Abstract
Objective. To conduct an integrative review of existing literature evaluating burnout and stress to identify reliable, valid, psychometrically sound survey instruments that are frequently used in published studies and to provide best practices in conducting burnout and stress research within academic pharmacy.
Findings. We reviewed 491 articles and found 11 validated reliable surveys to be most frequently cited in the literature that can be used in future burnout and stress research. We also noted frequent misunderstandings and misuse of burnout and stress terminology along with inappropriate measurement. Additionally, we identified a variety of useful websites during the review. Lastly, we identified a relative dearth of published research evaluating organizational solutions to burnout and stress beyond personal factors, ie, resilience.
Summary. Burnout and stress among student pharmacists, faculty, and staff is an important research area that necessitates more robust, rigorous evaluation using validated reliable surveys with appropriate contextualization within psychological frameworks and theory. Future research evaluating organizational-level attempts to remedy sources of burnout and stress is also needed.
INTRODUCTION
Greater attention has been focused on personal well-being in recent years, and substantial efforts have been devoted to evaluating stress and burnout among student pharmacists, faculty, and staff. Studies have attempted to quantify and compare the stress and burnout experienced by students based on year in the program, gender, ethnicity, or in comparison to other populations.1-5 In addition to quantifying and identifying stress and burnout, research has also explored both the personal and organizational impact of stress and burnout on personal well-being and organizational effectiveness with compelling findings regarding the breadth of impact that burnout and stress can have.6-10 Unfortunately, there is a relative dearth of research, especially in pharmacy education, regarding interventions and their resulting impact on faculty, staff, and student overall well-being, etc.
Noticing stress or burnout among students or colleagues is often the beginning of these research projects, but thoughtful consideration is required to research these observations and meaningfully contribute to and expand upon existing literature. Frequently, scholars who begin research in this area quickly identify the challenges and complexity inherent to this research. Unfortunately, many of these studies fail to be published or have inadequate findings, as they succumb to common methodological flaws. Many of these flaws can be attributed to not having a clear definition of or simply a misunderstanding or misuse of the terms stress and burnout. Other studies fail to follow the scientific method and do not consider the true intent of a stress or burnout project at the outset and, therefore, are not sufficiently explicit in drafting their research question. Lastly, some researchers attempt to write and publish a manuscript simply because data is available, as their institution is collecting or has collected data on stress or burnout; this approach is also ill-advised. For example, the Accreditation Council for Pharmacy Education (ACPE) Standards, specifically Standard 24, encourages colleges and schools to assess and correct underlying causes of ineffective learning experiences, such as “perceived stress in faculty, staff, and students.”11 Although conducting projects for accreditation purposes is legitimate and certainly benefits the institution, simply conducting a descriptive analysis of these data or relating such an analysis to other factors via a cross-sectional design does not constitute meaningful research in this area. Given its lack of rigor and theoretical grounding, such research would be of limited value to the Academy and would likely not get published.
The intent of this integrative review is to provide faculty members and novice researchers interested in burnout and stress research a resource highlighting psychological theory; giving concise definitions of burnout, stress, and related pertinent terminology; offering a summary of reliable, validated, rigorous quantitative measurement tools; and providing suggestions for future research. Specifically, this article is focused on an individual perspective and does not address organizational measurement instruments or programs, nor does it address qualitative methods of measurement for burnout and stress, as these are beyond the scope of this review. We hope that this paper will help improve the rigor of burnout and stress research in pharmacy education and expand scientific inquiry and application of findings, ultimately helping to not only assess but also correct underlying causes of burnout and stress for students, faculty, and staff.
