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Happiness
The Evidence Behind the Emotion
CE633 :: 1.00 Hours
This CE module is relevant to advance practice nurses.


Authors:

Rosalinda Alfaro-LeFevre, MSN, RN, ANEF
Rosalinda Alfaro-LeFevre, MSN, RN, ANEF, is the president of Teaching, Smart/Learning Easy in Stuart, Fla. She’s known nationally and internationally for her writings and programs on teaching critical thinking and improving personal and professional performance.


Objectives
The goal of this program is to provide healthcare professionals with information about the science of happiness, including evidence-based strategies for improving well-being. After studying the information presented here, you will be able to:
  • Define happiness, positive psychology and well-being
  • State three physiological and three psychological benefits of happiness
  • Describe four evidence-based strategies for increasing happiness

 
Accreditation Information
 
This course is intended for an interprofessional audience, including nurses, dietitians, dietary managers, EMTs and paramedics, fitness professionals, health educators, occupational therapists, radiologic technologists, respiratory therapists and social workers.
 
Nurses: Take this version of the course to ensure you receive appropriate credit.
 
For the version accredited or approved for another profession, go to your specific profession at www.continuingeducation.com or Nurse.com/CE. If you have a CE Direct login ID and password (generally provided by your employer), please log in as you normally would at cedirect.continuingeducation.com and search for this topic title.


“I remember one morning getting up at dawn. There was such a sense of possibility. You know, that feeling ... I remember thinking to myself: So, this is the beginning of happiness, this is where it starts. And of course, there will always be more ... it never occurred to me it wasn’t the beginning. It was happiness. It was the moment, right then.” (Clarissa in Michael Cunningham’s Pulitzer Prize-winning novel “The Hours”)
 
Most of us want to be happy, but we’re not quite sure what it means. Often, we see it as a destination rather than a journey. Yet happiness is more complex than simply arriving at a happy “place” in life. It actually involves things like how you feel on a day-to-day basis, how well you’ve resolved past issues, and how you imagine your future. Whether you’re struggling with stress or discouragement or simply going through life, knowing ways to be more content can make the difference between feeling tired and beaten and finding joy in each day. This module examines the science of happiness and reviews information from positive psychologists and organizations dedicated to improving world happiness. Using lots of examples, it explains the physiological changes your body experiences when you’re happy (or sad). The insights and strategies you’ll gain from understanding the science of happiness as described in this module can help you improve physical and psychological health at every stage of life — from dealing with a first-born child to helping a parent in hospice. 
 
The University of Pennsylvania Positive Psychology Center defines positive psychology as being “the scientific study of the strengths and virtues that enable individuals and communities to thrive.”1 Positive psychology, a relatively new field, focuses on positive emotions, positive individual traits, and positive institutions.1 One meta-analysis study found that positive psychology interventions “significantly enhance subjective and psychological well-being and reduce depressive symptoms.”2 (Level A)
 
In a Pew Research study on social and demographic trends, only 34% of participants were “very happy.”3 Half said they were “pretty happy,” and 15% said they were “not too happy.” When reading about happiness, one common theme appears: happiness at home, at work, in our communities, and in our hearts and minds affects our health and performance.
 
Applying positive psychology principles can improve our own well-being and help us teach our patients and coworkers to do the same. Patients with major chronic health issues especially need our help. For example, a study of patients on hemodialysis found that they had lower life satisfaction compared with those not on dialysis.4 Organizations can benefit from focusing on staff well-being and job satisfaction because unhappiness with job circumstances leads to poor performance and burnout.
 
What Is Happiness?
 
The search for the meaning of happiness began 2,500 years ago in China, India, and Greece with philosophers such as Confucius, Buddha, Socrates, and Aristotle.5 Many of their observations are amazingly similar to what recent studies confirm. However, it’s not been until this century that we’ve been able to gain the data needed to answer questions like: What exactly does happiness entail? How does happiness and sense of well-being affect overall health and longevity? and What can individuals, families, and communities do to increase happiness?
 
Psychologists differentiate between transitory happiness, such as the pleasure of a great hot fudge sundae, and enduring happiness.6 Transitory happiness brings momentary pleasure, but enduring, or “authentic” happiness as positive psychologist Martin Seligman calls it, is a deep satisfaction with how you live your life.6 It depends on living a meaningful, values-based life in a community in which you feel you belong. Happiness has two dimensions: pleasure, which refers to the present benefit, and meaning, which has both present and future benefits.6 One study found happy people are more likely to have community involvement, fulfilling marriages and relationships, high incomes, a long life, superior work performance, and robust health.7
 
How Is Happiness Measured?
 
