrative support, other managers, and students. Participants completed assessments at baseline, at 1-month (i.e., 1 month after the last day of 3GT), 6-months, and 12 months follow-up. Links to online assessments were sent to participants via email.

Patient and Public Involvement
Neither patients nor the public were involved in the current study.

Measures
To assess changes in well-being, we used four validated scales (emotional exhaustion, depression symptoms, subjective happiness, and work-life balance) at each assessment point (see  Table 1 for Chronbach alphas). These four metrics were selected a prioi 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.

Burnout (Emotional Exhaustion (EE) Sub-scale): The Maslach Burnout Inventory, which
is the gold standard tool in the field of burnout, has been used extensively with healthcare workers. A meta-analysis has revealed that of the three sub-scales (emotional exhaustion, depersonalization, and personal accomplishment), emotional exhaustion consistently produces the largest and most consistent coefficient alpha estimates, while depersonalization and personal accomplishment were both lower and less consistent than emotional exhaustion. 31 In addition to being more psychometrically robust, emotional exhaustion can be used to discriminate between burned out and non-burned out outpatients suffering from work-related neurasthenia (according to ICD-10 criteria). 32 We used a 5-item derivative 33   statements, and is the first threshold for percent concerning because it indicates at least mild emotional exhaustion. 34 These "percent concerning" thresholds should not be considered clinically diagnostic, but rather identify those whose scores represent more of a struggle on a Benchmarking data in diverse populations demonstrate mean SHS scores consistently flank a  fewer days as "percent positive," referring to scores greater than 2 as work-life imbalance. We use the imbalance designation (percent of respondents with a mean over 2) as the "percent concerning". 39 Internal consistency in the current study was good (Cronbach's alpha = .81).

Good Things Intervention
The original 3GT intervention encouraged participants to keep a log of things that go well for 7 days . 26 We adapted 3GT to our HCW population to be simple and quick, but we modified it in several ways. First, we extended the length of the intervention to last 2 weeks (15 days), starting and ending on a Monday. In pilot testing, we found that more people complete the full two weeks if they start on a Monday. Second, using Qualtrics survey software, we sent nightly email reminders to enter "What went well today, and what was your role in making it happen?" in three text boxes. Third, to induce a brief savoring period, they were instructed to select a positive emotion that best fit how they felt about their good thing, from a drop-down list of 10 positive emotions (e.g., Joy, Gratitude, Hope, etc.) with options for "not applicable" and "other". 40 Prior to submitting their responses, participants could chose to anonymously share their good things with other participants in the following night's log. All participants, upon completion of their log, were automatically redirected to the log of good things participants submitted and approved for sharing the day before. This exposure to shared good things was another opportunity for savoring.

Statistical Analysis
Cronbach's alpha was used to assess the internal reliability of the scales (values above 0.70 are considered acceptable, 0.80 good, and 0.90 very good. 41 Feasibility of 3GT for HCWs was assessed through attrition (uptake) and participant evaluations. Independent samples t-tests examined whether baseline levels of the well-being metrics predicted dropping out of the study at the 1, 6, and 12 month follow-ups. Paired samples t-tests were used to test for improvement in the well-being variables across the baseline and 1, 6, and 12-month follow-ups. These analyses used list-wise deletion for missing data. Participants who were lost to follow up were still included in any analysis for which they had provided data. For all analyses, p-values < 0.05 were considered significant and all tests were two-tailed. A power analysis indicated that our sample size provided high power (1-β) > .9 to detect relatively small effect sizes (Cohen's d = . 3).
Cohen's d effect sizes for correlated samples were computed using the formula d = M diff /SD pooled .
Generally, effect sizes around .2 are considered small, .5 are considered medium, .8 large, 1.2 very large, and 2.0 huge. 42 Analyses were performed using IBM SPSS software version 24. This study was approved by our Institutional Review Board (Study Protocol ID: Pro00038083).