METHODS
In conducting this integrative review, we used a university librarian to assist in identifying previously published exemplar articles and validated instruments to measure burnout and stress. Database searches of PubMed, PsycInfo, CINAHL, and Web of Science were conducted. The Medical Subject Headings (MeSH) used for stress were stress, psychological; occupational stress; compassion fatigue; mental fatigue; caregiver burden; and stress disorders, post traumatic. The MeSH terms used to identify articles related to burnout were burnout, psychological and burnout, professional. To limit the results to validated instruments, the MeSH terms used were reproducibility of results; data accuracy; dimensional measurement accuracy; and scientific experimental error. This search strategy yielded 491 manuscripts that two of our study’s authors independently reviewed for inclusion of measurement instruments in this review. All debatable measurement instruments for inclusion were discussed among all authors using a consensus process to arrive at a shared final decision.
Defining Concepts Related to Occupational Stress
Most theories of occupational stress share a few common features (Figure 1).12 Stress is best depicted as a process rather than an emotion or event, because people tend to think of it in terms of both the causes, hereafter referred to as stressors, as well as their response.13 Stressors commonly arise from the physical or psychological demands of work and include factors such as workload, time pressure, role ambiguity or conflict, organizational politics, and information and communication technologies. For students, these may manifest as course and experiential workload, examination deadlines, assignment ambiguity or misinformation, use of multiple educational technologies, and outside employment. Faculty must also manage challenges related to workload and deadlines as well as ambiguity or conflict across multiple roles (eg, school vs practice site responsibilities), academic bureaucracy, and a growing number of technology platforms (eg, email, videoconferencing, file-sharing services, collaborative workspaces).
Model of occupational stress. Stress is best depicted as a process rather than an emotion or event.
If the response to a stressor is negative, it is referred to as a strain, and the relationship between stressors and strains is complex.13 For example, having too few stressors has been found to lead to boredom and can thwart the sense of accomplishment that results from overcoming challenges.14 Stressor response is also highly variable, as some people may experience significant strain with mounting demands whereas others may thrive in such environments. Many theories of occupational stress account for this variation by recognizing an intermediate step, sometimes referred to as appraisal because it represents an individual’s viewpoint or appraisal of a stressor as either a challenge or a hindrance.10 Challenges are viewed as being surmountable with effort (eg, workload) and can improve well-being until they exceed one’s capacities.15-17 Hindrances, by contrast, are perceived as being outside a person’s control (eg, organizational politics) and appear to exert only detrimental effects unless counteracted by sufficient resources (eg, supervisor support, autonomy in making decisions about one’s work).15,17
Appraisal is then followed by an initial response (eg, changes in heart rate, feelings of distress), and maladaptive responses eventually result in strains, especially following prolonged exposure. Feelings of psychological distress in the short-term are often referred to informally as stress, but they are more precisely viewed as a form of psychological strain and can lead to burnout if left unaddressed.13 Although the focus of this review is psychological strain, responses to stressors can also be physical (eg, headaches, gastrointestinal disorders) and behavioral (eg, substance use, disordered eating), and often these phenomena coexist.18,19 Both the initial response to a stressor and the eventual strain can ultimately affect organizational outcomes (eg, performance, turnover), illustrating the importance of well-being as an organizational priority even if strains are limited to a few students or employees.
Numerous personal and environmental factors can influence how a person appraises and responds to a stressor. Personal factors include personality and other dispositional traits (eg, neuroticism, locus of control) as well as skills and experiences accumulated over time, such as resilience, or one’s capacity to bounce back from adversity.20 Environmental factors include job resources such as supervisor or coworker support, levels of autonomy or control (ie, decision latitude) in the job, and organizational culture, which can manifest as formal policies as well as unwritten norms (eg, expectations to respond to email after hours). Both personal and environmental factors can serve as the targets of interventions to improve student and employee well-being, although individual-focused approaches tend to predominate the literature.21 Given that most stressors originate from work itself, organizational interventions aimed at reducing work-related demands (eg, providing greater role clarity, streamlining technology use) or increasing work-related resources (eg, increased organizational support, greater decision latitude) are likely to be more successful in the long-term.18
Measuring Burnout
Burnout is a psychological strain resulting from exposure to chronic, unmitigated stressors.22 Although most experts agree that burnout is limited to the work environment, others have challenged this assertion based on overlap between burnout symptoms and those of depression and other mental health disorders.23,24 Despite these relationships, one of the strongest arguments in favor of conceptualizing burnout as a workplace concern is that this allows one to attribute the problem to work-related factors rather than personal failings.
