Student Pharmacist Perspectives on Factors That Influence Wellbeing During Pharmacy School

INTRODUCTION

A growing body of literature suggests that health care graduate students, including pharmacy, medical, and dental students, experience psychological distress, including anxiety, depression, or perceived stress, at significantly higher rates than their age-matched peers.^1-3 Burnout, a workplace syndrome characterized by exhaustion, reduced empathy, and diminished sense of accomplishment, may develop concurrently with anxiety and depression.⁴ Burnout in students is associated with increased anxiety, depression, suicidal ideation, substance use, thoughts of dropping out of school, and poorer school performance.^5,6 In contrast, positive wellbeing is associated with improved mental health outcomes, academic self-efficacy, and better academic performance.^7-11

Studies investigating student pharmacist wellbeing have largely explored the impact of grit, resilience, self-esteem, self-awareness, and mindfulness.^12-16 Although individual factors likely play a role in student pharmacist wellbeing, systems factors may be the primary drivers of wellbeing, as has been suggested for the pharmacy workplace and in other fields.^5,17-21 Moreover, health care leaders, including the National Academy of Medicine (NAM), now widely recognize that both intrinsic personal and extrinsic systems factors serve as important influencers of health care student and provider wellbeing.²² The NAM encourages institutions to explore both individual and systems drivers of wellbeing to optimize health care student and professional wellness.²²

In 2017-2018, the American Association of Colleges of Pharmacy (AACP) Student Affairs Standing Committee met to explore factors that contribute to student pharmacist wellbeing and identify strategies that promote positive wellbeing.²³ In its AACP report, the Committee recognized the importance of identifying the intrinsic and extrinsic influencers of wellbeing and recommended a “multipronged approach… that includes individual and system initiatives” to promote positive wellbeing within pharmacy education.²³ With limited research exploring student perspectives on the factors that contribute to wellbeing, the Student Affairs Standing Committee delivered a call-to-action to begin dialogue with student pharmacists “to learn their needs, perceptions, and recommendations to support and promote student wellbeing.” ^16,23,24

In this study, we sought to address this critical gap in understanding student pharmacist perspectives regarding the intrinsic and extrinsic factors that most influence student wellbeing. Specifically, we aimed to explore first-year student pharmacist perspectives on the influence of individual, educational system, and health care system factors on their wellbeing during pharmacy school.

METHODS

We conducted a study using student reflections to understand first-year student pharmacists’ perceptions of the factors that influence their wellbeing as interventions addressing early student needs may set the foundation for improving wellbeing for students as they advance through their training. All first-year student pharmacists at the University of Wisconsin-Madison School of Pharmacy, a four-year program, participated in a spring semester course focused on the social and behavioral aspects of pharmacy practice. Coursework included a small-group activity and a lecture devoted to links between leadership and professional wellbeing. To prepare for these class sessions, students were required to write a two-page essay reflecting on their wellbeing since starting pharmacy school and the individual, educational system, or health care system factors that they perceived as having the greatest impact on their wellbeing. Narrative reflections were chosen because they have been shown to provide “a rich source of data” and a “window” into the student experience that might otherwise be difficult to elicit using other approaches such as semi-structured interviews and surveys, making them a useful tool for unearthing student perspectives about sensitive topics that might otherwise be difficult to share.^25-27

At our institution, all first-year students complete 50 hours of community- and hospital-based patient care experiences in addition to in-class work. Students are also strongly encouraged to volunteer for additional extracurricular and clinical experiences to increase their exposure to patient care and strengthen their resumes. Most first-year students also work paid jobs within the pharmacy industry. For their reflection, students were asked to consider these experiences in pharmacy school holistically, including in-class and out-of-class experiences. To encourage organic student responses and prevent priming students on the subject of wellbeing, reflections on the subject of wellbeing were assigned to students prior to exposure to course content and graded based only whether they completed the assignment. Students were reminded that wellbeing experiences could be positive, negative, or mixed, and they were encouraged to write exclusively about experiences that contributed to their personal wellbeing, regardless of the varied examples provided in the prompt (Appendix 1).

Student reflections were submitted and analyzed during the study period, from February to July 2019. We invited all first-year students who submitted reflections to participate in the study. Students were informed that all student essays would be de-identified. Written consent was obtained for inclusion of the student reflection for analysis and for direct use of student quotations. Students completed brief demographic surveys on paper at the time of consent. The University Social and Educational Sciences Institutional Review Board deemed this study exempt.