Respondent Demographics
Two hundred and twenty-eight HCWs (81% female, 76.3% day shift) participated in at least day 1 of the 3GT intervention, and 55 (24.6%) of them identified as registered nurses. See Table 1 for demographic information. Of these, 127 participants completed the 1-month follow- Of those who participated, 48.2% reported 21 or more years of experience in their profession. The most common response for number of years in current position was 1-4 years.   Table 2), however, participants higher in problems with work-life balance, depression, and lower in happiness, were less likely to complete 1 month assessments. None of the baseline measures predicted dropping out at the 6 or 12 month mark. Table 3 shows the means and results of the analyses across the whole sample, as well as the sub-group of respondents reporting concerning levels of each well-being metric at each assessment point. Paired t-tests conducted on the entire sample revealed significant improvement, ps < .05, in emotional exhaustion, depression symptoms, and happiness at 1, 6, and 12-months, and in work-life balance at 1 and 6 months. Effect sizes across all four metrics were small to medium ranging from .16 to .52. Exploratory sub-group analyses on participants who met "percent concerning" criteria at baseline also revealed significant improvement across assessments, ps < .05, as well as moderate to very large effect sizes (.55 -1.57). Finally, we examined whether the number of completed 3GTs days predicted changes in well-being across the study. We computed well-being change scores for all metrics between baseline and follow-up assessments, and used spearman correlations to detect associations between change scores and number of completed 3GTs days. No significant associations were found, ps > .05.     1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  good things makes me realize how many of those things (or similar) also happened to me, and feels like it amplifies my good feelings and sense of contentment, gratitude, happiness." "Pushes you to look for the good all day long!"

