Addressing Burnout in Pharmacy Residency Programs

Understanding Burnout

Burnout is a job-related syndrome that a person develops as the result of prolonged response to chronic interpersonal stressors.⁶ Over time, the person’s inability to recover from work-related stress manifests as one or more of three burnout subdomains: emotional exhaustion, depersonalization, and reduced personal accomplishment.^1,7 Health care provider burnout has been associated with diminished well-being, decreased job satisfaction and performance, substance abuse or dependence, depression, and suicidality.^1-3,6,8,9 In addition to affecting clinicians personally, burnout has a significant impact on the health care systems where they work and the patient care they provide. Medical errors, mortality, and infections have been associated with provider burnout as well, demonstrating its negative impact on patient care.^1,2,8

The Collaborative on Clinician Well-Being and Resilience reports that 45% to 60% of medical students and residents suffer from substantial symptoms related to burnout.¹ As a profession, pharmacists may be predisposed to burnout as a result of regulatory compliance, excessive documentation, and incongruities between training and daily tasks.^8,10 The prevalence of burnout in pharmacy residents has not been reported directly; however, based on the findings from several studies, rates of pharmacist burnout are likely from 46% to 62%.^9-11

Health system administrators and pharmacy residency directors should understand the factors that influence the development and/or severity of burnout, identify at-risk individuals, and employ appropriate training and well-being strategies. Individual factors associated with increased risk of burnout include: younger age, female gender, having young children or no children, being unmarried, perceived stress, hours worked, days on call, and moral distress.^1,4,7,9-13 Professional stressors nearly double the risk of burnout and include having inadequate administrative and teaching time, uncertainty about health care reform, difficult colleagues, too many non-clinical duties, and underappreciated contributions.⁹ Lack of autonomy and control, heavy workload, no or minimal margin for error, interruption-driven environments, workplace disorganization, and ambiguity in the work itself are all early predictors of burnout related to the practice and learning environment.^1,4,7,9-13

These risk factors provide a glimpse into why many clinicians are predisposed to burnout. However, the specific risk factors for pharmacy residents have not been defined. Residency training in itself is an incredible stressor and has been associated with burnout, increased perceived stress and incidence of depression, and decreased quality of life.^12-14 Moreover, residents are typically young, in their first pharmacist role, spend long hours on site, and often participate in on-call programs, where they may be faced with traumatic and stressful medical emergencies. The new practitioners’ pursuit of accelerated training through residency and progressive development requires substantial time and effort, potentially reducing dedicated time for well-being activities known to reduce burnout.^4,13 Additionally, the increase in responsibilities, expectations, and pressure to excel all place residents under greater professional, situational, and personal stress.⁴

Addressing Pharmacy Resident Burnout

Resident well-being is the cornerstone to combatting burnout in pharmacy residency training programs. Well-being has been described as the presence of positive and absence of negative emotions, satisfaction with life, fulfillment, and positive functioning.¹ By definition, well-being is a psychological state subject to change from moment to moment. Well-being can be addressed by implementing new programs, improving the practice and/or learning environment, and supporting individual well-being efforts. The Guidance Document for the ASHP Accreditation Standard For Postgraduate Year One (PGY1) Pharmacy Residency Programs provided by the American Society of Health-System Pharmacists (ASHP) were updated in 2019 to include statements about burnout and well-being.¹⁵ Implementation of these standards, however, is left up to each residency program. As such, many programs may struggle to integrate well-being initiatives into their curricula despite having a strong desire to do so. Even with the availability of well-being initiatives, residents may be averse to using such programming because of pressures to achieve, meet expectations, and/or obtain recommendations for jobs or second-year training programs. Others may fear that admitting they have a problem and/or seeking help will have implications on their licensure and jeopardize their career. Routine discussion of burnout with residents in a group setting may help destigmatize burnout and empower trainees to explore and adopt strategies to mitigate burnout and improve well-being.

Currently, many well-being strategies emphasize improving individual coping skills. Individual-based approaches are undeniably important, but evidence outlines the importance of creating positive practice and/or learning environments, providing support, and developing interventions at the system and organizational levels.^16,17 Unfortunately, the implementation of organization-wide well-being initiatives has not been well-established and reports of implementation are limited to several case studies.¹⁰ The National Academy of Medicine has developed a conceptual model to highlight the importance of clinician well-being and further illustrate the necessity of adaptation in the practice and/or learning environment.⁷ While the most effective strategies have not been determined, residency programs can address burnout by supporting initiatives at the program, preceptor, and individual levels. Below we propose several strategies based on the available interdisciplinary literature. A brief summary of the supporting evidence is provided in Table 1. No one strategy is necessarily better than another; thus, programs administrators should consider developing a combination of strategies tailored to the specific needs of their program and residents.