Various techniques have been used to measure happiness; most involve questionnaires. The University of Pennsylvania’s Authentic Happiness website has several questionnaires, including the Authentic Happiness Inventory Questionnaire, which measures overall happiness, and the General Happiness Questionnaire, which measures enduring happiness.8
 
Happiness is measured by assessing subjective well-being. Subjective well-being includes emotional feelings, such as happiness, satisfaction with life, and satisfaction in various domains, such as family, self, and work. It is generally defined as a person’s self-report of global life satisfaction or happiness and can be measured by The Oxford Happiness Questionnaire.
 
Another measurement tool is The Satisfaction With Life Scale, a five-item instrument in the public domain that can be used as long as attribution is given to its authors. Other tools include the Flourishing Scale, an eight-item questionnaire that reflects self-report of success in key areas such as relationships and optimism, and the Scale of Positive and Negative Experience; SPANE is a 12-item scale that asks for responses based on experiences during the previous four weeks.
 
Physiology of Happiness
 
Happiness produces physiological changes. When people feel happy, PET (positron emission tomography) and functional MRI scans show activity in the left prefrontal cortex.9 When that area of the brain is stimulated, people feel more positive.
 
Optimism, important for happiness, is linked to brain function. The rostral anterior cingulate cortex, part of the frontal cortex, and the amygdala both become more active when we imagine positive events.9 The neurotransmitter dopamine may play an important role in happiness because it mediates the transfer of positive emotion signals between the left prefrontal areas and the limbic area of the brain.10
 
Happiness is associated with lower levels of cortisol and, therefore, a stronger immune system.11 (Level B) Evidence from a study that measured antibody titers at several points after vaccination showed that people with greater left-sided prefrontal activation had greater antibody titers, suggesting “more robust immunity” in response to vaccination.11 (Level B) Another study found that those with a “positive emotional style” were less likely to become ill after exposure to a few drops of a rhinovirus or influenza virus.12 (Level B) Many publications and health-related websites link a high sense of well-being to improved health and longevity.
 
Born Happy?
 
There’s evidence that some people, because of their genes, are born happy. In a study of 2,574 people, those with a more efficient version of the serotonin transporter gene 5-HTTLPR reported significantly higher levels of life satisfaction.13 It’s believed that genetics accounts for about 50% of satisfaction with life or happiness.14 This genetic predisposition is called the “happiness set point,” the point we return to if something disrupts our happiness.14 If genetics doesn’t fully explain happiness, what are other contributing factors? Seligman created a happiness formula: H = S + C + V.6 In this formula, enduring happiness (H) depends on the sum of:
  • S: The genetic happiness set point (50%)
  • C: The circumstances of a person’s life, such as health (10%)
  • V: Factors under our voluntary control, such as engaging in a meaningful life (40%)
 
If you think about the above, improving circumstances of someone’s life and teaching people to do things that are under their voluntary control can significantly boost happiness over and above their set point.
 
The World Happiness Report (http://worldhappiness.report/) ranks more than 150 countries by their happiness levels and addresses global efforts to manage life circumstances. In this report, authorities from many fields — economics, psychology, survey analysis, national statistics, health, public policy, and more — describe how measurements of well-being can be used effectively to assess progress in various countries. The report addresses the state of happiness in the world and shows how the science of happiness explains personal and national variations in happiness. Surprisingly, it reflects a worldwide demand for more attention to happiness as criteria for government policy.15
 
What Makes Us Happy?
 
Let’s consider some factors that researchers have found contribute to happiness.
 
Age: Contrary to what you might think, many publications point out that most people become happier and experience better emotional well-being with age. However, a Gallup telephone survey of 340,847 people from ages 18 to 85 old found that happiness decreased gradually until 50 and then trended upward, while worry after this age declined. At about 70, happiness leveled off or declined slightly.16
 
Religiousness and spirituality: Some studies show a correlation between religiousness and happiness. A Pew survey found that people who attend religious services weekly or more often are happier than those who attend less often.3 However, researchers are unsure of the reason for this effect. Is it that religious people often attend church, where they can make connections and establish a support network? Does religion promote happiness by reducing stress and giving meaning to life?
 
