Well-Being May Be the Missing Component of Professionalism in Pharmacy Education

• student pharmacist
• well-being
• self-care
• professionalism
• relationship

Professionalism and well-being are of particular relevance and importance in pharmacy education given the increased stress that the COVID-19 pandemic has placed on health care professionals in recent years. Student pharmacists have played vital roles in patient care as frontline workers during the pandemic through their experiential course work within health systems and community pharmacies, and as integral members of mass COVID-19 vaccination efforts. The heightened levels of responsibility and consequences of actions taken during these times have affected even seasoned professionals and have been especially taxing on the mental health and well-being of student pharmacists.

When new and shifted professional obligations are layered on top of existing academic, financial, and family-related responsibilities, some students find themselves overburdened and exhausted from the rigor of overwhelming demands and unrelenting self-sacrifice. While stress and pressure in the short term can stimulate drive and motivation and allow us to “rise to the challenge,” prolonged stress may lead to chronic fatigue and burnout. Particularly during times of global crisis, people are known to come together to work tirelessly toward a cause, demonstrating high levels of altruism. However, this high level of motivation and enthusiasm is not sustainable indefinitely and often wanes over time.

When feelings of burnout arise, they can compromise our ability to make sound decisions and may even lead to behaviors viewed as unethical or unprofessional. Student pharmacists must be provided with the tools, resources, and time needed to invest in themselves to maintain their own well-being, which in turn, allows them to fulfill the pharmacy profession’s standards of professional conduct and engagement. Issues related to the unprofessional behavior of some student pharmacists can be linked to a lack of well-being; well-being initiatives could be a missing component when it comes to efforts focused on enhancing student pharmacist professionalism. Afterall, how can a person be altruistic if they do not care for themself first? Therefore, should pharmacy schools adopt initiatives to promote student wellness in order to maximize professionalism? Additionally, one may ask, can these two constructs coexist in harmony or are they in opposition of each other? Before exploring this relationship further, it may first be helpful to understand the history of professionalism and its associated components.

Scholars have worked to define professionalism for many years, and several definitions and defining traits exist in the literature, many with altruism at their core. ¹ Parsons and colleagues described a characteristic of “collectivity orientation,” which implies a sense of the common needs being more important than selfish needs. ² As a result of the autonomy, trust, and special recognition bestowed on professionals, there are also higher expectations of and standards for professionals. These ideas led the American Pharmaceutical Association-Academy of Students of Pharmacy/American Association of Colleges of Pharmacy-Council of Deans (APhA-ASP/AACP-COD) Task Force on Professionalization to develop a working definition of professionalism: “displaying values, beliefs and attitudes that put the needs of another person above your personal needs.” ³ This task force went on to publish one of the sentinel works about student professionalism in pharmacy, with this definition as its foundation. ⁴ The Oath of Pharmacist, Pledge of Professionalism, and Pharmacists’ Code of Ethics also describe behaviors that are expected of all pharmacists; the basis of these codes are the provision of trustworthy service to others. Interestingly, neither traditional nor current definitions and attributes of professionalism include well-being.

Professionalism is a widely known and accepted construct within pharmacy education and the profession itself. It can be assessed through various methods and validated instruments, which has led to a plethora of articles in the literature. Additionally, with the incorporation of key elements of Standard 4 within the Doctor of Pharmacy programs in 2016 many institutions have implemented initiatives and co-curricula aimed at further enhancing student pharmacist professionalism. These programs may include professional seminars, student organizational involvement with leadership opportunities, and service-learning events among others. ⁵ However, there may still be an opportunity to hone certain professional attributes within the affective domain that could consist of efforts focused on enhancing well-being. ⁶

Well-being is one of the elements pertaining to the affective domain but not often cited in descriptions. ⁶ While there is no single definition of well-being, the Centers for Disease Control and Prevention states that “well-being includes the presence of positive emotions and moods, the absence of negative emotions, satisfaction with life, fulfillment and positive functioning.” ⁷ In turn, well-being may be viewed as innate, but it can be influenced by several factors and encompasses an emphasis on personal wellness and self-care. In contrast to professionalism, well-being is only beginning to come into focus within higher education and pharmacy practice; however, it is of utmost importance. While there is substantial literature regarding mental health, stress reduction, quality of life, well-being, and the impact of their associated interventions within other professional student bodies, less data exist related to student pharmacist well-being. Additionally, student pharmacist well-being is only mentioned briefly in Standards 14 and 15 of the Accreditation Council for Pharmacy Education (ACPE) Standards, where the need to offer pharmacy students financial, mental, and physical wellness services is explicitly stated. ⁸ However, recent literature suggests a great opportunity to enhance student pharmacist well-being as data indicate poor student performance related to stress, mental health-related quality of life, and coping ability. ⁹ Furthermore, well-being often declines as students progress in the Doctor of Pharmacy curriculum, with higher rates of student stress, anxiety, and depression reported later in the pharmacy curriculum. ^{10, 11}

One of the phenomena that is not often discussed in scholarly literature is the relationship between aspects of personal well-being, such as stress, and professionalism. There are limited data available on this relationship. ¹² We know that society has expectations of the professional-based characteristics noted above; however, when those expectations are not met, it usually makes headlines, even if the professional was “off duty.” Consider stories of a physician that abuses a partner, a theologian that is cited for tax evasion, or an educator with a substance abuse problem. Although these kinds of scenarios may happen with other members of society, they are not usually publicized unless they happen to members of society who are not expected to have those sorts of problems. Society expects pharmacists, as members of a profession, to behave in certain ways all the time, not just when performing our jobs. Living up to and fulfilling others’ needs and expectations all the time can be challenging for professionals early in their careers, including student pharmacists. Intense workloads are often required of pharmacists in training. These pharmacy learners demonstrate their commitment to the profession through altruistic behaviors, such as working extended hours at the expense of personal time.

