key: cord-0969191-rdk9cz51
authors: Jones, Adam M; Clark, John S; Mohammad, Rima A
title: Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic
date: 2021-02-13
journal: Am J Health Syst Pharm
DOI: 10.1093/ajhp/zxab051
sha: d3e6ca745bf0def908ed950eeaccf4d4799b97c2
doc_id: 969191
cord_uid: rdk9cz51

PURPOSE: To describe the prevalence of burnout and secondary traumatic stress (STS) in health-system pharmacists during the coronavirus disease 2019 (COVID-19) pandemic. Methods. A cross-sectional, professional pharmacy organization listserver–based online survey of a target group of health-system pharmacists across the United States was conducted. The survey was sent out through professional organization listservers and was anonymous and voluntary. The survey questionnaire included items regarding demographics and employment characteristics, COVID-19–related questions, a survey of respondents’ perceptions of the prevalence and severity of burnout, and the Professional Quality of Life Scale (ProQOL). The ProQOL assessed respondents for compassion satisfaction (subcategorized as burnout and STS) and compassion fatigue. Descriptive statistics was used to assess the prevalence of burnout and STS. RESULTS: Four hundred eighty-four health-system pharmacists completed the survey. Based on respondents’ self-ratings of burnout, 47% were identified as having current burnout and 81% as having a history of burnout. Based on ProQOL scoring, 65.3% of respondents were identified as having a moderate or high likelihood of burnout, which was a prevalence higher than that indicated by respondents’ self-ratings. Additionally, 51.4% of respondents were identified as having a moderate or high probability of STS and 99.4% as having a moderate or high probability of compassion satisfaction. CONCLUSION: The survey found that over half of health-system pharmacists were affected with burnout, half with STS, and three-fourths with compassion satisfaction during the COVID-19 pandemic. Unfortunately, the development of burnout and STS in these health-system pharmacists may lead to several work-related consequences (eg, increase risk of medical errors, depression); therefore, addressing burnout and STS is crucial. Further studies of the consequences of burnout and STS during the COVID-19 pandemic are needed.

described as compassion fatigue, STS, and vicarious traumatization. Job-related burnout has been described as work-related stress whereby a person has physical or emotional exhaustion with a feeling of decreased accomplishment and personal identity. This can reflect negative feelings associated with the person's work and may be associated with very high workload or lack of support in the work environment. STS has been described as stress due to indirect exposure to extreme or traumatic stressful events as a result of one's work.

Those with STS may develop fear, difficulty sleeping, upsetting images, and a need to avoid things that are associated with or remind them of the event. Burnout and STS lead to compassion fatigue. Compassion satisfaction, which has been described as having professional satisfaction in one's position, can also be present. A person who has both compassion fatigue and compassion satisfaction may have a better chance of overcoming compassion fatigue due to increased job satisfaction. 3 A c c e p t e d M a n u s c r i p t Prior to the COVID-19 pandemic, burnout rates among healthcare professionals were reported to be higher than in the general working population. 2 Additionally, studies indicated that burnout rates for pharmacists were over 50% and largely driven by emotional exhaustion. [4] [5] [6] [7] Recently, there have been several studies that have shown an overwhelming psychological impact on frontline healthcare professionals during the COVID-19 pandemic.

Two studies reported a high prevalence of psychological burden in non-critical care healthcare professionals in other countries. 8, 9 Another study confirmed these findings and also showed high rates of psychological burden among physicians, especially younger, frontline, and less experienced physicians; factors associated with the highest prevalence of mental burden included heavy COVID-19 caseloads, increased hours worked, and limitations in logistic support. 10 A recent systematic review (13 studies; total n = 33,062) showed rates of anxiety and depression in healthcare professionals of 23.2% and 22.8%, respectively. 11 Based on these studies, it can be inferred that the COVID-19 pandemic has put significant pressure and stress on healthcare professionals.

Unfortunately, compassion fatigue, including burnout and STS, can lead to medical errors, impact standards of patient care and relationships with coworkers, and lead to physical and mental health conditions. 3 Therefore, it is crucial to evaluate the extent of compassion fatigue in healthcare professionals, including health-system pharmacists. To our knowledge, there are no published studies specifically focused on the prevalence of burnout and STS and perceptions related to burnout among health-system pharmacists in the setting of the COVID-19 pandemic. The study described here evaluated the prevalence of burnout and STS in health-system pharmacists during the pandemic.