Money: As many lottery winners will tell you, money doesn’t necessarily deliver on its promise of happiness. The link between money and happiness is complex. While some authors find that money can bring happiness, it can also bring more responsibilities and stress. Studies find that just because you live in a rich country, it doesn’t mean you’re guaranteed happiness; people living in some poor nations are happier than those living in rich countries.15 Happiness depends more on social factors than economic factors.15 Yet economics does affect happiness: having money gives you the ability to do things that are important to you, whereas struggling to pay debt and live within a budget is stressful.
 
Marriage: Studies support that being married contributes to happiness. But the unanswered question is whether married people are happy because they’re married, or whether happy people tend to be the ones who marry?17 Those who see their spouse as their best friend benefit even more from marriage. Divorced people may be happier than those in unhappy marriages. If your marriage was unhappy, getting a divorce gives you the freedom to build strong, mutually rewarding relationships and friendships that are so important for happiness.  


Strategies for Happiness
 
A review of many articles and websites suggests that you should consider making some of the following strategies a priority in your life.  
 
Connect socially: Staying connected and involved with friends, family, organizations, and communities gives the support and interaction needed to feel you belong, can make a difference, and are valued. Today we have both real and virtual (email, texting, Facebook, etc.) connectivity. Most articles address the need for real, rather than virtual, connections. Today we have outreaches through virtual and phone connections, as discussed later. Some people say they are “over-connected” with superficial, rather than meaningful, experiences. Virtual and real social connections bring new challenges that may have to be managed for a person to be happy.
 
Too many superficial connections can increase stress because few meaningful discussions happen and unhealthy assumptions may be made. For example, teenagers may check in on their 453 friends on Facebook and think, “All my friends have fabulous lives. Why am I the only one struggling like this?” Some questions to ask in relation to happiness and social connections are: How do I feel about this connection or relationship? Do I feel like it’s a healthy relationship? Does it help me reach my goals? Do the positives outweigh the negatives? What can I do to make this a positive connection?
 
One study shows that with happy connections, happiness may be contagious because it becomes “a network phenomenon.” A 20-year study of 4,793 participants found clusters of happy and unhappy people in social networks and reported that a person is 15% more likely to be happy if he or she is connected to a happy person.18 (Level B)
 
Isolation and loss of human connections is a national and international concern, especially for the elderly.19 Too many elderly people live alone, trapped in their homes, rarely able to get out. Some go for days without so much as using their own voice.19 Some communities now have volunteers who make phone calls to isolated elderly people simply to have a conversation with them. These calls may be their only human connection in days or weeks.19
 
“Pay it forward.” One morning, at the drive-through window of a coffee shop, a customer paid for her order and then picked up the tab for the stranger in the car behind her. Then that customer paid the bill for the following customer — and so on, for the next 226 customers, in three hours of spontaneous generosity.20 Since then, we have heard countless stories of random acts of kindness and paying it forward. It turns out that not only does generosity make you happy, it can be socially contagious.20 Paying it forward can become a life habit. When someone does something nice for you, you can say something like “That is so thoughtful. I’m going to pay it forward to someone else when I get chance.”
 
Keep a positive attitude. Optimism has been linked to improved sense of well-being and better outcomes. The saying goes, “Whether you think you can or you think you can’t, you’re right.” Screening patients for depression and dealing with negativity are often tops on the list of issues that must be addressed when patients are recovering from (or dealing with) complex health issues. A good example of this is the story of a 71-year-old man who was recovering from cancer surgery and yelling at everyone from his family to his nurses. It seemed as though he couldn’t get past the anger of having this devastating diagnosis (even though his cancer was very treatable). Finally, one brave nurse went into his room and said, “You have GOT to snap out of it! I realize this is hard, but you’re making this much harder on yourself and everyone else with this attitude!” The patient took this advice to heart, and everything changed dramatically in 24 hours. Sometimes, all it takes is to realize that you’re overcome by negativity and that a positive attitude feels so much better.
 
Be grateful. Gratitude helps you overcome negative feelings and gain a positive attitude. Negativity brings stress and sleepless nights. Positivity reduces stress because feeling that things will go well helps you gain confidence. Conveying gratefulness to others, like making it a point to show colleagues or friends appreciation, increases their sense of worth and happiness. When you make someone else happy, you feel it as well!
 
