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Professional Affairs
Pharmacist Burnout: A Decline in the Health of Healthcare Professionals

by Jen Phillips, PharmD, BCPS, FCCP, FASHP Associate Professor, Pharmacy Practice, Midwestern University Chicago College of Pharmacy and Jane Lee, PharmD Candidate, Midwestern University, Chicago College of Pharmacy

The Issue

The term “burnout” describes the characteristics of chronic, unrelieved stress that can result in running out of the sustenance necessary to continue functioning at a healthy capacity. Common signs involve emotional exhaustion, amplified depersonalization, and feelings of inadequacy in the workplace.^1,2 Perhaps the most surprising of these three for a healthcare professional, is depersonalization, which involves viewing people as objects rather than human beings.² Exhaustion and inefficacy may be reversible with appropriate rest and refocus, but depersonalization can result in a permanent psychological shift in the way healthcare providers think about their profession. A 2014 study analyzing the prevalence of burnout among practicing physicians (N=35,922) found that more than half (54.4%) exhibited at least one symptom of burnout.² Moreover, these results represented a 10% increase in burnout compared to a similar study performed 3 years earlier in 2011.¹

The Data

The consequences of clinician burnout include detrimental effects on quality, safety, patient satisfaction, and healthcare costs. Specifically, stress levels, burnout, and emotional exhaustion among physicians and nurses has been correlated with increased number of malpractice lawsuits,³ health-care associated infections,⁴ and mortality.⁵ From a patient perspective, depersonalization has been shown to affect patient satisfaction,^6,7,8,9 and patient adherence to medical advice.¹⁰ These consequences substantiate a need for increased awareness of burnout and systematic changes to prevent it from occurring in all healthcare practitioners and trainees.

Most of the published research describing the prevalence of stress, depression, and other detrimental effects of burnout has involved the medical and nursing disciplines. Medical residents and students, in particular, have been found to have worse outcomes than age-similar individuals in different careers.¹¹ Limited data exists for other members of the health care team, but there seems a high likelihood that these results can be extrapolated to other members of the healthcare team, including pharmacists.

One cross-sectional study evaluated the effects of job demands and interpersonal interactions of 566 hospital pharmacists on work-related outcomes, such as organizational and professional commitment, job satisfaction, burnout, and professional identify.¹² The researchers based their objective on the job demands-resources model (JD-R). The JD-R model assumes that pharmacist burnout occurs through exhaustion and job disengagement from lack of resources.¹² The researchers found a correlation between poor work environments (defined as high-demand/unpleasant interactions) and the frequency (r 2 =0.08, p<0.01) and intensity (r2 =0.07, p<0.01) of emotional exhaustion.¹² In addition, there was also a correlation between positive work environments (defined as low-demand/pleasant encounters) and the frequency (r2 =0.11, p<0.001) and intensity (r2 =0.05, p<0.001) of feeling personal accomplishment.¹² The results of this study support the JD-R model and provided an alternative method of looking at the quality of pharmacy practice work environments.

The impact of stress and burnout among trainees has also been evaluated. One study investigated stress levels in pharmacy residents.¹³ This cross-sectional study assessed stress reported by PGY-1 and PGY-2 residents through survey questionnaires sent to program directors from 2011 to 2012.¹³ To measure stress and negative affect levels, the 10-item Perceived Stress Scale (PSS10) and the Multiple Affect Adjective Checklist-Revised (MAACL-R) were utilized. Both are validated or widely used psychological tools. Age and program year did not result in significantly different PSS10 scores.¹³ However, MAACL-R scores for hostility were higher for PGY2 residents compared to PGY1 residents (50.83 vs. 48.62, respectively, p=0.017).¹³ Working more than 60 hours per week correlated with higher stress levels on the PSS10 (r=0.143, p=0.001) and higher scores on the MAACL-R hostility subscale (r=0.0088, p<0.05), depression subscale (r=0.118, p<0.05), and dysphoria subscale (r=0.119, p<0.05) for the entire sample¹³ This is important to note, as the data suggests that even with the American Society of Health-System Pharmacists’ (ASHP) current residency duty hour limitation set at a maximum of 80 hours per week, residents may still be experiencing inappropriate amounts of stress.

