key: cord-1030624-w49xskm2
authors: Bakken, Brianne K.; Winn, Aaron N.
title: Clinician Burnout During COVID-19 Prior To Vaccine Administration
date: 2021-04-20
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.04.009
sha: fc1190de7bc64778cbda0a6609a966b0f57a7034
doc_id: 1030624
cord_uid: w49xskm2

Background COVID-19 has significantly disrupted pharmacy practice. Little research has been done to assess how COVID-19 has impacted pharmacists’ employment, workload, and feelings of burnout. Objectives The objective of this study was to characterize the impact of COVID-19 on pharmacists’ employment status, workload, feelings of burnout, and emotional health concerns related to COVID-19. Methods Wisconsin pharmacists were surveyed using an online instrument between August 25, 2020 and September 22, 2020. Data analysis was performed in December 2020, which examined employment status, three common burnout risk factors (workload, rewards, and social interactions), and emotional health concerns related to COVID-19. Results 439 of 1,300 pharmacists completed the survey (33.8%). The study analysis included pharmacists in community (N=127) and hospital/health system (N=107) settings. With regard to employment changes and workload, hospital (36%) pharmacists were more likely to have their hours reduced compared to community (13%) pharmacists (p-value <0.01) and conversely community (19%) pharmacists more likely to have their hours increased compared to hospital (8%) pharmacists (p-value=0.01). For the burnout domain of workload, 45% of pharmacists reported increased feelings of physical exhaustion at work and 53% reported increased feelings of emotional exhaustion at work, with no difference between settings. Regarding the burnout domain of rewards, 6% of hospital pharmacists and 1% of community pharmacists experienced a reduction in hourly wages or salaries as a result of COVID-19. For the burnout domain of depersonalization, 25% of pharmacists reported their ability to connect with colleagues and patients decreased during COVID-19. Additional emotional health concerns reported by pharmacists included 40% experiencing more anxiety and 25% experiencing more sadness or depression during the COVID-19 pandemic, with no difference between settings. Conclusions This study found that burnout domains related workload, rewards, and depersonalization were negatively impacted by COVID-19. Pharmacy managers need to proactively combat burnout as well as be reactive when employees show signs of burnout in order to maintain their workforce and meet the COVID-19 associated challenges.

Pharmacists are involved throughout the entire medication-use process and are a vital member of the interprofessional healthcare team. Pharmacists provide medication expertise and ensure medications are used safely and effectively across a variety of practice settings. The two most common practice settings for pharmacists include community and hospital/health system settings. 1 In community practice, pharmacists provide point-of-care testing, vaccine administration, and education to patients. In hospitals and health systems, pharmacists oversee purchasing, conduct admission medication histories, monitor inpatient medication therapies, compound and dispense medications for administration, and a variety of specialized roles.

The COVID-19 pandemic has significantly impacted the workplace, the workload, and the workforce across all employment sectors in the United States, including pharmacy. The impact of COVID-19 included both challenges and opportunities for pharmacists. The effects ran the gamut from layoffs and pay cuts to working additional hours and taking on new roles and responsibilities. On September 9, 2020, the United States Department of Health and Human Services issued guidance authorizing pharmacists to procure, dispense, and administer the COVID-19 vaccine when it becomes available. 2 During the American Society of Health-System Pharmacists Midyear Meeting in December 2020, Dr. Anthony Fauci described the critical role pharmacists would play in combating the COVID-19 pandemic, including testing and vaccine administration. 3 Dr. Fauci also warned pharmacists of the challenging months that lie ahead once the vaccine becomes available. 3 Clinician burnout has become a significant area of concern for healthcare professions in recent years, including pharmacy. The International Classification of Diseases (ICD) defines burnout as a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. 4 The Maslach Burnout Inventory (MBI) is a questionnaire commonly used to gather information related to the areas of exhaustion, depersonalization, and personal accomplishment. 5 Additional research from Maslach and colleagues identified six risk major factors for burnout, which include: (1) heavy workload, (2) lack of control, (3) lack of reward, (4) lack of community or social interaction, (5) unfair or inequitable work, and (6) value misalignment between the employee and the job. 6 Before COVID-19, several studies across a multitude of pharmacy practice settings identified burnout among pharmacists in the United States. [7] [8] [9] [10] [11] [12] [13] The 2019 National Pharmacist Workforce Study (NPWS) reported that 71% of practicing pharmacists rated their workload as "high" or "excessively high", an increase from 66% in 2014. 1 Across practice settings, the largest proportion of pharmacists reporting their workload as "high" or "excessively high" were in community settings such as chain (91%), mass merchandiser (88%), and supermarket (82%), distantly followed by hospital (64%) and ambulatory care (57%) settings. 1 During the pandemic, the workload for individuals working in healthcare increased exponentially and often without any additional rewards or incentives. More time spent at work, and the pandemic itself, limited opportunities for social interaction with family, friends, and colleagues. Maslach's burnout risk factors of heavy workload, lack of reward, and lack of social interaction were likely amplified for individuals working in healthcare.