Keeping a happiness or gratefulness journal is a powerful way to develop a positive attitude. Some people keep their journal in a notebook; others do it on a computer. Some people put little pieces of paper with “happy things” written on them in a jar. Writing happy things down forces you to focus on what’s good in your life and stop dwelling on the bad. With happiness journals (or jars), every day you have to find something that happened to be glad about — whether profound or simple. An example of a profound entry is “Susie took her first step since the accident.” An example of a simple entry is “I really liked lunch today. The food and company were great.”
 
Tend to your body. We’ve all heard the adage “When you have your health, you have everything; when you don’t have your health, nothing else matters.” Caring for ourselves must be a priority. When you eat well, stay hydrated, and get enough sleep, you feel better. When you feel better, you have the physical and mental energy to work through daily challenges and focus on what’s good about the day.
 
Many publications address the use of exercise to improve mood and fight depression. When you exercise, your body releases chemicals called endorphins (manufactured in your brain, spinal cord, and many other parts of your body). These endorphins interact with the brain receptors to reduce your perception of adverse events, including pain. In some cases endorphins act as sedatives, promoting sleep.21 They also trigger positive feelings that are similar to that of morphine.21 For example, runners and those who work out often relate that they feel almost euphoric (known as a “runners’ high” or “exercise high”). This feeling can be accompanied by improved self-esteem and a positive and energizing outlook on life.
 
Act happy. Acting happy by assuming a positive affect can lead to happiness.22 When you act happy, even if you’re not feeling it, it puts your mind into a positive state. Some authors go so far as to say, “Just start laughing.” Laughing doesn’t just signal happiness, it produces it; our bodies can’t distinguish between real and fake laughter, and you get a health boost either way.22 When we laugh out loud, our stress hormones decrease and our endorphins rise. One author says, “You can fake it until you make it” and recommends laughing in your car or shower a few minutes every day.22 Try laughing out loud right now and see how it makes you feel.
 
Give yourself permission to be happy. The world around you may be suffering or in disarray, but you have a responsibility to tend to your own happiness — only then can you really help others. If you find the news is overwhelmingly discouraging or sad, turn off it off or change the channel. Make time to do things that make you happy in the moment, for example, going to a “feel good” movie or listening to a happy song that really gets you going. Think about using these strategies with your patients. Playing favorite music and dancing can bring joy to patients and families in many settings, from mental health to home care … even ICU and hospice. 
 
Learn to forgive and leave baggage behind. Carrying emotional baggage — wrong doings, disappointments, resentments, and past traumas — depletes your brain power. Building on the work of renowned psychologist Albert Ellis, Seligman developed the ABCDE approach to reducing negative thoughts that contribute to unhappiness.6
  • Adversity: What is the problem? Describe it.
  • Beliefs: How do you feel about the situation? Do you feel silly, embarrassed, or something else?
  • Consequences: What are you likely to do because of what happened? You might avoid similar situations or be worried you are going to encounter the same problem.
  • Disputation: Are your beliefs true? Argue with yourself as to whether your beliefs are valid and dispute those that aren’t. On further consideration, you’ll likely find that your beliefs are not correct.
  • Energy: Do you notice how when you change negative thoughts and feelings, you have more energy?
 
To overcome our natural tendency to focus on the negative, two experienced researchers recommend the CIA approach.23
  • Control: Focus on what you can control.
  • Influence. Recognize the factors that influence your beliefs and knowledge, and the beliefs and knowledge of influential people in your life.
  • Acknowledge. Acknowledge that there are people and situations over which you have little or no influence or control. In these cases, you have no responsibilities related to them and need to let go of worries and concerns.
 
Learning to forgive is very important because forgiveness gives you peace and frees you from ruminating on negative thoughts. Forgiveness doesn’t mean that the offending person wasn’t wrong; it means that you choose to let go of negative feelings that are ruling your life. As the Mayo Clinic suggests, “When someone you care about hurts you, you can hold on to anger, resentment, and thoughts of revenge — or embrace forgiveness and move forward.”24 
 
Be kind to your mind. One way to be kind to our mind is to meditate. Many authors address the physical and psychological benefits of meditation. People who learn to meditate free their minds and bodies from the stress in their lives. They become resilient and benefit from having fewer stress-related hormones.  
 
Mindfulness — living in the moment and paying attention to simple pleasures — can improve everything from depression to learning to patient care.25 A beginning step to mindfulness is to enjoy the simple pleasures in life by focusing on what we take for granted, such as sunshine after days of rain.
 