A c c e p t e d M a n u s c r i p t Methods Study design. A cross-sectional, professional pharmacy organization listserver-based online survey of a target group of health-system pharmacists across the United States was conducted. Our local institutional review board approved the study prior to initiation. The primary objective of the study was to describe the prevalence of burnout and STS in healthsystem pharmacists during the COVID-19 pandemic. The survey was sent out through American Society of Health-System Pharmacists (ASHP) listservers to 5 ASHP Communities that include health-system pharmacists: the COVID-19 Community (n = 53,000), Clinician

Well-Being and Resilience Community (n = 391), New Practitioners Community (n = 7,500), Inpatient Practitioners Community (n = 20,800), and Pharmacy Practice Leaders Community (n = 14,500). The survey was completed anonymously and on a voluntary basis. A response rate calculation was not performed, since the targeted communities included non-healthsystem pharmacists and the collected data therefore did not represent health-system pharmacists only. Pharmacists who indicated that they practice in a US health system were included in the study. Incomplete survey responses were excluded from the study. The single-item burnout measure was used to assess respondents' self-rating of burnout. 12 The ProQOL was used to measure the negative and positive effects of helping others who experience suffering and trauma. 13, 14 Through assessment with of this tool, which has been used to assess both compassion satisfaction and fatigue in healthcare professionals in extremely stress events, compassion fatigue is subcategorized as consisting of burnout and STS. The ProQOL includes 30 validated, reliable, and standardized questions that provide statements (eg, "My work makes me feel satisfied," "I feel worn out because of my work as a *helper+") for which responses are provided on a Likert scale with scores ranging from 1 (never) to 5 (very often). The survey asks respondents to consider each statement about themselves or their current work situation and reflect on how frequently they have experienced the effect of interest in the last 30 days. An individual score is provided for each statement, with item scoring based on the ProQOL categories: compassion satisfaction, A c c e p t e d M a n u s c r i p t burnout, and STS. Prior to calculating the overall score based on ProQOL category, the scores of the 5 items related to positive experiences were reversed (ie, if 1 was selected, the score was changed to 5). Scores for the 10 ProQOL items related to compassion satisfaction were summed to provide a compassion satisfaction score. For the burnout score, scores for the 10 ProQOL items related to burnout were added up. Scores for the 10 ProQOL items related to STS were summed to provide an STS score. In accordance with the ProQOL scoring method for the 3 ProQOL categories, a calculated score of 22 or less indicated a low likelihood of compassion satisfaction, burnout, or STS; a score between 23 and 41 indicated a moderate likelihood, and a score of 42 or more indicated a high likelihood. For example, a respondent's burnout score of 15 indicated a low likelihood of burnout in that respondent.

In general, the higher the score for compassion satisfaction, the higher the likelihood of greater compassion satisfaction. The higher the score for burnout or STS, the higher the likelihood of burnout or STS to occur. Inversely, the lower the score for compassion satisfaction, the lower the likelihood of compassion satisfaction; the lower the score for burnout or STS, the lower the likelihood of burnout or STS to occur.

The primary outcome of the study was the prevalence of burnout and STS in healthsystem pharmacists during the COVID-19 pandemic. Descriptive statistics was used to describe respondents' characteristics, ProQOL scores and categories, burnout characteristics, and COVID-19-related factors. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 27 (IBM Corporation, Armonk, NY).

A c c e p t e d M a n u s c r i p t

Of the 625 health-system pharmacists who started the survey, 484 completed it. Survey respondents had an average age of 42 years, and most were female (71.5%), Caucasian (86.4%), married (69.6%), and/or had children (59.1%). The majority of survey respondents stated they had a hobby (70.7%), exercised regularly (61.2%), regularly got 7 to 9 hours of sleep per day (60.7%), and/or had no student loans (63.0%). Almost half of survey respondents practiced in a state in the top 10 for COVID-19 cases, and three-fourths worked in an inpatient hospital setting. Table 1 summarizes the demographic, employment, and other characteristics of respondents.

As for the impact of the COVID-19 pandemic on employment status and other, related factors (see Table 2 ), 46.7% of respondents stated that their work hours had increased. Few respondents indicated that they had lost their job or had been furloughed (<6%) or had a reduction in salary or benefits (16.1%). Unfortunately, almost 34% of respondents stated that they had lost childcare due to the COVID-19 pandemic, which may have impacted their ability to work.