The COVID vaccination effort will require a significant and sustained effort over several months. Given the recent reports of excessive workload and burnout in pharmacy, does the current pharmacist workforce have the energy, vigor, and bandwidth required for such a momentous effort? Will COVID-19 further diminish an already exhausted pharmacist workforce and result in higher rates of burnout?

The purpose of the Wisconsin Pharmacy Workforce Survey was to describe the demographics and workplace characteristics of pharmacists and technicians employed in Wisconsin in 2020. The survey was also designed to explore relevant issues and trends impacting the pharmacy profession, including the impact of COVID-19. The study objectives for this manuscript are to: (1) determine the impact of COVID-19 on the pharmacist workforce in community and hospital practice settings, and (2) characterize the impact of COVID-19 on the employment, burnout, and overall emotional health.

The survey was created to assess how the COVID-19 pandemic impacted: (1) pharmacy operations, (2) personal employment, (3) personal feelings of burnout and satisfaction, emotional health and other domains. For this study, we focus on questions related burnout domains and emotional health. For the reward domain, we focus on questions related to changes in personal employment. We identified survey questions from previously used surveys including the 2019 National Pharmacist Workforce Survey and where needed developed our new questions. For the workload domain, we used questions related to exhaustion that were used in the 2019 National Pharmacist Workforce Survey. Similarly, for the social interaction domain, we used questions to measure depersonalization that were used in the 2019 National Pharmacist Workforce Survey. We developed questions about a patients social and emotional health. The survey was pilot tested using a convenience sample of academic, community, and hospital pharmacists. We report on 27 questions from the survey in J o u r n a l P r e -p r o o f this study. The online survey was distributed via email using a 3-contact Dillman approach and data was collected using Qualtrics (Qualtrics, Provo, UT, USA).

The sampling frame included licensed pharmacists living in the state of Wisconsin obtained from the Wisconsin Department of Health and Professional Services (WDHPS) database of in-state pharmacy licenses, current as of July 23, 2020. The list obtained included a total of 6,651 individuals, however, only 1,300 (19.5%) provided functioning email addresses (see Appendix Figure A ). Pharmacists with email addresses available in the database received three emails containing a hyperlink to the online survey. Pharmacists were asked to click on the survey link to access the survey. Survey respondents were allowed to skip questions they did not feel comfortable answering. The three email prompts to pharmacists were distributed on the following dates: (1) August 25, 2020 (2) September 8, 2020 and (3) September 22, 2020. On October 17, 2020 the survey data files were downloaded.

The analysis focused on the two largest pharmacist populations, community and hospital/health system settings. Proportions and means were calculated for key variables. Pharmacists in community and hospital/health system settings were compared using t-tests and chi-squared tests for bivariate relationships. Likert scale responses to the question stem, "To what degree did you experience the following during the COVID-19 pandemic?" were dichotomized from a five-point scale. The combination of responses for "extremely" and "a lot" were compared to the combination of responses for "moderately", "very little", and "not at all". We chose this specification to ensure that we are focusing on large, meaningful changes to a pharmacist's experiences. For the Maslach Burnout Inventory items with the question stem, "To what degree did you experience the following before COVID-19 compared to during the COVID-19 pandemic?" pharmacists recorded their response before and after the COVID-19 pandemic. Responses to these items show whether pharmacists' burnout has increased or decreased.

Of the 1,300 pharmacists with active email addresses, a total of 439 pharmacists responded to the survey, resulting in a response rate of 33.8% (see Appendix Figure 1 for study flow). The sample used for this study included pharmacists that self-identified as working in community and hospital/health system practice settings.