Discussion
The current pilot study adapted and tested the 3GT intervention for use by HCWs.
Participants of our nightly web-based intervention exhibited improvement across all four of our well-being metrics: burnout (EE), depression, problems with work-life balance, and happiness.
The study also tested whether baseline levels of well-being predicted completion of the follow-up assessments. Baseline levels of emotional exhaustion did not predict dropping out of any of the follow-up assessments; however those who dropped out at the 1-month assessment  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   19 mark had higher levels of depression, problems with work-life balance, and lower levels of happiness at baseline. Baseline wellbeing did not predict completing or dropping out of the 6 or 12 month assessments. These results indicate that at least some wellness indices appear to have short-term predictive power for who is at risk of dropping out. However, in concert with the "percent concerning" findings, these results suggest that if someone who is really struggling at baseline is able to power through and complete the intervention, he/she is likely to experience an even greater benefit than those with relatively higher wellbeing at baseline. These findings compliment prior work indicating that those with worse wellbeing (i.e., lower positive affect, clinically depressed) appear to benefit the most from positive psychology interventions. 28,44 Relieving HCW burnout is a national imperative. Not only is burnout associated with devastating provider outcomes like substance abuse and suicidal ideation, 7,8 it's also linked to consequential patient safety outcomes, including medication errors and standardized mortality ratios. 16,19 Existing interventions for burnout largely center on learning mindfulness-based meditation. Meditation training appears helpful for HCW burnout 20 , however, in addition to the time commitment required, it is not broadly appealing to many providers due to religious, logistical or personal reasons. In other words, MBSR appears beneficial, it just isn't the right fit for many.
Since 2001, the Job Demands-Resources Model has accurately and repeatedly demonstrated that increasing demands while decreasing resources creates strain on the workforce. 45 This strain has been called burnout, low engagement, compassion fatigue, low safety culture and other similar monikers. Rigorous psychological research has consistently shown that experiencing positive emotions is associated with the ability to recover after emotional upheavals. 46 Positive emotions, like hope, gratitude and serenity, help people build  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   20 personal resources, such as social bonds, intellectual skills, and motivation for personal growth. 47 Positive emotions also have the ability to recharge our self-regulation when we are feeling depleted 48 and to undo the cardiovascular aftereffects of an emotional upheaval, relative to negative emotions and control groups. 47 When access to positive emotion "engines" is interrupted, through new or increasing demands, we end up going to work each day with weaker and weaker batteries. This isn't weakness on the part of the person, it is the failure of our healthcare systems to create environments that promote well-being in the workforce.
By merging the well supported theories of positive emotion 49  Prior research has found that those experiencing burnout are more likely to attend to negative stimuli, even at the expense of not attending to positive stimuli that could improve ones' mood. 29 By having HCWs report nightly on three good things that happened that day, they might be re-calibrating their emotional well-being through more frequent experiences of positive emotions, as well as expanding their awareness of positive events. Although the mechanisms of  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  3GT as a resiliency tool has several strengths. The first is that the tool itself has little to no costs to deploy. We utilized a web-based format, but it is effective when administered as a paper based intervention 26,27 . Further, completion of the tool requires minimal time commitment from the participants; it takes approximately 3 minutes to complete each day. The tool is straightforward as well, requiring no additional skills training, and we found that it was applicable to everyone regardless of work-place role. Participants submit a wide variety of "good" things each night, including events that occurred inside and outside of the workplace.
The wide variety of 3GTsubmissions have been identified by qualitative researchers as generally fitting under one of three overarching themes: having a good day at work, having supportive relationships, and making meaningful use of self-directed time 50 . The low cost, minimal time and effort commitment, and widely enjoyable nature of 3GT are attractive features for burned out providers and organizations looking for ways to address the urgent need to improve wellbeing.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  Our study has several limitations. First, the study was a non-randomized pilot, and there was not a control group, which precludes any discussion of causality. Rather, we can only say that participants who signed up for 3GT and completed follow-up assessments reported significant improvements across all outcomes. It is possible that participants who engaged in 3GT but did not complete post assessments did not benefit to the same degree as those who did complete post assessments. Without a control group, we also cannot say that the results we found were not due, in part or in whole, to expectancy or placebo effects. Nevertheless, previous 3GT studies have used control groups (cites) to demonstrate that the 3GT intervention is responsible for the changes in well-being. 26,27 We note also that our sample is comprised largely of women (81% of participants at baseline), however this is generally in line with base rates of women working in healthcare in the US (in 2017, 75% of healthcare workers were female). 51 Future research should oversample for men and examine whether 3GT is equally effective across genders.
Even among people seeking treatment for obesity using weight loss programs in medical centers, a third had to half discontinue their program and are lost to follow-up. 54,55 Similarly, over 40% of people seeking treatment through a smoking cessation clinic were lost to follow-up 56 , and another 48% of web-based smoking cessation individuals are lost to follow-up. 57 Attrition is a primary barrier to evaluating web-based interventions, with levels often reaching 60-80%. 58 It is unclear from our study whether the effects observed were the result of the intervention alone. Intrinsic characteristics of the cohort that completed follow-up assessments may have predisposed them to improvement in emotional exhaustion and depression. Still, prior randomized controlled studies of 3GT for one week (a smaller dose) have demonstrated improvement with this intervention, which we believe extends to our results. 53 We note also that those who needed this intervention the most, (i.e., those with higher burnout and depression, and worse work-life balance at baseline) were more likely to drop out of the study before the 1 month follow-up (after which time attrition did not change much  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   24 does not prevent future sources of strain. In the long term, a family of valid and accessible interventions need to be targeted at both facilitating individual well-being ("levers that I can pull for myself right now") and preventing problems of strain ("levers that my institution/work setting pull for me to provide additional resources that prevent and alleviate strain").
Despite these limitations, this pilot study expands on previous research by demonstrating that a modification of 3GT for HCW appears to offer a simple and effective intervention to improve emotional well-being, and decrease emotional exhaustion. Current research is underway to evaluate the efficacy of 3GT with respect to the endurance of the improvements, to examine mechanisms of action, and to use control groups.