We conducted open and axial coding using the standard content analysis approach to thematic analysis.^28,29 Coding was performed using the online software, Dedoose, version 8.2.14 (www.dedoose.com). In the initial phase of analysis, two members of the research team iteratively coded all student reflections, using the constant comparative method.^28,29 They developed a codebook with operational definitions for each emergent code to ensure shared understanding and consistency in coding. Next, axial coding was performed with division of codes into hierarchical groups. To further ensure consistency and reliability of data analysis, coders and lead researchers met biweekly to discuss codebook development, all coding and categorization, address minor discrepancies in coding, and revise codes until agreement was reached. In the final phase, we identified emergent themes that spanned student reflections. All team members discussed and revised themes until consensus was achieved regarding final representative themes.

RESULTS

Upon admission, the first-year pharmacy class contained 135 students with a median age of 22 years. Most first-year students identified as being female (64.5%), an in-state resident (72.1%), and either Caucasian (81.5%) or Asian (13.3%). A total of 133 students submitted a reflection as part of the first-year course, and 49 (36.8%) consented to participate in the study (Table 1).

Five themes emerged among the factors that most influenced student pharmacists’ wellbeing: workload (rigor, rapid succession examinations, cumulative workload); learning environment (culture, values); meaningful pharmacy school experiences (greater purpose); relationships (social connection, isolation); personal factors (personal traits, health, personal life circumstances). Themes and representative quotes are presented in Appendix 2.

Within the first theme, workload, students described that the required pharmacy school coursework was often overwhelming. Students identified two high-risk periods of feeling overwhelmed: initial entry into pharmacy school and periods in which several examinations and quizzes were administered in rapid succession. Students indicated that despite achieving success in their undergraduate studies, they were surprised and underprepared for the challenges and rigor of pharmacy school. Students who adapted to the workload identified a sense of accomplishment, pride, and positive wellbeing, whereas students who struggled to adapt experienced frustration and distress. Additionally, students described reduced capacity to engage in physical health maintenance, exhaustion and illness, isolation from family and friends, and psychological distress during periods of highly concentrated coursework and knowledge assessments.

Students also described the workload impact of pharmacy employment and extracurricular activities on wellbeing. Students stated that although employment and extracurricular activities were not explicitly required, engagement in numerous extracurricular activities was implicitly expected by the institution and future employers. Taking on a multitude of extracurricular commitments was time consuming, making schedules difficult to manage and reducing time otherwise allotted for self-care and social experiences that support wellbeing.

Within the second theme, learning environment, students described how the learning environment influenced their wellbeing. Students stated that institutionally, high value was placed on student excellence, achievement, and preparation for future success. These institutional aims had mixed impact on student wellbeing. On one hand, students expressed that these institutional values provided a sense of security in believing that if they persevered through the hardships of pharmacy school, the rigor of their institution would help them become excellent pharmacists. However, students reported that emphasis on student excellence and achievement created an implicit cultural value suggesting that students should strive to be “the perfect pharmacy student who works, excels academically, holds many leadership positions, and seems to manage everything exceptionally.” For some students, the perceived pressure to achieve perfection amplified their existing perfectionistic tendencies, creating distress when they did not meet the perceived performance expectations. For others, this pressure engendered feelings of inadequacy and a sense of competition that was counterproductive to their wellbeing.

Students stated that despite training in a high-pressure environment, they felt supported by an institutional devotion to mentorship, student support, community, and inclusion. There was a shared sense that the institution provided students with sufficient academic guidance and emotional support when needed, and the learning community would be readily available to meet individual student needs. Students provided multiple examples of experiences with advisors, teaching faculty members, and upperclassmen who demonstrated adherence to these values.

Within the third theme, meaningful pharmacy school experiences, students described how pharmacy school experiences that provided a personal sense of meaning or purpose had positively influenced their wellbeing. Students identified that positive patient care experiences and interactions with interprofessional team members helped demonstrate the greater impact of their work and helped to solidify a sense of future career fit. Additionally, students shared that curricular and extracurricular activities that they believed would help them develop into effective future pharmacists provided them with a sense of purpose in their work. Students expressed that the activities that allowed them to personally derive greater meaning or purpose could at times mitigate the negative impact of a rigorous workload.