The primary work-related reward is financial compensation (e.g. salaries, overtime, bonuses). 6 As seen in Table 1 , we found that community and hospital/health system pharmacists were impacted by COVID-19. Compared to community pharmacists, we found that hospital/health system pharmacists were more likely to have had their hours reduced, 13% vs 36%, p-value <0.01 and conversely community-based pharmacists more likely to have their hours increased compared to hospital/health system pharmacists (19% vs 8%, p-value=0.01). Our survey findings showed that 6% of hospital pharmacists and 1% of community pharmacists experienced a reduction in hourly wages or salaries as a result of COVID-19. Moreover, 6% of hospital pharmacists and 2% of community pharmacists experienced temporary furloughs during COVID-19.

In addition to pharmacists experiences, we also examined pharmacists concerns about their employment. We observed 23% of pharmacists were concerned about their financial well-being with no difference between community and hospital-based pharmacists, Table 2 . Moreover, we found that 26% of hospital-based pharmacists and 14% of community pharmacists were concerned about being furloughed or losing their job during the outbreak.

Overall 42% of pharmacists indicated they experienced an increase in workload or work-related responsibilities during the COVID-19 outbreak with no statistical difference between hospital and community practice settings (42% and 41%, respectively, p-value=0.77), Table 1 . As shown in Table 2 , Panel B, 45% of pharmacists reported increased feelings of physical exhaustion at work, 53% reported increased feelings of emotional exhaustion at work during COVID-19.

With regard to social interactions, roughly a quarter of pharmacists reported their ability to connect with colleagues and patients decreased during the COVID-19 pandemic. Both community and hospital pharmacists reported feeling less interested in talking with patients during COVID-19 (26% community, 22% hospital).

Impact of COVID-19 on Social/Emotional Health We found that COVID-19 negatively impacted pharmacists in the community and hospital/health care settings, Table 2 , Panel A. Most pharmacists felt confident about being able to do their job (72% for hospital/health care and 64% for community), however, roughly 40% of pharmacists reported experiencing more anxiety and about a quarter experienced more sadness or depression. Interestingly, despite seeing large differences between community and hospital/health systems on the impact of COVID-19 on pharmacists' employment status, we saw just over 40% of pharmacists in both settings had an increase in work responsibilities.

Our survey found that pharmacists have been impacted by COVID-19 in multiple dimensions. First, we found that many community pharmacists hours increased and the opposite association with hospital-based pharmacists. This is likely due to hospital systems reducing services in response to or in expectation to a surge of COVID patients. Second, for both hospital and community pharmacists, social and emotional health was negatively impacted by COVID. These factors suggest that burnout increased during COVID-19 for both community and hospital/health-system pharmacists. Our survey findings showed that the COVID-19 pandemic has increased the prevalence of increasing workload, diminished reward, and reduced social interactions, placing pharmacists at higher risk for burnout.

Burnout is primarily a job-specific phenomenon that is commonly associated with excessive workload and increasing job demands relative to the resources available. 14 Our survey found over 40% of pharmacists indicated they experienced an increase in workload or work-related responsibilities during the COVID-19 outbreak. Elevated or excessive workload without adequate recovery can result in negative physical and emotional outcomes, including exhaustion which is what we observed in our survey. We found that close to half of pharmacists reported increased feelings of physical exhaustion at work and increased feelings of emotional exhaustion at work during COVID-19. During the response to COVID-19, pharmacists were working longer hours, taking on additional responsibilities, and assuming new roles or activities, which likely contributed to feelings of physical and emotional exhaustion. Pharmacists are now expected to be leading the COVID-19 vaccination efforts. It is likely that pharmacists' workload and feelings of exhaustion will continue to increase as they continue to administer the COVID-19 vaccine.

Work-related rewards can take many forms including financial compensation (e.g. salaries, overtime, bonuses). 15 COVID-19 brought about financial concerns for many businesses and organizations, which forced administrators to make very difficult employment decisions. Our survey found that at least 1 in 5 pharmacists were concerned about their financial well-being and were concerned about being furloughed or losing their job during the outbreak. Reductions in compensation and hours, as well as temporary furloughs were more prevalent among hospitals pharmacists in our study. This was likely attributed to the preemptive canceling of elective procedures and clinic visits to proactively prepare for a surge of COVID-19 patients needing inpatient hospital beds. The anticipated surge hit the Midwest region significantly later than anticipated, resulting in low inpatient census and lost revenue for hospitals and healthsystems in the early part of the pandemic. For example, while the number of new cases per day J o u r n a l P r e -p r o o f peaked in New York on April 3, 2020 (10,842), the number of new cases per day peaked in Wisconsin on November 15, 2020 (7,045). [16] [17] Insufficient rewards and the accompanying feelings of continually having to do more with less, is among the six major risk factors for burnout. 14, [18] [19] The financial impact of COVID-19, may have caused pharmacists to be concerned about losing their jobs and their financial stability. The COVID-19 vaccination efforts will likely require further expansion of workload and responsibilities, additional hours, and reduced time off, while likely not providing any financial rewards or incentives. As pharmacists continue to be asked to do more with less, burnout will likely increase. If financial rewards are not an option, social and intrinsic rewards will be essential for recognizing the efforts of pharmacists.

