Abstract
Objective. To review the literature assessing student pharmacist well-being and the impact of well-being–associated interventions.
Findings. Of the 15 studies included, six assessed student pharmacist well-being while nine evaluated the impact of a well-being intervention. While various approaches exist to assessing student pharmacist well-being, the body of literature suggests, overall, that student pharmacist well-being is poor. Since well-being is multifaceted and individualized, some pharmacy schools have identified various ways to incorporate tailored well-being activities, including mindfulness, into required, elective, and cocurricular experiences within the Doctor of Pharmacy program, with varying outcomes.
Summary. This review highlights the limited and variable information available on the assessment of student pharmacist well-being as well as unique strategies to incorporate well-being initiatives into Doctor of Pharmacy curricula. Schools of pharmacy should identify the well-being needs of student pharmacists through a standardized well-being assessment instrument and provide meaningful well-being resources and interventions within the curriculum. There is a growing need for faculty to invest in student pharmacist mental wellness in addition to academic success. Future accreditation standards will inform the Academy on how to advance well-being initiatives.
INTRODUCTION
Well-being is a state of health encompassing the physical, emotional, and mental conditions of an individual. In 1954, the World Health Organization (WHO) originally defined health as “not merely the absence of disease or infirmity, but a state of complete physical, mental, and social well-being.” 1 The WHO later updated the definition to “a state of well-being in which every individual realizes his/her/their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his/her/their community.” 2 The WHO acknowledges that there is no universally accepted definition of well-being due to differing cultural perspectives and concepts, which range from socioeconomic status and quality of personal relationships to simply being happy. 3 When a person’s well-being becomes compromised over a long period of time, mental health issues may arise. These conditions contribute to job burnout, decreased work productivity, as well as feelings of exhaustion and depletion.
Mental health and well-being are of special importance to colleges and schools of pharmacy. Within the Accreditation Council for Pharmacy Education (ACPE) standards for Doctor of Pharmacy degree programs, Standards 14 and 15 mention health and wellness in regard to promoting wellness and healthy behaviors in the management of various disease states focused on patient care. The Standards also call for pharmacy programs to have appropriate resources to promote student success and well-being. 4
In 2019, the American Association of Colleges of Pharmacy (AACP) collaborated with the ACPE, the American Pharmacists Association, the National Association of Boards of Pharmacy, and the National Alliance of State Pharmacy Associations to provide recommendations for student pharmacist well-being. This consensus report underscored the importance of applying strategies that address self-care techniques for well-being and preventing burnout, rewards and incentives for engaging in well-being activities, and formal training to address behavioral health. These types of interventions are more valuable than ever due to the stress pharmacists and student pharmacists have experienced while serving communities during the COVID-19 pandemic. 5
It is imperative to assess and understand the well-being of student pharmacists to best craft methods of outreach, support, and intervention. Such methods may help student pharmacists avoid negative coping strategies in practice and, thus, provide optimal levels of patient care and support. However, well-being is extremely difficult to quantify because well-being has a dynamic, evolving definition tied to many subjective factors. Multiple survey instruments have been developed in an attempt to appropriately assess well-being. 6-9
The objective of this scoping review is twofold; in order to determine the gaps and limitations in available literature, the review aims to examine current assessments and measurements of student pharmacist well-being and evaluate interventions used to improve student pharmacist well-being.
METHODS
Following the Arksey and O’Malley framework, 10- 11 this scoping review was undertaken to identify studies that assessed student pharmacists’ well-being and any well-being–associated interventions employed in the pharmacy curriculum. This review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).
Three electronic databases (PubMed, ERIC, and Embase) were searched using a combination of keywords and Medical Subject Headings (MeSH). Due to the limited amount of literature available, the initial search term of student pharmacist well-being yielded insufficient evidence. The authors broadened the search to all health care professionals and higher education students to retrieve a sufficient number of articles for screening. In order to capture all the possible well-being literature on this novel topic, the authors did not set a time limit on the articles retrieved. Keywords included the following terms: students, public health/psychology, students, medical/psychology, students, pharmacy/psychology, burnout, psychological, health, health promotion, wellness, wellbeing, well-being, and well being. MeSH terms included student/pharmacy, health, and health promotion. To further identify articles assessing student pharmacist well-being or targeted well-being interventions, the investigators also conducted a manual review of references of the included articles to identify relevant articles not found in the initial search.