Conclusions
Given the relationship between healthcare worker well-being and healthcare quality, current findings that well-being metrics appear to improve across repeated measures are encouraging. 3GT has now been demonstrated as a low-cost strategy to potentially improve well-being, such that refinement and extension of this type of intervention is warranted.
Funding: This work was supported by NIH grant number R01 HD084679-01.
Contributorship Statement: JBS developed the procedure, collected the data, contributed to analyses, and co-wrote the paper. KCA contributed to analyses and co-wrote the paper.
Competing interests: None declared.
 I made it to the gym and had a great workout.
 The surgeon I work with is always a pleasure to be around.
 I saw another friend from high school today and was really nice to be together and laugh.
 I am grateful for a positive response I received from a colleague after I allowed myself to be vulnerable by reaching out.
 It was NOT snowing today.
 Busy night at work, but had really great teamwork.
2) Participant evaluation statistics  95.8% agreed with "I would recommend the 3 Good Things exercise to a friend."  85.3% agreed with "I have encouraged others to try 3 Good Things."  92.7% agreed with "I would like to participate in 3 Good Things again next year."  92.8% agreed with "I would recommend the 3 Good Things exercise to a supervisor."  94.3% agreed with "My overall impression of the 3 Good Things exercise is favorable."  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59    I wish it were ongoing. I don't feel like doing it myself but I was instantly struck by the power of being part of group of people who were asked to see their lives through this positive filter.
 I thought it was very well organized and liked how it made me focus on the positive.
 I like the idea of it -but I don't like having to do one more task each and every day!  Am still trying to note 3 good things a day, & believe it helped "reroute" my thinking.
 I appreciated stepping back to recognize all the things I take for granted that are good in my life is not as impactful.
 On some days, especially early on, I felt that the good things I shared were small, relatively insignificant, things I did not value as greatly, but shared simply because they were the only things in my day I could think of that I and others would identify as  I will miss my daily reminder email!  It was actually something I did just for myself, taking time for myself. I think that led to taking time for myself in other ways ( i.e. breaks at work, exercising in the a.m. before work -I have NEVER done that before and it feels good!) It really changed my outlook at the end of the day to the good things instead of dwelling on the negative. eventually I was looking for good things and making good things happen.  I did enjoy it. I liked reading through everyone's responses --the good kind of rubs off! It was interesting to see people turn something negative into something positive, i.e. see the silver lining or put a positive spin on things.
 I became tuned into the present and what I was feeling.
 Pushing myself to take a minute (or two) for me to think, look back, look ahead.

Unconditional Linear Growth Model
To assess change in burnout (our primary outcome) across the assessment points we fit an unconditional growth model, with random intercepts and slopes. Assessment time point was the only predictor. Assessments (4) were nested within individual.
The fixed effects indicate that there is a significant intercept (γ00 = 55.78, p < .001) and a significant linear slope (γ10 = -2.78, p < .001). The model-implied mean burnout at baseline was 55.78, and it varied significantly across participants. The model implied mean burnout decreased significantly over time, on average by 2.78 units with each assessment.
There was not significant covariance between intercepts and slopes (τ10 = -30.77, p = .142), indicating that baseline levels of burnout does not predict one's rate of change overtime during 3GTs.

Gender as a Time-Invariant Covariate
To explore whether gender plays a role in in the reduction of burnout across the assessment points, we added gender (1=man, 0 = woman) as a time-invariant covariate to the model.
In the results of the fixed effects, we again find that the intercept is significant (γ00 = 54.14, p < .001), and the model-implied mean level of burnout at baseline is 54.14 for women. The main effect of time point is also significant (γ10 = -2.72, p < .001), reflecting that the model implied linear slope of the trajectory is significantly decreasing over time for women. The main effect of gender is not significant (γ01 = -2.78, p < .001), and this reflects that the model-implied intercept is not significantly different by gender (i.e., genders did not differ at baseline). The interaction between gender and time point is not significant, although it is at the level of a trend (γ11 =.15, p = .08), indicating that the model-implied linear slopes do not differ in magnitude between men and women.
In the random effects results, we find that significant variability remains in the random intercept (τ00 = 624.93, p < .001) and the random slope (τ11= 27.46, p < .001), after accounting for gender. There was not significant covariance between intercepts and slopes, after accounting for gender (τ10 = -28.79, p = .17).

Discussion
Key results 18 Summarise key results with reference to study objectives Achieved on pg. 17 We carefully describe and interpret the results of the study in the discussion section, particularly since this was a non-randomized pilot study. We were mindful not to overstate the impact of these findings, and rather present them as a promising first step in evaluating 3GT with healthcare workers.