Within the fourth theme, relationships, students identified that social connection was a salient determinant of their wellbeing in pharmacy school. Students described that trusted pharmacy school friendships provided psychological support through shared understanding of pharmacy school challenges, sense of belonging and inclusion, and joy through camaraderie. Students frequently remarked that pharmacy school friendships supported academic success. Collaborative studying augmented learning, motivated them to learn more, and encouraged healthy competition.

Students also detailed the value of relationships with family, life partners, and close friendships outside of school. These relationships provided a sense of self outside of the school setting and a helpful distraction from school life. Students pointed to the practical support they received in living with or near family in the completion of life tasks, including grocery shopping, meal preparation, and laundry. Others described that the geographical distance from family and inability to attend family events during high-stress times in pharmacy school were distressing and isolating.

Within the final theme, personal factors, students identified the impact of personal health, traits, and life circumstances on wellbeing. Overwhelmingly, students detailed ways in which they were resilient and adaptable, persevering through challenging pharmacy school experiences. Students identified themselves as hard workers who held themselves to exceedingly high standards, which often led to academic accomplishment. However, students shared that although their perfectionism could drive academic success, it frequently led to distress when they fell short of performance expectations or compared themselves to peers. Additionally, students indicated that they struggled with setting personal boundaries, including limiting the time they spent studying and participating in extracurricular activities. As a result, students described spending less time on personal health and non-school life experiences.

Additionally, students identified how personal health and life circumstances contributed to wellbeing. Good health was supportive of wellbeing, while personal health challenges, including mental (anxiety, depression), emotional (isolation, feelings of inadequacy), physical health (illness, fatigue), and personal stressors (long commutes, financial challenges) had the potential to interfere with school performance and increased psychological distress.

DISCUSSION

Despite growing recognition by the AACP and educators that student pharmacist wellbeing initiatives should be prioritized, knowledge regarding student perceptions of factors that influence wellbeing remains limited.^16,23,30,31 Students in this study indicated that rigorous coursework, rapid succession examinations, and cumulative curricular and extra-curricular workload were salient contributors to distress in pharmacy school. Students identified that finding meaning or purpose in their work helped to mitigate some of the negative impact of the rigorous workload. Institutional emphasis on student success helped some students feel secure, supporting the student belief that a rigorous academic environment would support professional growth, while other students felt distressed by the high-pressure environment. Institutional focus on mentorship and community and social connection were supportive of student wellbeing. Students identified mental health, personal traits, and life circumstances as important influencers of wellbeing. Notably, despite participation in required and extra-curricular clinical experiences, students in our study did not delineate health care system factors as influencers of their wellbeing.

The influence of workload on student pharmacist wellbeing is supported by the literature on student pharmacists, pharmacists, and work-stress.^{17-21,30,32-36} Thematic analysis of the experiences of student pharmacists’ in Ireland identified that course workload and multiple simultaneous deadlines often left students feeling overwhelmed and with limited time to spend in activities that reduced stress.¹⁶ Likewise, classwork, out-of-class work, and timing of examinations have been ranked among the most prominent stressors for student pharmacists.²⁴ Efforts to mitigate the stress of traditional coursework and concentrated examination schedules have been trialed within health care professional student education with promising results.^37-39 Curricular models that reduce time spent in class, utilize prerecorded lectures and online coursework, and promote active in-class learning, have been shown to improve student pharmacists’ satisfaction and examination scores.^37,38 Additionally, in a study involving medical students, systematic scheduling and curricular changes, including adjusting examination schedules to allow adequate time between learning assessments, reducing in-class time requirements, adapting pass-fail grading, and developing learning communities resulted in significantly lower psychological distress and improved class cohesion, with no detriment to standardized testing scores.³⁹ These findings suggest that education system interventions, particularly those that address curriculum delivery and approach to assessments, may potentially be used to reduce distress related to course workload and rigor without sacrificing student learning outcomes.