Strategies

Receiving continual program support is paramount to residents understanding burnout, improving their well-being, and reshaping the culture of postgraduate training. During the orientation period, first-year residents should be educated about the prevalence and warning signs of burnout, as well as made aware of mitigation strategies and resources for well-being and resilience.¹⁵ Programs should also consider holding a well-being retreat or conference as a part of orientation and establish seminar-type lectures related to well-being.^1,6,16,18,19 Regular follow-up sessions should be offered throughout the program to remind residents of the resources available to them.

Another strategy to consider is hosting facilitated group discussions. These sessions offer clinicians the chance to share and process experiences that may be stressful and/or traumatic.^6,16 Simultaneously, group discussions provide a safe environment and may initiate a paradigm shift in the stigma associated with burnout. Such sessions may also provide the opportunity for health system administrators and residency directors to recognize the signs and symptoms of burnout early and intervene as appropriate.

Integration of well-being measures into the resident development plan provides an opportunity for program administrators to emphasize the importance of residents’ well-being and ensure regular assessment of residents for signs of burnout. Further, programs may want to consider integrating well-being and/or burnout assessment into learning experience evaluations. This encourages residents to reflect on their self-care and well-being practices and provides program administrators with insight into the resident’s well-being.

Burnout is characterized by the inability of a person to recover from the stress of work-related events. It can be inferred that removing oneself from the work environment enables recovery from burnout. Time away from work also provides residents with time to practice self-care and physical well-being. Residents should be made aware of the program’s time-off policy during orientation and encouraged to use the provided time to prevent burnout and improve their well-being.

Completion of postgraduate training through residency requires oversight and a coordinated program to meet the rigorous ASHP standards. As a result, most programs are highly structured and offer residents limited flexibility and personal choice. However, autonomy, flexibility, and a sense of control are protective factors against burnout.¹¹ For pharmacy residents, autonomous decisions may take the form of topic selection for a research project or continuing education lecture, availability for and number of elective rotations, and selection of their mentor or advisor. Potential interventions to broaden flexibility include allowing residents to alter their schedule as their career goals change and developing projects and presentations based on residents’ individual areas of interest.

In addition to embracing autonomy and flexibility, preceptors can significantly impact resident well-being and resilience through mentorship and advising, serving as a well-being role model, giving attention to the resident’s perceived workload, and offering recognition for resident success.^6,11,13,16 Specifically, mentoring is a crucial component of professional development and residents can especially benefit in the transition from student to new practitioner.¹¹ Potential roles include aid with relocation, navigation of the licensure process, rotation selection, and professional development. Other roles may be resident-specific and dependent on the resident’s career goals, practice interests, identified strengths, and areas for improvement. In addition to advising, positive modeling behaviors can be impactful.¹⁷ These behaviors include employing personal well-being and resilience techniques, maintaining positive work-life integration, and demonstrating interests outside of work. Preceptors should be encouraged to share their own experiences with burnout and mitigation strategies if they feel comfortable doing so.

The resident’s perception of workload has major implications on their personal and professional lives.^11,13,20 Those involved in the training of residents should involve the resident in establishing expectations and activities to align the learning experience with the needs, career goals, and expectations of the learner. As a program, all longitudinal requirements should be frequently reviewed to ensure each is enriching, supportive of the program objectives, and meaningful for the resident and program.

Current evidence outlines the importance of strategies, but it would be imprudent to neglect the importance of individual well-being efforts.^1,16 Effectively managing their personal stress is vital to residents’ well-being. However, not all coping strategies are healthy or advisable. Despite temporarily providing perceived stress relief, maladaptive coping strategies can negatively impact burnout and well-being.²⁰ Examples of maladaptive coping include disengagement, denial, self-blame, alcohol use, and substance abuse/dependence. Conversely, adaptive coping mechanisms such as planning, positive reframing, active coping, acceptance, and use of support help alleviate stress and encourage well-being.²⁰ Top coping strategies reported by pharmacy residents include spending time with family and friends, staying optimistic, and engaging in other activities they find meaningful.¹³

Mindfulness has been shown to improve career satisfaction and reduce stress, burnout, and anxiety and depression.^1,3,4,17-19 Informal activities that usually take less than 10 minutes have great utility in health care as these exercises can be conducted “on the fly.” Typically, these involve pausing and grounding oneself in the present moment.

Finally, getting adequate sleep and dedication to sleep hygiene are imperative for proper functioning and physiologic restoration. Pharmacy residents are expected to perform at high levels during their training, yet many pharmacy residents report not getting enough sleep.¹³ Obtaining sufficient, quality sleep should be an individual priority and one that is supported by the residency curricula, including having an enforceable duty hours policy in place.⁶ In addition to proper sleep, engaging in physical activity improves quality of life and decreases burnout in postgraduate training.⁶ Scheduling the activity or coordinating group activities helps maintain accountability, but the most beneficial duration or type of activity to reduce burnout has not been identified.