Burnout is commonly conceptualized as a syndrome consisting of three dimensions: exhaustion, depersonalization, and inefficacy. Exhaustion and depersonalization are thought to represent the core of burnout.25 Burnout-related exhaustion is traditionally measured in emotional terms, although some scales also include physical and cognitive fatigue. Exhaustion receives the most attention in the literature because it is the dimension that occurs most frequently; however, experts suggest that exhaustion alone is insufficient for defining burnout.22 Depersonalization (also referred to as disengagement or cynicism) refers to putting emotional distance between oneself and work, often as a response to exhaustion.22 The third dimension of burnout, inefficacy (or lack of professional accomplishment), is the least studied, and some research suggests it may occur independently from exhaustion or depersonalization.26
Although burnout has been a topic of focus in pharmacy, less attention has been paid to the optimal psychological state(s) that organizations should strive to achieve, as less burnout does not necessarily mean that people are thriving at work. In pharmacy education, most have advocated for building resilience and fostering well-being. The term resilience is often used informally, but a review of stress frameworks (Figure 1) illustrates that this framing is imprecise. Resilience may offer some protection from burnout, but it is only one of numerous factors affecting the stressor response, and its association with immutable characteristics (eg, age, gender, race) suggests that it is not entirely under a person’s control.27 Well-being is a better term, but because it spans physical, mental, and social health across all domains of life, interventions to improve overall well-being may be too broad to address burnout specifically.
Work engagement is a phenomenon that likely represents the optimal state of people at work, although experts disagree as to whether it is the opposite of burnout or simply a positive work-related state of mind.25 Work engagement is also a three-dimensional phenomenon and consists of vigor (ie, high levels of energy and persistence), dedication (ie, feeling a sense of pride and enthusiasm), and absorption (ie, being fully engrossed in one’s work, sometimes referred to as flow).28 To ensure that the full breadth of work experiences is captured in an organization, experts recommend measuring both constructs rather than viewing low levels of burnout as representing high levels of work engagement.25
To measure burnout, researchers have used a variety of validated and unvalidated questionnaires. The Maslach Burnout Inventory (MBI),29 the Oldenburg Burnout Inventory (OLBI),25 and the Copenhagen Burnout Inventory (CBI)30 are the most common validated instruments reported in the health professions literature.
The MBI is the most widely recognized burnout instrument. The original MBI for human services workers (MBI-HSS) measured burnout in human services professionals (eg, police, clergy, social workers) and addressed three scales: emotional exhaustion, depersonalization, and personal accomplishment. The MBI has since been adapted for use with medical personnel (MBI-HSS (MP)), educators (MBI-ES), students (MBI-GS (S)), and general use (MBI-GS) by slight wording alterations of select questions and scale changes to reflect the respective environments and group being studied. For example, the MBI-GS (S) scales are exhaustion, cynicism (toward studies), and professional efficacy (in relation to school accomplishments). The MBI instruments contain either 16 or 22 items and take 10-15 minutes to complete. The MBI is proprietary and, thus, involves a fee for use (https://www.mindgarden.com/117-maslach-burnout-inventory-mbi).
The OLBI was developed to overcome some psychometric issues of the MBI and measures two dimensions of burnout: exhaustion and disengagement from work. The OLBI exhaustion dimension differs from the MBI in that it includes physical and cognitive aspects of exhaustion, not just affective aspects.31 In the OLBI, disengagement includes the depersonalization component, but it also addresses a general distancing of oneself from work and work activities and not just the people with whom one works.25 Also, unlike the MBI, the OLBI does not include personal accomplishment for reasons described in detail previously.32 The OLBI instrument contains 16 items and is available as an appendix in a study by Demerouti and colleagues.25
The CBI was also developed as an alternative to the MBI and consists of three subdimensions: personal burnout, work-related burnout, and client-related burnout.30 The philosophical core of the CBI is the attribution of fatigue and exhaustion to specific aspects of a person’s life. Compared to MBI and OLBI, one major difference of the CBI is that it does not measure depersonalization/cynicism because the authors view them as a separate phenomenon.30 The CBI is a 16-item instrument and available for free online (https://nfa.dk/da/Vaerktoejer/Sporgeskemaer/Sporgeskema-til-maaling-af-udbraendthed/Copenhagen-Burnout-Inventory-CBI).