One hundred twenty-seven results were imported into the reference management software Zotero, (Corporation for Digital Scholarship). Screening was undertaken by four reviewers. Each member reviewed all imported articles and scanned the reference list of each included article to identify other potential articles. Studies were included if they pertained to assessments of well-being in student pharmacists or reported on curricular activities in pharmacy education that focused on well-being. Studies that involved interprofessional education were included if pharmacy was one of the disciplines evaluated. The investigators considered articles published only in the English language. All study designs were eligible. Studies were excluded if they did not focus on student pharmacists’ well-being. The assessments of well-being strategies described in each paper were tagged with appropriate keywords and were also categorized with subheadings of the well-being domains defined by the Centers for Disease Control and Prevention (CDC) (physical, economic, social, emotional, psychological, life satisfaction, and engaging activities). 12 The process of tagging studies to well-being categories was accomplished through prospective discussions among the reviewers about the studies’ parameters. For example, studies that assessed students’ perceptions of stress using the Perceived Stress Scale were tagged to both the survey/questionnaire and stress/stress management categories, while an article describing how a well-being mindfulness activity was incorporated into the curriculum was tagged to the mindfulness/curriculum/intervention category.
RESULTS
Screening in the abstract phase excluded 75 results, leading to 52 results for potential eligibility (Figure 1). Each of the included studies and were reviewed in detail by the research team. After a detailed full-text review of the 52 articles, 15 (n = 2309 students) were included in the results based on the set criteria and tagged accordingly (Appendix 1).
Flowchart of study selection according to PRISMA-ScR guidelines.
Of the 15 articles included in this review, seven of the studies (n = 507 students) were conducted in the United States, and eight (n = 1555 students) were conducted internationally. Six of the studies sought to assess student pharmacist well-being using various rating scales (n = 1589 students). Four other studies incorporated a well-being intervention into the pharmacy curriculum (n = 193 students), while the effects of mindfulness implementation were assessed in the remaining five studies (n = 280 students). Investigating student pharmacist well-being is a fairly new concept, as all included studies except one were published after 2019.
Six studies assessed the well-being of student pharmacists (Appendix 2), and each study chose a different approach to assessing it. One study evaluated the quality of life (QOL) of 711 student pharmacists as a predictor of well-being by using a validated WHO-BREF instrument. 13 The investigators found that 82.1% of the students had a fair overall QOL and poor well-being in all four domains. The RAND 36-Item Health Survey (RAND-36) is another widely used scale that measures QOL. One pharmacy school assessed 104 first- and third-year student pharmacists (representing 53% of study participants) using the RAND-36, which assesses the domains of emotional well-being, physical pain, and emotional functioning, and found a decline in well-being in third-year student pharmacists. 14 In another study, other schools of pharmacy assessed psychological well-being in 447 student pharmacists (representing 98.9% of study participants) as a composite of three survey instruments: the Diener Mood Rating Scale (MRS), the Rosenberg Self-Esteem Scale (SES), and Satisfaction with Life Scale (SWLS). By using a composite result of these domains, the investigators drew conclusions regarding student pharmacists’ psychological well-being and its positive relationship with burnout. 15 Another study conducted a qualitative assessment of 49 (36.8% of the study participants) first-year student pharmacists’ well-being was conducted through thematic analysis of student pharmacists’ reflections on personal well-being. Investigators conducted the analysis by coding the student pharmacists’ reflections of their own well-being and developing unique factors of well-being based on their specific student population. Factors of well-being discovered through the thematic analysis included workload, learning environment culture and values, meaningful pharmacy school experiences, relationships, and personal factors. 16 While the aforementioned studies assessed student pharmacists’ well-being at a single point in time, only one study assessed student pharmacists’ well-being longitudinally. In this study, a longitudinal assessment of 76 first-year student pharmacists (100% of study participants) was conducted with a survey instrument that defined well-being by the Gallup well-being domains and assessed the students for 29 weeks. By assessing student pharmacists’ well-being over time, the investigators discovered that different domains of well-being can fluctuate throughout the course of a year. 17 The final study included was conducted at the University of Ghana and evaluated student pharmacists at two time points in order to discern a relationship between perceived stress and how it impacted quality of life 18