Another way of being kind to your mind is to stop being so hard on yourself. Are you ridden with guilt? Are you full of “shoulds” (“I should…”)? Give yourself a break. Everyone makes mistakes, and no one is perfect. You can’t change the past, and you have only so much time in a day. Carrying guilt and “shoulds” in your mind brings nothing but negativity. Gain perspective. Let this type of baggage go.
 
Pursue goals. Having goals gives you a sense of meaning, purpose, and direction; it keeps you interested and engaged (all of which contribute to happiness).26 Keep in mind that goals must be realistic and have intrinsic meaning (something you want to achieve, rather than something you’re doing just to please someone else).26 For example, individuals who choose a healthcare career, more because their parents want them to do it than because they personally want it, are less likely to be happy than those who value what they can accomplish as clinicians. Unrealistic goals set you up to fail. For example, many of us hope to lose weight too quickly; injuries related to aggressive exercise regimens is common. Pacing yourself toward realistic goals leads to success.
 
Choose to be happy and learn to be resilient. The Mayo Clinic Handbook for Happiness suggests applying the following four strategies for 10 weeks to develop a “habit” of happiness:27
  • Train your attention. This includes practicing gratitude exercise when awakening.
  • Cultivate emotional resilience. Build resilience through gratitude, compassion, acceptance, meaning, and forgiveness.
  • Start a mind-body practice. This includes a range of activities, such as reading, music, and meditation.
  • Pick healthy habits. For example, exercise, obtain good-quality sleep, and eat a healthy diet.
 
Live a meaningful life. Live life consistent with your values and goals. For example, if you believe people should volunteer in their communities, make time to volunteer yourself. Realize that while the ideas of living a meaningful life and being happy are related, doing one doesn’t guarantee the other. Researchers make some important points about the relationship between happiness and living a meaningful life:28 
  • Satisfying your own needs and wants may increase happiness, but it may be irrelevant to meaningfulness.
  • Meaningfulness is linked to being a giver rather than a taker.
  • Higher levels of worry, stress, and anxiety are linked to higher meaningfulness but lower happiness.  
 
The Path to Happiness
 
The path to happiness involves integrating our past (what have we learned), our present (what are we doing), and our future (where we want to go). As the poem "Moments in Life" says, “When the door of happiness closes, another opens; but sometimes we look so long at the closed door that we don’t see the one which has been opened for us…. The happiest people don’t necessarily have the best of everything; they make the most of everything that comes along their way.” Remember that everyone has a happiness “set point,” but we can all use strategies such as pursuing goals, expressing gratitude, and building positive social networks to create an environment in which happiness can flourish. Remember that happiness is a journey, not a destination, and that it takes time to develop “habits of happiness.”
 
The rewards of working to live a happy life are immense from both psychological and physiological perspectives: Happiness is linked to a high sense of well-being and improved health and longevity. Don’t let your feelings about the past or worries about the future rob you of happiness today. If you apply some of the insights and strategies discussed in this module, you can improve your own happiness and help your patients and coworkers to do the same.
 
Happiness Resources
 
To learn about how your personality influences happiness, see the continuing education program Harmonize Diversity Through Personality Sensitivity: Don’t Worry, Be Happy!, offered by OnCourse Learning.
 
EDITOR’S NOTE: Cynthia Saver, MS, RN, past author of this CE activity, has not had an opportunity to influence the content of this version.
 
OnCourseLearning guarantees this educational activity is free from bias. 



References
1. University of Pennsylvania Positive Psychology Center. Positive Psychology Center Web site. http://ppc.sas.upenn.edu. Accessed August 8, 2017.
 
2. Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health. 2013;13:119. doi: 10.1186/1471-2458-13-119.
 
3. Are we happy yet? Pew Research Center Web site. http://www.pewsocialtrends.org/2006/02/13/are-we-happy-yet. Published February 3, 2006. Accessed August 8, 2017.
 
4. Bennett PN, Weinberg MK, Bridgman T, Cummins RA. The happiness and subjective well-being of people on haemodialysis. J Renal Care. 2015;41(3):156-161. doi: 10.1111/jorc.12116.
 
5. The history of happiness. The Pursuit of Happiness Web site. http://www.pursuit-of-happiness.org/history-of-happiness. Accessed August 8, 2017.
 