Thankfully, while seeming to conflict based on classic interpretations of altruism, practicing self-care to promote personal well-being is not in conflict with being an altruistic, self-sacrificing professional. Professionals have to take care of themselves before taking care of others or eventually they will have nothing left to give. Traditionally, student pharmacists have been trained to adopt a “patient first” mentality, sometimes at the expense of their own needs. More recently it has been suggested that the “triple aim” to optimize health system performance be revised to a “quadruple aim” that includes a new emphasis on health care provider well-being and improving the work-life of the care team in order to minimize provider burnout and enhance patient safety. ¹³ Burnout, as a result of chronic stress, is one of the biggest threats to professionalism and can erode professionalism at its foundation. We see the influence of stress on professionalism when a student pharmacist makes a poor decision when under an extreme amount of pressure, like cheating on a high-stakes examination. However, if that same student were previously taught stress management techniques to build resilience, the core tenets of professionalism as outlined by Smith, ¹ such as self-imposed and enforced values and behavior, may have been preserved.

So how do we know when we need to take care of ourselves first and put others’ needs second? As noted, constant and immense amounts of stress at work can lead to burnout, which can have deleterious consequences on our physical and mental well-being. This same concept of burnout may also be applied to a student’s “work” in pharmacy school. The presence of burnout in pharmacy practice faculty has been clearly documented within the literature, ¹⁴ leading us to postulate on the effect this may have on student pharmacists. Therefore, it is our responsibility as pharmacy educators to be aware of this finding and act to address the issue within ourselves and our institutions, while also dedicating ourselves to enhancing student pharmacist well-being using existing literature as a guide. In a study by Babal and colleagues, first-year student pharmacists perceived five key areas that influenced their well-being: workload, learning environment culture and values, meaningful pharmacy school experiences, relationships, and personal factors. ¹⁵ Additionally, various mindfulness-based programs have been studied in health care professional student populations with favorable results. ^{16, 17} Another pharmacy program embedded optional well-being challenges within a required didactic course to encourage student engagement in protective self-care behaviors. ¹⁸ Finally, a formalized Mental Health First Aid (MHFA) training course involving student pharmacists was shown to decrease stigmatizing beliefs among pharmacy students, ¹⁹ which may help to foster an environment of open dialog and inclusivity related to well-being issues. To promote self-awareness, we suggest that students utilize the My Well-being Index assessment (https://app.mywell-beingindex.org/account_setup) to identify early warning signs of burnout and take immediate actions to mitigate the effects.

Unfortunately, it is often not until a catastrophic event occurs in life that we realize the importance of prioritizing our own health and practicing self-compassion. As faculty, we can normalize conversations about conflicts between personal and professional demands and guide students in decision-making processes, as well as in navigating the necessary negotiations and compromises with which we are confronted in life. Demonstrating transparency and grace about their own struggles is of utmost importance during faculty interactions with students, as this shows students that they are not alone in such struggles. Encouraging the practice of mindfulness, being present in the moment, and engaging in uplifting self-talk may help students to center and ground themselves. Colleges may enact programs to support the development and maintenance of both professionalism and well-being. One way is through helping students develop meaning in their “work” through intentional mentoring/advising programs, as well as formal training programs involving mindfulness and MHFA. Educators can also provide students with dedicated time for stillness and self-reflection. However, it is difficult to be present in the moment to allow for rejuvenation and thoughtfulness if students are distracted, eg, incessantly connected to technology. Strategies are needed for students to bring non-judgmental awareness to the present moment. Being fully present can allow students to formulate a response that is appropriate for the challenges encountered on their unique professional journeys. Many professional pharmacy organizations (American Pharmacists Association [APhA], American Society of Health-System Pharmacists [ASHP], National Community Pharmacists Association [NCPA], and American Association of Colleges of Pharmacy [AACP]) also provide resources on their websites that pharmacy schools may use to develop intentional and tailored programs. Finally, the AACP 2019 House of Delegates approved a policy introduced by the 2018-2019 Academic Affairs committee that states: “AACP affirms that fostering leader, faculty, staff, and student well-being is a vital responsibility of the academy and individual schools and colleges.” ²⁰ The recently created AACP Well-being Connect Community and the 2021-2022 Student Affairs Committee are also increasing awareness of and promoting inclusion of well-being programs into pharmacy schools.

Although seemingly in competition, prioritizing personal well-being through incorporation of self-care strategies can indeed save lives, by allowing a person to be fully present in the moment and dedicated to others through genuine professional and altruistic actions. In this way, well-being should certainly become one of the many components of professionalism. Student pharmacists, with institutional and faculty support, must engage in self-care to be the utmost professional in the truest sense of the word. Various resources are available and under development to foster well-being initiatives.

• Received July 14, 2021.
• Accepted August 5, 2021.

• © 2022 American Association of Colleges of Pharmacy