Hospital and community pharmacists are experiencing unprecedented stress as a result of the COVID-19 pandemic. The sources of the stress are many, starting with the sheer volume of patients needing hospital care. In addition to managing medication orders, pharmacists have been called on to collaborate in developing the medication section of treatment protocols in a time where sufficient data for making the best decisions are lacking.
Pharmacists’ roles are expanding to administering COVID-19 vaccines, even as they try to keep up with the demand for information from anxious patients who have COVID-19 or tested positive for the virus. Some pharmacists are interacting with patients via digital patient platforms, creating new challenges for effective communication and patient management. And, unfortunately, pharmacists are also facing the loss of colleagues in multiple disciplines to COVID-19.
All of this is happening in an environment where pharmacists were already facing heavy workloads and other challenges. It’s no wonder that the danger for burnout is at a new high. Pharmacists need to understand what burnout is, recognize its dangers, and take action to prevent it. Prevention will help pharmacists avoid personal distress caused by burnout and litigation based on burnout-related errors.
Burnout defined
The 11th Revision of the International Classification of Diseases (ICD-11) defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” The definition says the syndrome is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy. It’s an occupational phenomenon, not a medical condition.
This definition aligns with the three dimensions in social psychologist Christina Maslach’s model of burnout: emotional exhaustion (feelings of being emotionally overextended and exhausted by one’s work); depersonalization (an unfeeling and impersonal response toward patients); and diminished personal accomplishment (lacking feelings of competence and successful achievement in one’s work). The Maslach Burnout Inventory Human Services Survey (MBI-HSS) comprises three scales that measure each dimension and can be used to assess burnout, which occurs gradually in response to work environment stressors and can cause significant harm.
Dangers of burnout
Burnout can lead to job dissatisfaction, reduced commitment, and distraction, all of which can result in errors that harm patients, including medications errors and errors that result for inadequate patient education. This harm can lead to lawsuits against the pharmacist. At an organizational level, burnout among staff can result in increased absences and high turnover, creating “churn” that is expensive in terms of orientation costs, loss of efficiency, and legal fees when an error results in a lawsuit. When burnout is not addressed, the personal toll on pharmacists can be serious, including depression, anxiety, sleep disorders, and substance use disorders.
A common problem
Burnout is common among pharmacists. A 2017 survey by Jones and colleagues found that 61.2% of pharmacists experienced burnout, primarily driven by high emotional exhaustion as measured by the MBI-HSS. A 2018 study by Durham and colleagues noted that 53.2% of health-system pharmacists reported scores indicating a high degree of burnout on at least one subscale of the MBI-HSS.
Burnout isn’t limited by practice setting. For example, a 2020 study by Ball and colleagues found that 64% of critical care pharmacists surveyed had at least one area of burnout on the MBI-HSS, while a 2020 study by Mathew and colleagues reported that 74.9% of community pharmacists experienced burnout in at least one of the three subscales of the MBI-HSS. A 2020 systematic review of burnout in pharmacists found that although prevalence is lower than previously reported, it’s still notable.
Causes of burnout
Stressors leading to burnout can be divided into two categories: personal and workplace. Personal stressors include a person’s health, family dynamics, financial hardship, and life/work imbalance. Workplace stressors include heavy workload, lack of autonomy, negative coworker relationships, cumbersome documentation requirements, patients who are unhappy or even disruptive, and technology (for example, excessive alerts in the electronic health record and systems that are cumbersome for users).
Padgett and Grantner summarized the contributing factors for burnout in healthcare workers as challenges of the work, competing demands, time constraints, performance metrics, lack of control, conflict with leaders, and technology limitations. Time constraints and performance metrics are especially key factors for pharmacists.
The Jones survey reported the following factors as predictors of burnout: inadequate administrative and teaching time, uncertainty of health care reform, too many nonclinical duties, difficult pharmacist colleagues, and feeling that contributions are underappreciated. Both hospital and community pharmacists who weren’t in a stable relationship, didn’t have children, and worked more than 40 hours a week were more likely to report burnout.
Maslach and Leiter have noted that imbalances in workload, control, reward, community, fairness, or values can cause burnout:
- Workload is particularly relevant for pharmacists, as they often are practicing under unrealistic productivity requirements.
- Control refers to the ability to influence work-related decisions, to engage in professional autonomy, and to have access to needed resources.
- Insufficient reward (both material rewards such as salary and intrinsic rewards such job satisfaction) can contribute to burnout. For example, pharmacists may feel undervalued by their managers and by the organization in general.
- An unsatisfying community, which is marked by relationships with coworkers that are characterized by a lack of support and trust, as well as unresolved conflict, can lead to burnout.
- A perceived lack of fairness in decision-making can spark distress, especially if people feel they are not being treated with respect.
