Impact of a Pandemic

Impact of a Pandemic on Resilience Levels within a Health-System Pharmacy

By: Dr. Kristen Augustina Korankyi Dr. Shannon Nicole Kraus Dr. Docia Okai

Key Points:

• COVID-19 increased responsibilities of healthcare workers and this study examines its psychological effect on pharmacy staff in a large academic medical center. • There was a slight increase in feelings of depression experienced by the pharmacy team based on a 3.2 point average change on the Patient Health Questionnaire 9 (PHQ-9). • Programs to promote resilience such as an online app/website with resilience training tips may help to prevent burnout in pharmacy team members with future studies examining their success.

Abstract

Purpose: Determine the impact of a pandemic on levels of resilience, burnout, and overall well-being among staff members at a health-system pharmacy.

Methods: Participants were emailed a REDCap® IRB approved survey comprised of the validated General Well-Being Index (WBI), Patient Health Questionnaire 9 (PHQ-9), COVID-19 related questions adapted from the Copenhagen Burnout Inventory and supplemental demographic questions. During the three-week survey collection period, email reminders were sent weekly. Additional supplemental questions solicited current perspectives on resilience and ways to promote employee well-being. Results were analyzed via descriptive statistics.

Results: 142 staff members responded (with 14 partial responses) resulting in a 90.1% completion rate and a 21.7% survey response rate. The median score for WBI was 2, which is similar to the median score in a national sample of US workers. A WBI score of ≥2 indicates greater risk of adverse outcomes including 2.9-fold higher risk of burnout and 1.8-fold higher risk of severe fatigue. There was no difference in the overall PHQ-9 score based on position within the pharmacy, however, technicians did experience a slightly significant change (~4.4-unit increase) compared to pharmacists (p<0.0401). There were no statistically significant demographic differences reported on WBI.

Conclusion: Reported burnout levels among a pharmacy department during a pandemic are similar to US workers surveyed prior to the

pandemic. There does not appear to be an influence of demographic variables related to PHQ-9 or WBI scores. Nonetheless, there is an opportunity to prioritize resilience training in order to cultivate well-being within the pharmacy department.

Keywords: professional burnout, resilience, health-system pharmacists, technicians, pandemic, COVID-19

Introduction

Burnout is a continual stress reaction characterized by emotional exhaustion, depersonalization, and lack of personal accomplishment.1

During the earlier months of 2019, the coronavirus (COVID-19) pandemic hit the world and ultimately shook the core of healthcare. As infection rates increased, mortality rates did as well.2 This perpetuated an increase in demand for healthcare workers with a parallel decrease in medical supplies and equipment. Shifts in demand translated into long working hours and strenuous working environments. Apart from the increased work burden, fear of contracting the virus and infecting loved ones were major contributors to stress. Previous literature evaluated the impact of the pandemic on emergency healthcare workers, by comparing individuals who worked in that department before the pandemic to those who were transferred there as a result of the pandemic.3 The Copenhagen Burnout Inventory was used and showed that all health care workers were experiencing moderate to severe burnout during the pandemic and nurses had higher burnout rates compared to physicians.3 A majority of the survey participants agreed that ways to cope with burnout should include the use of technological media such as watching TV or videos on the internet, spending time with loved ones and acts of gratitude from peers or from the work department.3 Additionally, a multicenter cohort survey was conducted in 2018 to measure the levels of and risk factors of burnout among health-system pharmacists.4 The Maslach Burnout Inventory Human Services Survey (MBI-HSS) was used to measure the degree of burnout. The survey study examined three MBI-HSS subscales of emotional exhaustion, depersonalization and reduced personal accomplishment with each scored individually. The results of the study showed that the survey participants were at a moderate risk of burnout with the highest percent of burnout in administration and the intensive care unit.4

Overall, current research on pharmacist burnout especially in light of a pandemic seems to be non-existent. Therefore, the goal of this quality improvement (QI) project is to determine the impact of a pandemic on levels of resilience, burnout, and overall well-being among pharmacists, pharmacy technicians, pharmacy residents, pharmacy leaders and pharmacy staff members at a health-system pharmacy.