6. Seligman MEP. Flourish: A Visionary New Understanding of Happiness and Well-being. New York, NY: Simon and Schuster; 2012.
 
7. Lyubomirsky S, King L, Diener E. The benefit of frequent positive affect: does happiness lead to success? Psychol Bull. 2005;131(6):803-855. doi: 10.1037/0033-2909.131.6.803.
 
8. Questionnaire Center. Authentic Happiness Web site. https://www.authentichappiness.sas.upenn.edu/testcenter. Accessed August 8, 2017.
 
9. Davidson RJ. The neural circuitry of emotion and affective style: prefrontal cortex and amygdala contributions. Soc Sci Inf. 2001;40(1):11-37. doi: 10.1177/053901801040001002.
 
10. Buckner C. 4 chemicals that activate happiness, and how to gamify them. Technology Advice Web site. http://technologyadvice.com/blog/information-technology/activate-chemicals-gamify. Published July 11, 2014. Accessed August 8, 2017.
 
11. Rosenkranz MA, Jackson DC, Dalton KM, et al. Affective style and in vivo immune response: neurobehavioral mechanisms. Proc Natl Acad Sci USA. 2003;100(19):11148-11152. doi: 10.1073/pnas.1534743100.
 
12. Cohen S, Alper CM, Doyle WJ, Treanor JJ, Turner RB. Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza A virus. Psychosom Med. 2006;68(6):809-815. doi: 10.1097/01.psy.0000245867.92364.3c.
 
13. De Neve JE. Functional polymorphism (5-HTTLPR) in the serotonin transporter gene is associated with subjective well-being: evidence from a US nationally representative sample. J Hum Genet. 2011;56(6):456-459. doi: 10.1038/jhg.2011.39.
 
14. The set-point theory of happiness. Changing Minds Web site. http://changingminds.org/explanations/emotions/happiness/setpoint_happiness.htm. Accessed August 8, 2017.
 
15. Helliwell J, Layard R, Sachs J, eds. World happiness report 2017. World Happiness Web site. http://worldhappiness.report. Published 2017. Accessed April 13, 2017.
 
16. Stone AA, Schwartz JE, Broderick JE, Deaton A. A snapshot of the age distribution of psychological well-being in the United States. Proc Natl Acad Sci USA. 2010;107(22):9985-9990. doi: 10.1073/pnas.1003744107.
 
17. Ford L. Does marriage make you happier? What a new study found. http://dailysignal.com/2015/02/12/marriage-make-happier-new-study-found/. Published February 12, 2015. Accessed August 8, 2017.
 
18. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338. doi: https://doi.org/10.1136/bmj.a2338.
 
19. Campaign to End Loneliness Organization Web site. http://www.campaigntoendloneliness.org/. Accessed August 8, 2017. 
 
20. Tsvetkova M, Macy M. The science of ‘paying it forward.’ https://www.nytimes.com/2014/03/16/opinion/sunday/the-science-of-paying-it-forward.html. Published March 14, 2014, Accessed August 8, 2017.
 
21. Exercise and depression. WebMD Web site. http://www.webmd.com/depression/guide/exercise-depression#1-2. Accessed August 8, 2017.
 
22. Dellorto D. 7 ways to boost your happiness. http://www.cnn.com/2014/09/19/health/finding-happiness/index.html?hpt=he_c1. Updated January 19, 2015. Accessed August 8, 2017.
 
23. Conyers M, Wilson D. Positively Smarter: Science and Strategies for Increasing Happiness, Achievement and Well-Being. Chichester, West Sussex, UK: Wiley Blackwell; 2015.
 
24. Forgiveness: letting go of grudges and bitterness. Mayo Clinic Web site. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/forgiveness/art-20047692. Accessed August 8, 2017.
 
25. Alfaro-LeFevre R. Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach. 6th ed. Philadelphia, PA: Elsevier; 2017.
 
26. Set your goals and make them happen. Action for Happiness Web Site. http://www.actionforhappiness.org/take-action/set-your-goals-and-make-them-happen. Accessed August 8, 2017.
 
27. Sood A. The Mayo Clinic Handbook for Happiness: A 4-Step Plan for Resilient Living. Boston, MA: Da Capo Press; 2015.
 
28. Baumeister R, Vohs J, Garbinsky E. Some key differences between a happy life and a meaningful life. J Positive Psychol. 2013;8(6):505-516. doi: 10.1080/17439760.2013.830764.