Prior studies of pharmacy and medical students have also identified the impact of learning climate on student experiences, as was described in our study.^31,40-42 In pharmacy schools with multiple campuses, differences in student-perceived stress and self-efficacy were found across institutions.³¹ Learning climate factors, including large class size and less faculty support, were suggested as possible contributors.³¹ Similarly, medical students have been shown to experience lower rates of burnout when they perceive that their educational institution (advisors, leadership, faculty members, peers) support them, faculty members prioritize student education, and the school promotes collaborative learning.⁴⁰ Numerous studies demonstrate that collaborative learning and working environments and positive social connection are associated with greater engagement, professional accomplishment, and less burnout.^4,5,40,43,44 The students in this study similarly identified that trusted pharmacy student relationships and collaborative learning environments with peers, upperclassmen, and supportive faculty members were important influencers of wellbeing, providing emotional support and augmenting motivation to learn. Creating peer mentoring programs, student learning communities, and team-based learning opportunities may all serve as feasible means of encouraging positive social connection among peers, augmenting student learning, and improving student wellbeing, as these interventions have previously been shown to be beneficial in the health care professional student setting.^39,45

Our findings indicated that both mandatory and voluntary clinical and academic experiences had positive impact on student wellbeing when the activities were perceived as personally meaningful. Although the impact of meaningful experiences on health care student wellbeing has not been well studied, the literature increasingly suggests that engagement in meaningful work reduces health care professional burnout.^32,46 Shanafelt and colleagues surveyed physicians about the work activities that were most personally meaningful, including time spent in patient care, research, education, administration, and non-patient care tasks, and percentage of time spent in each activity. Physicians spending more than 20% of their time in work they deemed most personally meaningful had significantly lower burnout compared to physicians spending less time in meaningful work.³² Similarly, engagement in work perceived by occupational therapists as personally valuable or meaningful has been correlated with lower burnout and stronger sense of professional identity.⁴⁶

These findings, along with the findings in our study, suggest that maximizing student engagement in personally meaningful experiences would be beneficial for student wellbeing. This may be achieved in part by requiring students to participate in interprofessional and healthcare-related experiences early in their matriculation, as clinical experiences were described by students in our study as supportive of student professional growth and a sense of career fit. Additionally, students should be encouraged to choose their voluntary extracurricular commitments with intentionality, taking on only activities that support the student’s vision of meaningful student pharmacist work. Likewise, students should be discouraged from adding extracurricular activities solely as a means of bolstering their resume, as this increases workload demands and may increase students’ perceived stress.

Finally, the influence of individual factors, including mental health, personal traits, and life circumstances, on student wellbeing has been well studied.^12-16,24,47 Unique to our study is that students described themselves fairly universally as resilient and provided concrete examples of ways they strived to adapt to pharmacy school. Students described that despite their resilient traits, acute and chronic stressors from pharmacy school could accumulate and result in sustained negative wellbeing that was difficult to overcome. Therefore, while students would likely benefit from readily available mental and physical health resources, systemic education and institutional changes that support individual student wellbeing remain imperative.

There are several limitations of this study. First, this research was conducted at a single Midwest institution in the United States and had a small sample size, which may limit the generalizability of our findings. Second, data were collected from only first-year students, which sheds light on the early student pharmacist experience but may not reflect the experience of more advanced student pharmacists. Third, because of the potentially sensitive nature of the content students provided in their essays, our sample was limited to students who consented to submitting their reflections for analysis, potentially leading to selection bias and limiting the representativeness of our findings. However, consistency of themes discussing factors affecting wellbeing suggests that the study population represented a variety of students with a range of wellbeing experiences, both positive and negative. Finally, because the prompt listed an array of factors that could potentially contribute to wellbeing, students might have described factors in their reflections that they might not have otherwise considered had examples not been provided.

Future studies could aim to understand the influencers of wellbeing at institutions across the United States and internationally, and explore the perspectives of student pharmacists in later years of the curriculum to understand how influencers of student wellbeing shift over time. Future studies could also seek to quantify the degree to which each factor influences wellbeing, so that educational systems could appropriately target interventions that simultaneously support educational success and promote positive wellbeing. Additionally, because meaningful work and its importance in pharmacy education remains underexplored, future studies should investigate the concept of meaningful work, especially as it relates to student wellbeing. Obtaining ongoing input directly from student pharmacists regarding their wellbeing will remain imperative in addressing the current gaps in our understanding of student wellness needs and should guide future curricular and institutional changes that cultivate positive student wellbeing.

CONCLUSION

This study aimed to explore first-year student pharmacists’ perspectives on the influence of individual, educational system, and health care system factors on their wellbeing during pharmacy school. Results indicated that workload, learning climate, meaningful experiences, social connection, personal traits, and life circumstances were salient influencers on wellbeing. Education systems should prioritize systematic strategies that address curricular and learning climate factors, maximize student engagement in meaningful experiences, optimize social connectedness, and provide individual student support.