Methods

Study Population

The survey population included 591 Wake Forest Baptist Health employees including residents, technicians, pharmacists, administration, and support staff at five hospitals who were involved in inpatient and outpatient services (Figure 1). Hospitals within the system range in size from 50 to 900 beds. Patient acuity and specialty services at each hospital vary, but overall include oncology, emergency medicine, pediatrics, trauma, transplant, and general medicine. Participants were identified by an all pharmacy staff distribution list using Microsoft Outlook (Microsoft Corporation, Redmond, WA). During the 3-week survey collection period, email reminders were sent weekly.

Study variables and outcomes of interest

The primary outcome of this institutional review board approved study included results from the General Well-Being Index (WBI), a validated tool used to screen for dimensions of distress including fatigue, burnout, depression, anxiety/stress, mental/physical quality of life.5 Additionally, COVID-19 related questions were adapted from the Copenhagen Burnout Inventory and the Patient Health Questionnaire (PHQ-9) to screen for depression6,7. Secondary outcomes included demographics (age, ethnicity, gender, marital status), work characteristics (work location, position [technician, resident, pharmacist, manager/ supervisor/ director, other], years of service), and open-ended survey questions to elicit information on current perspectives on resilience and ways that a health-system pharmacy department could promote employee well-being. Results from the survey were used to determine the state of resilience among the pharmacy department before and during the COVID-19 pandemic and how to best build resilience among the pharmacy team.

Study data were collected and managed via anonymous survey collection using REDCap® (Research Electronic Data Capture) tools hosted at Wake Forest Baptist Health. REDCap® is a secure, web-based application designed to support data capture for research studies. Only the study staff had access to the REDCap® database and electronic survey created solely for use in the project.

The survey assessed current state of resilience, burnout and overall well-being among health-system pharmacy department employees and the influence of key demographic characteristics (Appendix 1). All participants who met the inclusion criteria of being a Wake Forest Baptist Health pharmacy employee were sent an electronic survey with the validated WBI, PHQ-9 and supplemental demographic questions. The general WBI is a brief assessment designed to identify healthcare workers in severe distress and most likely in need of an individualized intervention. The WBI has been completed by > 35,000 individuals and evidence indicates that the tool also identifies healthcare workers whose degree of distress places them at risk for serious adverse consequences (i.e. medical error, turnover, and/or suicidal ideation).5 The WBI also includes questions about satisfaction with work-life integration and meaning in work. Scores on the WBI correlate with meaning in work, high/low quality of life, fatigue, burnout, and recent suicidal ideation.5 The PHQ-9, or Patient Health Questionnaire is a validated instrument that consists of 9 criteria upon which the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) depressive disorders are based. It is adapted from the full PHQ.6 The Copenhagen Burnout Inven-

tory measures personal burnout, work-related burnout, and client-related burnout.7

Data analysis

Descriptive statistics comprised the bulk of the statistical analysis. The statistical analysis included frequencies and percentages for analyzing the baseline characteristics and change in PHQ-9 and WBI scores. ANOVA along with Wilcoxon Rank Sums test and Kruskal-Wallis test were used in order to adjust for covariates with a p-value of less than 0.05.

The WBI includes 9 questions, 7 are in the form of “yes” and “no” questions and the last 2 questions are answered using a Likert scale. One point is assigned for each yes to the 7 questions. For Likert type questions, response of a 1 or 2 on the 7-point scale is given 1 point.5 For the PHQ-9, major depression is diagnosed if 5 or more of the 9 depressive symptom criteria have been present at least “more than half of the days” in the past 2 weeks, and 1 of the symptoms is depressed mood or anhedonia.6,8 Other depression is diagnosed if 2, 3,or 4 depressive symptoms have been present at least “more than half the days” in the past 2 weeks, and 1 of the symptoms is depressed mood or anhedonia. The PHQ-9 is scored on a scale of 0 to 27 with ratings of minimal depression to severe depression.6,8