Forty-seven percent of respondents reported that they currently had burnout (based on the PWLS self-ratings), and 81% reported a history of burnout. Of the respondents who reported burnout, almost half indicated that they were definitely burned out and had symptoms of burnout and that burnout was related to the pandemic. As for duration of burnout when experienced (currently or in the past), most respondents (81.3%) reported burnout lasting for up to 12 months. Additionally, the mean respondent-estimated prevalence of burnout among pharmacists in their institutions was 43%, which was similar to the self-reported rate of current burnout (47%). The top 4 main drivers of pharmacist burnout cited by respondents were factors related to (1) workload, (2) efficiency and A c c e p t e d M a n u s c r i p t resources, (3) culture, and (4) work-life integration. Table 3 summarizes respondents' selfratings, perceptions, and descriptions of burnout.

Based on the ProQOL scoring methodology, almost all respondents (99.4%) were identified as having a moderate or high likelihood of compassion satisfaction (Table 4) .

However, most respondents (65.3%) were identified to have a moderate or high likelihood of burnout, and about half (51.4%)were identified to have a moderate or high likelihood of STS. The mean (SD) score for compassion satisfaction was 37.8 (5.5); for burnout, 25.3 (6.0); and for STS, 23.2 (6.0)-all within the moderate-likelihood range (a score of 23-41).

Several studies have shown that pharmacists are burned out even aside from the COVID-19 pandemic. [4] [5] [6] [7] A recent study showed that critical care pharmacists have a 64% risk of burnout, which is comparable to the risk among other healthcare professionals practicing in the critical care setting. 15 Another recent study showed that 70% of pharmacy staff had experienced moderate to high levels of burnout, with moderate levels of personal accomplishment and emotional exhaustion, but low levels of depersonalization. 16 Additionally, healthcare professionals who are exposed to traumatic and stressful events, such as the COVID-19 pandemic, can develop burnout stress disorders and, potentially, posttraumatic stress disorder. 17 This phenomenon has been described in several recent studies of nurses, physicians, and other healthcare professionals throughout the world. [18] [19] [20] [21] [22] [23] In a recent study by Ruiz-Fernandez et al, 24 the ProQOL was used to assess compassion fatigue, burnout, and compassion satisfaction in 506 nurses and physicians who were working in healthcare centers during the COVID-19 pandemic. Results showed that relative to physicians, nurses tended to have higher compassion satisfaction scores (84.4% had A c c e p t e d M a n u s c r i p t scores in the moderate or high range); however, physicians tended to have higher scores for compassion fatigue (94.1% had scores in the moderate or high range) and burnout (84% had scores in the moderate or high range). Both nurses and physicians had similar STS scores.

Our study showed that health-system pharmacists have rates of burnout and STS similar rates reported in recent studies. Forty-seven percent of pharmacists reported selfperceived burnout, and 51% reported that burnout was related to the COVID-19 pandemic.

However, ProQOL scores indicated a higher prevalence of pharmacist burnout, with scores showing that 65.3% had a moderate or high likelihood of burnout. Unfortunately, 81% of these pharmacists reported a history of burnout, with most reporting that burnout episodes lasted up to 12 months. In addition to burnout, 51.4% of surveyed pharmacists had a moderate or high likelihood of STS, which is a concern. Inversely, almost all pharmacists Overall, our study was unique compared to previous studies in health-system pharmacists, since we identified burnout, STS, and compassion satisfaction in the setting of the COVID-19 pandemic. Additionally, we reported results suggesting an overall prevalence of burnout and/or STS in health-system pharmacist of over 50%. The development of burnout and STS may lead to work-related consequences such as decreased productivity, decreased quality of patient care and patient satisfaction, increased employee turnover, and, more concerning, increased risks of medical errors, substance abuse, depression and suicide, and disrupted relationships. 3 Therefore, it is crucial to address burnout and STS among health-system pharmacists.

In a survey conducted during the early weeks of the COVID-19 pandemic, almost half of health-system pharmacists were experiencing burnout, as reflected by the high percentage of pharmacists identified as having a moderate or high likelihood of burnout based on ProQOL scoring. Additionally, a large proportion of health-system pharmacists had a moderate or high likelihood of STS, but the level of compassion satisfaction was also high.

These results showed that health-system pharmacists still had high compassion satisfaction in the setting of burnout and STS potentially due to the COVID-19 pandemic. Further studies are critical to better understanding the long-term effects of the COVID-19 pandemic on the well-being of health-system pharmacists.

The authors have declared no potential conflicts of interest. M a n u s c r i p t M a n u s c r i p t 

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