Recent literature is raising awareness that many student pharmacists are experiencing poor well-being; to address this, colleges and schools of pharmacy have implemented different strategies to incorporate well-being activities into pharmacy curricula (Appendix 3). Some studies have included semester-long interventions, while others have incorporated one-day activities. Certain schools have opted to include well-being activities within a cocurricular experience, while others have embedded well-being initiatives within a required or elective course. Nine studies included in this analysis developed a targeted intervention to improve student pharmacist well-being. In Finland, one school of pharmacy incorporated a seven-week optional course that was structured in an acceptance and commitment therapy (ACT) format. The ACT course format included an introduction to the psychoeducational method, audio and visual experiential exercises, and participant reflections. The investigators found that for 40 students (86% of study participants), well-being and time management increased during the course. 19 Another example of a longitudinal well-being activity was performed at the University of Kentucky, where four, month-long well-being activities were introduced in a required pharmacy course in which participation was optional for extra credit. These well-being activities involved a single, month-long challenge that students incorporated into their daily routines and wrote reflections on at the end of each month, which were aimed at “nudging” long-term behavioral changes to improve well-being. The 126 students (93% of the study participants) that completed the challenges reported that they attempted to continue the healthy habits, as they found them useful. 20 As an alternate strategy, another study incorporated a single well-being activity into a required course. The University of Waterloo incorporated a single “Check-In” activity into a required course; the Check-In consisted of a background reading, an in-person lecture component, and a faculty-student mentoring session. 21 The investigators found that the 76 student pharmacists (63% of study participants) reported the Check-In activity as rewarding, and both students and faculty reported it as a positive experience. Finally, at one school of pharmacy, 49 first-year student pharmacists (36% of study participants) wrote reflections on personal well-being in one of the required courses in the curriculum. These reflections were then used to find common themes (availability and accessibility of institutional resources, personal time management and organizational strategies, personal mental health and physical health strategies, and activities that maintain social relationships), and a discussion and lecture on well-being then followed. 22 All of the aforementioned strategies have unique benefits and limitations.
Of the nine studies that included a targeted intervention in the curriculum to improve student pharmacists’ well-being, five studies specifically focused on mindfulness and meditation, which are techniques that have been used to help nurture well-being. The strategy of mindfulness meditation in particular has been used for decades to help reduce stress and promote overall well-being. 23 Some pharmacy schools have incorporated mindfulness activities to promote well-being in student pharmacists, such as in one study, which incorporated use of the mindfulness meditation app Headspace. In this study, 92 student pharmacists (70% of study participants) voluntarily practiced 10 minutes of mindfulness meditation in the app every day for four weeks as an extracurricular activity. Results demonstrated enhanced mental well-being as well as decreased perceived stress. 24 Another university incorporated a voluntary, extracurricular six-month yoga and meditation class to help improve student well-being through anxiety and stress reduction. 25 Seventeen students, including nine students (53% of study participants) from the school of pharmacy experienced an improvement in their mindfulness and a decrease in their perceived stress scores. Finally, in another study, a school of pharmacy in Ireland incorporated a voluntary four-week mindfulness course into the pharmacy curriculum. 26 Compared to the 48 control participants who did not engage in the mindfulness course, the 51 student pharmacists who did realized a significant decrease in stress and increase in mindfulness. This mindfulness course originated from ideas generated through the thematic analysis of contributions from focus groups, in which student pharmacists vocalized interest in incorporating mindfulness as a coping skill for stress reduction. 27 The thematic analysis of feedback from 20 student pharmacists revealed five key elements: so much to do with so little time, the role of lecturers, wanting to do well, learning by doing, and using mindfulness as a coping tool. This mindfulness course consisted of a two-hour class session with group discussions followed by 20-minute at-home exercises each week. After incorporating the in-person mindfulness course, the pharmacy school also developed a four-week online delivery version of the same course with similar results. Fifty-two student pharmacists (37% of study participants) experienced a significant increase in professional efficacy and observation skills and a decrease in stress levels. 28
DISCUSSION
The concept of assessing and promoting wellness in health care professionals, such as nursing and medical students, is not new. Numerous publications have also assessed and highlighted the mental health challenges experienced by student pharmacists, which include stress, anxiety, depression, and burnout. However, literature focused specifically on student pharmacists’ well-being is limited. 29- 30 Although the authors of this review have found publications on how to assess the well-being of student pharmacists, each publication used a different assessment tool, which may be because well-being is multifactorial in nature, and the term has no universally accepted definition.