- Finally, values relate to the ideals and motivations that attracted people to their job; a conflict in values, for example being pressured to “cut corners” to speed medication delivery, will create distress.
Preventing burnout
Several resources exist to help prevent burnout. For example, a goal of the National Academy of Medicine Action Collaborative on Clinician Well-being and Resilience (
https://nam.edu/initiatives/clinician-resilience-and-well-being) is to address burnout. Additionally, the American Pharmacists Association (APhA) has created a webpage dedicated to promoting Well-Being & Resiliency (
https://pharmacist.com/wellbeing). It provides multiple resources for enhancing well-being and resilience, including an online self-assessment tools, articles and webinars, networking opportunities, and more.
You might begin your burnout prevention journey by conducting a self-assessment. Consider the risk factors in your personal and professional lives and assess the effectiveness of your coping skills. An additional option is to complete the Pharmacist Well-Being Index (
www.mywellbeingindex.org/versions/pharmacist-well-being-index), an interactive, online, validated tool. You can obtain your index in only a minute (
https://app.mywellbeingindex.org/assess) and compare your scores to peers and national averages. You’ll also gain access to custom resources and can track your progress over time.
Resiliency is a useful tool for preventing burnout. It has been referred to as the ability to “bounce back” from adverse experiences, but it’s more nuanced than that. Stephens defines resiliency as an individual’s use of coping skills to navigate stressful situations or perceived adverse events to reach a higher level of well-being. These coping skills also can enhance a person’s ability to handle future adversity. Because inadequate sleep can contribute to burnout, you may want to assess your sleep with the Epworth Sleepiness Scale (
http://epworthsleepinessscale.com/about-the-ess/).
Armed with the results of your assessment, you can implement the following strategies to prevent burnout:
- Speak up. If others, particularly managers, don’t know how you feel, nothing will change. For example, if documentation demands seem unreasonable, provide suggestions such as templates, which can save time, or recommend modifications to the electronic health record system to reduce the number of unnecessary flags. Documenting throughout your shift (instead of waiting until the end) can save time and improve the quality of your documentation, which will help you mount an effective defense in the event of legal action because of an error caused by burnout.
- Have realistic expectations. You can only do the best you can under your given circumstances. Given the demands of the pandemic, you simply may not be able to spend the time you want to explain medications to patients because of your workload. This doesn’t mean delivering substandard care, of course, but it does mean that nonessential elements, such as that bit of time socializing to better forge the pharmacist-patient relationship, might not be possible.
- Engage in physical self-care. For example, exercise regularly, eat a healthy diet, and get enough sleep. Yoga may be helpful in reducing stress. Follow the standard COVID-19 recommendations: Wear a mask, social distance, and wash your hands frequently.
- Engage in psychological self-care. Practice activities you find fun or restful such as reading, listening to music, or walking. Consider engaging in meditation and mindfulness or using deep breathing exercises. Keeping a journal or pursuing creative outlets (for example, painting, writing poetry) also may be helpful. Connect with friends and family on a regular basis, while adhering to social distancing requirements.
- Practice reframing. It can be challenging but try to focus on the positive and view challenges from a new perspective. For example, you may find managers and colleagues are more open to a new idea you had unsuccessfully proposed in the past because the current environment requires innovation.
- Choose your employer wisely. Don’t simply look at salary and benefits. Evaluate how the organization treats its employees. A simple method is to review the website to see how much employees are highlighted. Ask potential employers whether they have programs to support employee health.
Managing burnout
Burnout can occur despite prevention efforts, but early recognition facilitates effective management. The most common symptom is excessive fatigue, but pharmacists may experience a variety of negative effects (see Are you experiencing burnout?).
Pharmacists who experience burnout may want to take time to reaffirm their sense of purpose—why they chose the field—and consider the positive effects they are having on others, including patients and colleagues. It’s also important to explore opportunities to modify the work setting, such as reducing overtime and increasing autonomy. A frank discussion with management can result in modifications that reduce stress and, in turn, burnout. In some cases, it may be necessary to change jobs, but another option is to shift into another practice area or specialty (for example, from a retail chain pharmacy to a long-term-care facility) to rejuvenate your enthusiasm for your career. Other action steps include delegating whenever appropriate to do so, setting limits (such as not engaging in nonproductive conversations or taking on extra tasks), prioritizing, trying to avoid dwelling on work when not on the job, and bolstering self-care activities. See
Care during COVID-19 for more self-care ideas.
Talking with someone you trust can help, but also be open to seeking professional assistance. A therapist can help you sort out your emotions and make decisions as to next steps regarding the work environment. Keep in mind that the most important step you can take is to care for yourself.
