How Resilience and Wellness Behaviors Affected Burnout and Academic Performance of First-Year Pharmacy Students During COVID-19

DISCUSSION

Resilience provided some protection against burnout in our study, but the effects were inconsistent. For example, resilience did not predict exhaustion after controlling for age, gender, and race/ethnicity. The finding that resilience was partially explained by immutable factors—which may have, in turn, affected its relationship to burnout—aligns with a prior study of student pharmacists in which being married was more strongly related to lower burnout than personal behaviors.⁴ Although the relationship between age and resilience was expected, the finding that resilience was lower among students of color suggests that behavioral interventions (eg, mindfulness and other wellness behaviors) should not be the main approach to student well-being. Perceptions regarding the difficulty of overcoming adversity among students of color could be explained by numerous events at the time of this study, including the disproportionate effects of COVID-19 on communities of color, an increase in hate crimes against Asian people, and police violence against Black people. Indeed, a recent study in the Journal revealed some of the detrimental effects of racial trauma on the academic success and psychological well-being of Black student pharmacists.⁸

Our findings suggest that efforts to build resilience via behavioral change should be complemented with organizational support, especially for younger students and students of color. This aligns with a landmark report from the National Academies of Sciences, Engineering, and Medicine, in which health professional education and training programs are encouraged to address well-being from a systems-level rather than an individual-level perspective.⁹ Forms of organizational support likely to benefit all students include training faculty and administrators in follower-supportive leadership behaviors, increasing opportunities for faculty and peer social support, building social capital (eg, transparency and fairness in school policies, student voice in organizational decisions), and providing students with greater autonomy in their learning.¹⁰ Students of color are likely to derive additional benefit from an organizational climate of belonging and increased diversity among faculty and staff, as they are more likely to seek support from people who have faced similar experiences on account of their race.⁸

Wellness behaviors tended to decrease over time, but these trends did not correspond to decreases in resilience. This finding was even true for social time, which was a predictor of baseline resilience and decreased considerably by the end of the semester. The divergence between wellness behaviors and resilience raises questions regarding the connection between these phenomena, or at least the strength of their relationship relative to immutable factors. In practical terms, these findings suggest that professional organizations’ focus on promoting wellness behaviors to “build resilience” may be misplaced, even if resilience offers some protection against burnout. Schools of pharmacy would likely benefit more from resources to support organizational strategies, as these are generally more effective at improving long-term well-being compared to individual-focused approaches.^10,11

Baseline levels of exhaustion and disengagement already met some definitions for burnout, suggesting that problems may exist long before entry into the profession. One concerning possibility is that health professions select for students who are at increased risk of burnout because of their accumulated exposure to stressors when preparing and applying to school (eg, grade point average, standardized test scores, cocurricular activities). Some might argue that students matriculating in fall 2020 may have been exposed to an atypical amount of stressors at the onset of the pandemic; however, our finding that burnout scores were significantly lower than pre-pandemic scores at another school suggests this is not the case.⁴ Because the duration of burnout may help explain its overlap with depression,¹² these findings have major implications for the timing of burnout interventions in pharmacy education.

Academic performance was influenced more by markers of physical health (eg, nutrition, sleep) than by psychological well-being. The inverse relationship between sleep adequacy and grade point average was unexpected but could indicate that some students sacrificed sleep to achieve higher grades. With only one semester of data, we could not ascertain the longer-term effects of resilience, burnout, and wellness behaviors on grade point average.

A methodological strength of this study is that we measured burnout and wellness behaviors over time. Indeed, many of these variables changed over the course of just a few months, and results differed when variables were analyzed concurrently or as changes over time. These findings illustrate the importance of assessing burnout as a dynamic phenomenon rather than at isolated points in time.

Regarding limitations, our study was small and representative of one school, and it is unclear how our results generalize to other programs given variability in how the pandemic has been managed across the United States. However, one advantage of our student body is its diversity, which allowed us to assess for differences in the life experiences among students of color. A related limitation is our time frame, as it did not capture how the pandemic has evolved, including the availability of vaccines and emergence of new strains. Consequently, our study likely only measured students’ initial uncertainty about the pandemic, their reactions to social distancing requirements, and their experiences with remote learning. Another limitation is that we did not operationalize resilience as a dynamic phenomenon because it was not being targeted by a specific intervention. Given that students’ social time was associated with resilience at baseline, an intervention worth studying as the pandemic subsides is whether facilitated interactions between students, faculty, and staff affect resilience. Regardless of the intervention employed, we suggest that resilience be explicitly measured in future studies rather than using the term informally to refer to any attempt to improve student well-being via behavior change.