Since promoting well-being is multifaceted, the approach can be varied and individualized to meet the unique needs of the individuals involved. Our results yielded diverse interventional approaches to help promote the well-being of student pharmacists. Additionally, since well-being is subjective to the individual, debate may exist on how to best incorporate well-being initiatives that meet the needs of a diverse student body. One approach is to incorporate unique well-being activities into the required curriculum or cocurricular activities. Most schools of pharmacy already require a seminar class or professional development course as part of their curricula, which may serve as a useful location for such programming. Other approaches include making targeted well-being experiences an elective or optional activity in which students can voluntarily participate. Out of the targeted interventions reviewed, all yielded positive feedback from the students who participated.
Initiatives involving student well-being seem to have gained traction in 2017-2018, when the charge to the AACP Student Affairs Standing Committee was to develop a resource guide for its members on how to implement well-being strategies for student pharmacists. The report recommended discussions and programming on the topic of well-being, the creation of a well-being task force, and the curricular integration of well-being. 31 In 2018-2019, the AACP Academic Affairs Standing Committee was charged with assessing and promoting student pharmacists’ well-being. 32 The 2018-2019 Academic Affairs Report recommended that the AACP should consider developing programs that can evaluate student pharmacists’ well-being and identify factors affecting well-being. 32 The standing committee’s reports have led to the development of policies for schools of pharmacy that may influence future well-being initiatives, 33 and in 2018, the AACP hosted a Fall Institute on strategies to promote a culture of well-being among students and faculty. The committee’s charge for 2022 is to develop a resource guide for member institutions to help with implementing holistic well-being strategies for all students, faculty, and staff. 34 The newly created AACP Well-being and Resiliency Community is also developing a Well-being Toolkit for its member institutions. 35
The American Pharmacists Association (APhA) published its recommendations from its National Consensus Conference, including that schools should offer ongoing education and training on student pharmacist well-being and that ACPE standards require annual well-being assessments for student pharmacists to guide organizational initiatives. 5 In response to this, the draft of Standards 2025 addresses student pharmacists’ well-being specifically in Standards 14 and 15, which emphasize the importance of developing organizational resources and services to support well-being as well as specific policies to promote a well-being–friendly environment. 36 Once finalized, these future accreditation standards will likely include more defined key elements associated with student pharmacist well-being. In the meantime, schools of pharmacy can use the aforementioned AACP Policies on Professional Education as guidance. 33
Promoting well-being is needed now more than ever, especially for student pharmacists. With the inclusion of well-being recommendations in the draft of Standards 2025, it is crucial now for all major organizations/associations to collaborate on well-being initiatives for standardization. After reviewing the literature, it would be helpful for colleges of pharmacy to share a standard definition of student pharmacist well-being that is incorporated into its governing documents. Future researchers could develop a standardized and validated instrument to assess well-being, specifically geared toward student pharmacists. If a standard definition and assessment can be determined, this would lead to a possible secondary meta-analysis to measure impactful interventions and their associated outcomes. One limitation to standardization is that the interpretation of individual well-being is contingent upon subjective experiences and diverse backgrounds.