Time to act
The stress that pharmacists face is likely to continue now and into the post-pandemic world. Fortunately, implementation of preventive strategies and early recognition and management of burnout can help address this common problem and protect pharmacists from personal and legal harm.
Are you experiencing burnout?
Common symptoms of burnout include:
- Psychological symptoms
- Anger
- Anxiety
- Dreading going to work
- Fear
- Feeling detached or cynical
- Feeling overwhelmed
- Frustration
- Hopelessness
- Inability to feel happy
- Irritability
- Lack of empathy
- Physical symptoms
- Fatigue/exhaustion (most common)
- Gastrointestinal problems
- Headache
- Muscle tension
- Sleep disorders such as insomnia
Sources: Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative Statement: Burnout syndrome in critical care health care professionals: a call for action. Am J Crit Care. 2016;25(4):368-376; Burnout. Psychology Today. www.psychologytoday.com/us/basics/burnout.
Care during COVID-19
The National Academy of Medicine suggests the following strategies to support the well-being of pharmacists and other clinicians during the COVID-19 pandemic:
- Meet basic needs: Eat, drink, sleep, and exercise regularly.
- Take breaks: Taking appropriate rest leads to proper care of patients after your break.
- Stay connected: Give and receive support from your colleagues to avoid isolation, fear, and anxiety. Partner with colleagues to support each other and monitor each other’s stress, workload, and safety. Communicate with colleagues clearly and optimistically. Contact family and loved ones for support.
- Respect differences: Recognize and respect differences in yourself, your patients, and your colleagues, such as needing to talk versus needing to be alone.
- Stay updated: Rely on trusted sources of information and participate in meetings where relevant information is provided. However, avoid watching or listening to news reports 24/7. Graphic imagery and worrisome messages can increase your stress and may reduce your effectiveness and overall well-being.
- Perform self-check-ins: Monitor yourself over time for any symptoms of depression or stress, such as prolonged sadness, difficulty sleeping, intrusive memories, and/or hopelessness. Talk to a peer or supervisor, advise management so that they can provide support interventions, or seek professional help.
- Honor your service: Remind yourself and others of the important and noble work you are doing. Recognize colleagues for their service.
Source: National Academy of Medicine. Resources to support the health and well-being of clinicians during the COVID-19 outbreak.
https://nam.edu/initiatives/clinician-resilience-and-well-being/clinician-well-being-resources-during-covid-19.
RESOURCES
American Pharmacists Association. Well Being Resources. Webpage.
https://pharmacist.com/Advocacy/Well-Being-and-Resiliency/Well-Being-Resources.
Burnout. Psychology Today.
www.psychologytoday.com/us/basics/burnout.
Dyrbye LN, Shanafelt TD, Sinsky CA. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine. 2017.
https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care.
Hagemann TM, Reed BN, Bradley BA. Burnout among clinical pharmacists: causes, interventions, and a call to action. J Am Coll Clin Pharm. 2020;3:832-842.
Jones GM, Roe NA, Louden L, Tubbs CR. Factors associated with burnout among US hospital clinical pharmacy practitioners: Results of a nationwide pilot survey. Hosp Pharm. 2017;52(11):742-751.
Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-111.
McQuade BM, Reed BN, DiDomenico RJ, et al. Feeling the burn? A systematic review of burnout in pharmacists. J Am Coll Clin Pharm. 2020;3:663-675.
Mind Garden. MBI: Human Services Survey for Medical Personnel.
www.mindgarden.com/315-mbi-human-services-survey-medical-personnel.
Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative Statement: burnout syndrome in critical care health care professionals: a call for action. Am J Crit Care. 2016;25(4):368-376.
National Academy of Medicine. Resources to support the health and well-being of clinicians during the COVID-19 outbreak.
https://nam.edu/initiatives/clinician-resilience-and-well-being/clinician-well-being-resources-during-covid-19.
Padgett EH, Grantner GR. Pharmacist burnout and stress. U.S. Pharm. 2020;45(5):HSE-HS-10.
Pagnin D, de Queiroz V, Carvalho Y, Dutra A, Amaral M, Queiroz T. The relation between burnout and sleep disorders in medical students. Acad Psychiatry. 2014;38(4):438-44.
Patel SK, Kelm MJ, Bush PW, Lee H-J, Ball AM. Prevalence and risk factors of burnout in community pharmacists. J Am Pharm Assoc. 2020;S1544-3191(20):30483-0.
Raypool C. Burnout recovery: 11 strategies to help you reset. Healthline. 2020.
www.healthline.com/health/mental-health/burnout-recovery.
Stephens TM. Building personal resilience. Am Nurs Today. 2019;14(8):10-15.
World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019.
www.who.int/mental_health/evidence/burn-out/en.