Strategies to Address the Issue

As a response to the data that continues to emerge on the consequences of healthcare worker burnout, many organizations have begun studying the issues further. The National Academy of Medicine (NAM) issued an Action Collaborative on Clinical Well-Being and Resilience in 2017.¹⁴ The collaborative consists of over 50 sponsoring organizations that have committed to addressing the issue of clinician burnout. The NAM document separates factors affecting healthcare professional well-being into individual and external categories.¹⁴ Sub-factors such as the healthcare role, relationships and social support, learned skills and abilities, and personal elements, are grouped into the individual category.¹⁴ The external category is composed of the work environment, regulatory environment, organizational elements, and society itself.¹⁴ Some factors – such as organizational element, learned skills and abilities, and relationships/social support - may require less time and resources for improvement. All of these elements have communication-based cores. Improving communication can assist with these three factors. Other factors, including the work or regulatory environment, may take more time and resources to change.

In an article published by the Annals of Family Medicine, the authors present reasons to expand the “Triple Aim” to the “Quadruple Aim”.¹⁵ The Triple Aim was a framework developed by the Institute for Healthcare Improvement (IHI), as an initiative to “enhance patient experience, improve population health, and reduce costs”.¹⁵ Improving the lives of “health care providers, including clinicians and staff” was the goal of the fourth addendum.¹⁵ Even though the data presented supporting this addendum was on nurse and physician burnout, the authors summarized that “those who deliver care” are the focus of the fourth aim.

To respond to the issue of clinician burnout, pharmacy and other healthcare organizations have begun developing and implementing policies advocating clinician well-being and resilience in the workplace. The American Medical Association (AMA) recognizes burnout in students, residents, and physicians, and has policies in place supporting collaboration with other groups to maintain continued awareness of this topic. They also encourage research, monitoring of the issue, and mindfulness education. For nurses, the American Nursing Association (ANA) has a separate policy regarding fatigue, safety, and health, to be upheld by both nurses and employers. The American Pharmacists Association (APhA) encourages employers to provide tools for stress and conflict management. Regarding working conditions on public safety, APhA opposes having a quota for prescriptions that need to be dispensed during a certain time period. ASHP has policies addressing several topics related to clinician burnout, including: workplace violence, intimidating or disruptive behaviors, support for second victims, and the relationship between staff fatigue and medication errors. In addition, ASHP is one of the sponsors of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience and is actively working toward developing policies and strategies to address the issue of clinician burnout.

Conclusion

The issue of healthcare professional burnout must be addressed for the sake of the patients, who deserve safe, high-quality care and for the health and well-being of the healthcare workers. Strategies to improve resilience must be developed and shared with all healthcare professionals.

Many healthcare employers offer physical and mental well-being programs at their workplace, however, few offer programs specifically address issues such as burnout. As more research becomes available, institutions should use this data to expand the support and outreach programs available to employees. Managers should ensure that their healthcare workers are aware of the resources that are available to them. In addition, those who are involved in the training of pharmacy students, residents, or fellows should be aware of the potentially deleterious effects of stress on performance and well-being and should refer them to appropriate resources at the college/institution to assist them.

Pharmacists and technicians who are ASHP members may be interested in joining the Clinician Well Being and Resilience community on ASHP connect to join the conversation on this issue and potentially share tips, advice, resources, and support. Finally, academicians and clinicians involved in research can assist by conducting more research in this area so that we can understand the issue more thoroughly and devise evidence-based solutions to help curb this epidemic.

The issue of healthcare professional burnout is an important one that deserves attention and action. Improving visibility of this issue at the organizational, state, and local levels is the first step in addressing this problem.

References:

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14) National Academy of Sciences. National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience. Available at: https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed 2018 Feb 22.

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