Experts have also proposed possible approaches to nurturing well-being in student pharmacists. One expert stated, “Well-being initiatives in a college of pharmacy should focus on decreasing student perceived stress and increasing perceptions of satisfaction and fulfillment.” 37 Well-being initiatives for student pharmacists can come from interested individuals, dedicated faculty, and student organizations in schools of pharmacy. One thematic analysis of first-year student pharmacists yielded four individual approaches on how to cope with stress and well-being. The four main areas that students identified as fruitful for promoting well-being were in personal health, time management, socialization, and the use of institutional resources. 22 The investigators found that student pharmacists who were more involved in cocurricular activities studied more, had higher GPAs, and had stronger relationships with faculty, staff, and peers. 16 Religion and spirituality of student pharmacists also positively affected their emotional and mental well-being, which are also important for student success. 38 Another recommendation was for the establishment of faculty and staff cohorts that assist and support students who have low resilience and well-being. Student organizations can also develop events to promote resilience and well-being supplemental to curricular teachings; these events could include healthy meal offerings, organized exercise activities, outside speakers, social events, and community service. 39 Identifying and recruiting students, faculty, and staff members to lead these initiatives would provide diverse perspectives on well-being and would decrease the burden on individual students. 40
It is imperative for schools of pharmacy to identify opportunities for targeted interventions tailored specifically to the needs of their own students rather than adopting a universal intervention. It is unlikely that a universally accepted well-being intervention will be practically relevant for all students. Common themes that arose from this review suggest that well-being interventions could address the availability of organizational resources, offer personal self-help strategies, and incorporate mindfulness within the curriculum. These themes could help guide schools of pharmacy when crafting institution-specific well-being interventions. One example of meeting the organizational resource need is that schools could incorporate a certified Mental Health First Aid (MHFA) training course for their students. The MHFA training program has been shown to help mitigate the stigma of mental health struggles and nurture a well-being culture within a school of pharmacy. 41 The APhA has also partnered with the Mayo Clinic for students to use the My Well-being Index Assessment app, which allows individuals to track their well-being and plot their progress over time. Not only does it keep a record of one’s progress, but it also shows how one’s well-being compares to the average well-being scores of all pharmacists. Additionally, the app provides tailored resources to meet identified well-being needs. 42 This app is an example of how to support students with self-help strategies.
Well-being and COVID-19
The COVID-19 pandemic has taken a toll on student pharmacists’ career well-being, social well-being, financial well-being, physical well-being, and community well-being, as outlined by Gallup. 43 With new virtual and remote learning environments, students may have increased anxiety about completing their coursework efficiently. The ever-changing landscape of pharmacy education amid COVID-19 has led to a delay in research opportunities as well as missed professional meetings and ceremonies. Students have also become anxious about how they will conduct their experiential rotations and take licensing examinations. Schools of pharmacy may need to assist students with potential well-being challenges arising from the COVID-19 pandemic, such as by helping students focus on what they can control, such as maintaining a regular schedule, and promoting emotional well-being by doing something they enjoy each day. 44
CONCLUSION
Promoting student pharmacists’ well-being is a multifaceted initiative. Several avenues exist for assessing well-being and for providing impactful interventions based on the perceived needs and the culture of a student body. Student pharmacists are the future of the pharmacy profession, and schools of pharmacy must nurture students’ well-being, not only in terms of academic performance but also emotional health. Incorporating a “well-being curriculum” is critical for student success following the COVID-19 pandemic. Pharmacy faculty are well positioned to talk to students and advise them that well-being challenges may arise during their time in pharmacy school. During these conversations, caring, openness, and understanding are of the upmost importance.
Appendix
Descriptions of Studies Pertaining to the Well-being of Student Pharmacists
Appendix
Results of Studies Assessing Student Pharmacist Well-being
Appendix
Results of Studies Evaluating the Impact of Well-being Interventions on Student Pharmacists
- Received June 29, 2021.
- Accepted August 31, 2021.
- © 2022 American Association of Colleges of Pharmacy
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