The Burnout Assessment Tool (BAT) is the most recent instrument developed as an alternative to the MBI.33 The BAT is based on a reconceptualized definition of burnout that includes four primary dimensions, namely exhaustion, mental distance, emotional impairment, and cognitive impairment, and three secondary dimensions, namely depressed mood, psychological distress, and psychosomatic complaints. The BAT consists of 33 items and measures both the core and secondary dimensions, producing a single burnout score as opposed to the multiple scale scores of the MBI and OLBI. The questionnaire is available as an appendix in the original validation manuscript.33
In addition to the three primary instruments, a subscale of the Professional Quality of Life Scale (ProQOL)34 has also been used to measure burnout in several studies.35 The ProQOL is a 30-item instrument with 10 questions each addressing compassion satisfaction, secondary traumatic stress, and burnout. However, the burnout subscale has been criticized for lacking adequate construct validity and, therefore, should be used with caution.36,37
Other researchers have attempted to measure burnout with a single question: “Overall, based on your definition of burnout, how would you rate your level of burnout?”38 Because of the simple administration and no-cost availability, it was offered as an alternative to the MBI. While a single-item measure may approximate burnout fairly well, one criticism is that it predicts high emotional exhaustion but not low exhaustion or depersonalization.39
Other measures of burnout certainly exist in the literature. A 2018 systematic review by O’Connor found eight validated measures of burnout cited in the literature between 1997 and 2017.40 These measures, including the number of times they were cited, include the previously mentioned MBI (n=54), CBI (n=3), and OLBI (n=2) instruments in addition to the Pines Burnout Measure (n=3), the Psychologists Burnout Inventory (n=2), the Organisational Social Context Scale (OSCS) (n=1), the Professional Quality of Life Scale (ProQOL III) (n=1), and the Children’s Services Survey-emotional exhaustion subscale (n=1). Ultimately, researchers should seek to use a tool most suitable to their specific research question.
Measuring Stress
As described above, the term stress is often used to describe the short-term feelings of psychological strain that can result from situations in which a person perceives their current resources (physical and psychological) are insufficient to meet the demands.41 Similar to burnout, stress has been studied broadly in health care and pharmacy education as well as in elementary, high school, and college students. Common struggles for measuring stress include those mentioned previously, including the complex and dynamic relationship of stressors, strain, stress responses, and individualized differences in responses, to name a few. Stress, even among researchers in the field, is now seen as too nebulous of a term to be used when referring to such a variety of things.42 To combat this, researchers have defined a stress typology including considerations for timing, life stage, stressor attributes and responses, and the time frame for measurement to assist researchers.43 Additionally, researchers seeking to evaluate stress are encouraged to review items from the MacArthur Foundation Research Network on Socioeconomic Status and Health as well as the Stress Measurement Network supported by the National Institute on Aging; this network includes a toolbox of 30 psychological measurement areas ranging from caregiver stress and financial strain to salivary cortisol with included notes and/or scales for measurement (https://macses.ucsf.edu/whatsnew/default.php) (https://www.stressmeasurement.org/).
Regarding measuring stress, one of the most commonly employed scales to assess a respondent’s subjective perception of stress is the Perceived Stress Scale (PSS), which is a validated scale available in a four-, 10-, and 14-question version and has participants answer questions regarding their feelings and thoughts during the past month on a four-point scale of “never” to “very often,” with higher scores correlating to greater stress.44 Refer to Table 1 for the 14-item PSS.