Results

Overall, 142 staff members responded to the survey with 14 partial responses, resulting in a 90.1% completion rate and a 21.7% survey response rate. A majority of the respondents were female (83.6%) and were between the ages of 25-34 years old (44.5%). Also, many respondents were married or in a domestic partnership (61.3%) and white (84.7%). In terms of outcomes related to depression, about 47% of participants had a PHQ-9 score of 2 which indicates minimal depression. The average change in PHQ-9 score comparing feelings before and during the pandemic was 3.2 points, which represents a slight increase in feelings of depression during the COVID-19 pandemic. There was no difference in the overall PHQ-9 score based on position in the pharmacy (technician, pharmacist, resident, or supervisor/director; p= 0.1048), however, technicians did experience a slightly significant change (an average 4.4 unit increase in PHQ-9 score) compared to pharmacists, with an average 2.6-unit increase (p< 0.0401). In terms of the WBI, the median score was 2 (56.1% of participants), which correlates with national averages and represents an increased risk of burnout and severe fatigue. There were no statistically significant differences reported on the WBI related to demographic variables (p= 0.6266).

In addition to completing the survey, participants were asked to report what program format would be preferred in order to help promote resilience learning for the pharmacy team (Figure 2). A majority of participants (52%) stated an online app/website with resilience training tips of advice would be helpful. Other formats were ranked from highest to lowest percentages in the following order: half-day group workshop with a blend of in person and online components (25%), individual coaching sessions (16%), and 7% reported “other.” Comments left in the “other” field included daily focused attention on well-being during team meetings/interactions with colleagues, half-day group workshop plus an app for maintenance and reinforcement of tips and advice, and flex scheduling for employees to manage childcare/schooling and other personal needs.

Discussion

Healthcare professionals are relied upon daily to provide quality care for patients in a very fast paced environment. The demands placed upon healthcare workers can lead to feelings of burnout and emotional exhaustion, even without the impact of a global pandemic. In the 2018 study looking at levels and risk factors for professional burnout among health-system pharmacists, 53.2% of participants reported a high degree of burnout on at least one subscale of the MBI-HSS (emotional exhaustion, depersonalization, and reduced personal accomplishment) and 8.5% of respondents had scores indicating burnout on all 3 subscales.4 However, this study did not look at ways resilience could be built into the pharmacy profession or assess the impact of a pandemic on levels of burnout. Therefore, our present study indicates that in terms of depression before and during the pandemic, there was a slight increase in scores (3.2 points) during the pandemic. Additionally, the WBI score was reported as the national median of 2, indicating an increased risk of burnout and severe fatigue. Many respondents, 42.2% (54 people) were not aware of the current resources the institution had to deal with feelings of burnout and out of those who were aware of the current resources, only

Figure 2. If a program was started to help promote resilience learning for our pharmacy team, which format woud be best?

Online app/website with resilience training tips and advice Half-day group workshop (with a blend of in person and online components) Individual coaching sessions

Other

15.63 7.03

25 52.34

Figure 2. Other indicates responses that were descriptive that were not choices provided in the survey. These include: daily focused attention on well-being during team meetings/interactions with colleagues; half-day group workshop plus an app for maintenance and reinforcement of tips and advice; flex scheduling so employees can manage childcare/schooling and other personal needs. 28.1% actually used the resources. This illustrates that the methods available to build resilience before the pandemic need to be refined.

Our study identified methods to deliver resilience training to pharmacists. Other studies have examined methods of resilience training for healthcare professionals, with the predominant professions being nurses and physicians. These methods included continuing education courses focused on mindfulness-based stress reduction, yoga/breathing exercises, lifestyle advice (diet/exercise), and stress management delivered in a variety of ways including a half-day group workshop (in person/online), small group learning, one-on-one coaching sessions, and the use of an online app.9, 10,11,12,13,14,15 In our study, many participants stated an online app/website with resilience training tips of advice would be helpful. Overall, the results of our study indicate that COVID-19 did not significantly affect the well-being of pharmacy staff within a larger healthcare system. However, the median WBI score reflects an increased risk of burnout and fatigue, which demonstrates that there must be continued efforts to increase resilience among pharmacy staff members. Our study also identified a specific subset of pharmacy team members who are at an increased risk of burnout and fatigue. Technicians experienced a slightly significant change in PHQ-9 score (an average 4.4 unit increase in PHQ-9 score) compared to pharmacists, with an average 2.6-unit increase (p< 0.0401). Our study also identified methods to increase resilience and include an online app/website with resilience training tips and a hybrid online/in person group coaching session on resilience. These methods were similar to those employed in previous studies for nurses and physicians, which demonstrated improvements in resilience. Therefore, future studies may examine the impact of these training strategies on levels of burnout among health-system pharmacy team members.