With regard to social interactions, roughly a quarter of pharmacists reported their ability to connect with colleagues and patients decreased during the COVID-19 pandemic. The transition to working remotely or providing care remotely may have contributed to pharmacists feeling less connected to both colleagues and patients during the pandemic. The social isolation of working remotely and feeling less connected to colleagues during the pandemic is likely one of the factors contributing to increased burnout among practicing pharmacists.

For those that continued to work on-site during the pandemic, physical barriers (e.g. plexiglass partitions), social distancing, wearing masks that prevent recognizing facial expression, as well as the fear of contracting COVID-19 may have contributed to feeling less connected with both colleagues and patients. This is consistent with the findings from our survey as, many pharmacists reported feeling less interested in talking with patients during COVID-19, were concerned about getting infected at work during the pandemic and concerned about spreading the infection to their family or loved ones.

Efforts to reduce burnout often focus only on how the individual can combat burnout. Individual interventions often include promoting recovery in the form of adequate sleep and physical activity, incorporating mindfulness, improving coping and resiliency skills, or implementing strategies for work-life integration. 20 However, organizational structure and leadership contribute to burnout. 14,21 For example, when managers provide limited supervision, unclear expectations, limited feedback and recognition can all contribute to staff burnout. 21 Given the job-specific nature of burnout, interventions at both the individual and organizational level are necessary to curtail burnout. Beyond merely stating that well-being is a priority, administrators must also take action by creating work conditions that prevent burnout and implementing systemic structural changes that truly foster well-being. [22] [23] Pharmacy administrators should also monitor staff feelings or reports of burnout and engage staff in open dialogue about the potential causes. Similarly, pharmacy administrators should involve staff in developing workplace changes and especially when making difficult decisions (e.g. reducing compensation, furloughs). Findings from several studies of direct care providers show burnout was strongly associated with poor work control and low participation in decision making. [24] [25] Engaging pharmacy staff in decision making with openness, respect, and trust can foster staff feelings of control and fairness while reducing burnout.

This study has some limitations. First, we surveyed pharmacists in Wisconsin which limits generalizability. Second, our survey may suffer from non-response bias where the pharmacists with the highest workload would have the least amount of time to respond to a survey. Therefore, we our results would be a conservative estimate of the impact of COVID on many aspects of burnout. Forth, when analyzing responses from question stem, "To what degree did you experience the following during the COVID-19 pandemic?" we dichotomized Likert responses from a five-point scale and included "moderately" with "very little", and "not at all". This ensures that we are only focusing are very large changes and therefore our estimates are conservative and should be interpreted as being a lower bound estimate of how COVID-19 has impacted pharmacists. Fifth, this is a cross-sectional survey, and we are not able to conclusively determine that COVID-19 was the true cause of the changes we observe. Feelings of burnout may have been impacted due to other factors if COVID-19 would not have occurred. However, due to the disruption of COVID to society we find it unlikely that such trends would have occurred in absence of COVID.

Pharmacists are rising to the challenges at hand with courage and confidence in their abilities. However, the COVID-19 pandemic is and will continue to take a toll on pharmacists' physical and mental health. This research suggests that many pharmacists are experiencing increased burnout as a result of COVID-19, which will likely increase further as pharmacists begin to administer millions of doses of the COVID-19 vaccine in the months ahead. Now, more than ever, healthcare and pharmacy organizations need to take action and combat burnout in order to ensure a robust pharmacy workforce continues to be available. J o u r n a l P r e -p r o o f Note: Likert scale variables were dichotomized from a five-point scale. We grouped "extremely" and "a lot" versus moderately", "very little", and "not at all". Statistically significant P-values are identified with an asterisk*

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