Perceived Stress Scale-14 Itema (PSS-14)39
The Stress Overload Scale is another commonly used validated tool and consists of a 30-item scale used to evaluate overload when an individual experiences demands that exceed available resources. Respondents answer questions evaluating their stress in the past week using a five-point scale.45 A recently developed 10-item version (Table 2) may also be used to evaluate acute stress overload, ie, when demands are greater than resources.46
Stress Overload Scale-Short (SOS-S)40
Another tool to evaluate global stress is the Stress in Context questionnaire. This validated questionnaire specifically attempts to contextualize stress perception based on the environment, ie, work, home, etc. This questionnaire is relatively new, but it has demonstrated good correlations to the PSS in evaluating self-reported measures of stress, well-being, and health.47
Other measures of stress exist but are beyond the scope of this review. Given the complexity of this topic, we encourage researchers to use the term stress to refer to the dynamic stimulus-response process depicted in Figure 1 and use terms such as stressors and strains (or responses, if studying more than just maladaptive reactions) to refer to the various components of this relationship. Researchers should also specify their stressors and strains of interest, as a variety of validated instruments are often freely available for measuring these constructs. Another important consideration is to determine whether global or facet-level measures of strain are more appropriate. For example, a global measure such as the PSS (or OLBI, if interested in longer-term effects) might be appropriate for assessing the effects of implementing a new examination scheme (ie, workload, time pressure) on student well-being, whereas a study assessing the effects of student loans (ie, a financial stressor) might include both a global measure as well as a measurement specific to financial strain, which could be as simple as a single item.48
DISCUSSION
Burnout and stress are two popular areas of research inquiry in pharmacy education that when viewed in context are pieces of a larger, more complex and interconnected conceptualization of stress and well-being. Research into these areas is critical to the Academy, as the profession of pharmacy, the students, the faculty, and the staff all are impacted by varying levels of strain from multiple sources. As discussed in this integrative review, researchers must evaluate more than simply stress or burnout in order to produce scholarship that is both publishable and will help advance this research area. An example that researchers could use as guidance is a 2018 study conducted by Gordon and colleagues, in which the investigators explored the effects of a job-crafting intervention among health care professionals.49 The research was grounded in established theory (eg, the job demands-resources model), and the investigators explicitly defined and measured their outcomes of interest (eg, the exhaustion domain of burnout) using validated instruments (eg, OLBI). Investigators introduced an evidence-based intervention (ie, training health care professionals on how to craft their jobs) and then measured the effects of the intervention on participants over time (ie, a longitudinal analysis). Notably, the study did not involve pharmacists, providing an opportunity for future research given that pharmacists might craft their jobs differently than physicians or nurses.
In this article, we have provided an overview of stress and burnout and referenced literature where additional information about the frameworks describing these phenomena can be found. We have also provided a list of validated instruments commonly used to evaluate stress and burnout (Appendix 1). The information contained in this review may assist scholars in improving the rigor of their research. As illustrated in the example above, critical elements that researchers should employ include following the scientific method, asking specific research questions that are rooted in theory, correctly defining and measuring the outcome of interest with validated/reliable instruments, and taking into consideration the dynamic relationship between stressors, strain, and individual factors in relation to timing of data collection, etc. Lastly, we hope that this review will not only encourage further exploration into the measurement of burnout and stress but will also expand this research beyond simple measurement to also include novel ways to address these issues. It is our hope that this research will extend well beyond individualized traits and stress response (ie, resilience) and will include evaluations of whether organizational practices impact burnout and stress, including reports on the impact of theory-guided organizational changes on burnout and stress.
CONCLUSION
Burnout and stress are important research topics that warrant considerable attention within the Academy. Adherence to the research method and usage of validated reliable surveys will improve the rigor and utility of research findings in this area. Further research into burnout and stress remedies, including organizational practices, is needed.
Appendix
Comparison of Validated Instruments Measuring Burnout and Stress
- Received October 4, 2021.
- Accepted January 21, 2022.
- © 2023 American Association of Colleges of Pharmacy
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