Strengths of this study includes the use of Copenhagen Burnout Inventory and the PHQ-9, which assessed the physiological and psychological well-being of the participants. Additionally, this was a multi-centered study in a health-system pharmacy which adds to the body of literature on healthcare professional burnout. Limitations include a small sample size. Additionally, the time period in which the study was conducted may be a confounding variable seeing as it was at the end of the first wave of COVID-19. Future research on resilience in pharmacy staff members would possibly require a larger population of pharmacy team members in a variety of healthcare institutions, including smaller hospitals in addition to large academic medical centers. Diversifying the study population would help to examine trends in healthcare environments that increase risk of burnout (such as having larger volumes of prescriptions for multiple complex patients or increased patient care activities) and different perspectives on ways to promote resilience.

Conclusion

Results of this study demonstrated there was not a statistically significant difference in the well-being of the pharmacy staff at Wake Forest Baptist Health before and during the pandemic. However, the median WBI score reflects an increased

risk of burnout and severe fatigue. Half of survey respondents stated that an app or website with training would help promote resilience in the workplace. While timing of the survey may have impacted the results, it is nonetheless imperative to have resources to promote employee well-being during events such as COVID-19.

Authors: Kristen Augustina Korankyi, PharmD (Corresponding Author), High Point University Fred Wilson School of Pharmacy, High Point, NC and Wake Forest Baptist Health, Winston-Salem, NC. Kristen.Korankyi@cuw. edu. Shannon Nicole Kraus, PharmD, MS, BCPS, Wake Forest Baptist Health, Winston-Salem, NC. Docia Okai, PharmD, Wingate University School of Pharmacy, Wingate, NC and Wake Forest Baptist Health, Winston-Salem, NC.

Disclosures The authors of this manuscript have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter.

References:

1. PhysicianBurnout.AHRQ.https://www.ahrq. gov/prevention/clinician/ahrq-works/burnout/ index.html. Accessed November 2, 2020. 2. Burrer, S., de Perio, M., Hughes, M., Kuhar, D., Luckhaupt, S., McDaniel, C., Porter, R., Silk, B., Stuckey, M. and Walters, M., 2020. Characteristics Of Health Care Personnel With COVID-19 — United States, February 12–April 9, 2020. [online] CDC. 3. W.P.D. Chor, W.M. Ng, L. Cheng, et al., Burnout amongst emergency healthcare workers during the COVID-19 pandemic: A multi-center study, American Journal of Emergency Medicine, https://doi.org/10.1016/j. ajem.2020.10.040. 4. Durham M, Bush P, Ball A. Evidence of burnout in health-system pharmacists. American Journal of Health-System Pharmacy. 2018;75(23_Supplement_4):S93-S100. doi:10.2146/ajhp170818 5. Dyrbye LN, et al. “Ability of a 9-item Well-Being Index to Identify Distress and Stratify Quality of Life in US Workers.” J Occup Environ Med. 2016; 58(8):810-7. Kroenke K, Spitzer R, Williams J. The PHQ9. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x 6. Talaee N, Varahram M, Jamaati H et al. Stress and burnout in health care workers during COVID-19 pandemic: validation of a questionnaire. Journal of Public Health. 2020. doi:10.1007/s10389-020-01313-z 7. Patient Health Questionnaire (PHQ-9). Med.stanford.edu. http://med.stanford.edu/ fastlab/research/imapp/msrs/_jcr_content/ main/accordion/accordion_content3/download_256324296/file.res/PHQ9%20id%20 date%2008.03.pd. Published 2020. Accessed September 7, 2020. 8. Goodman M, Schorling J. A Mindfulness Course Decreases Burnout and Improves Well-Being among Healthcare Providers. The International Journal of Psychiatry in Medicine. 2012;43(2):119-128. doi:10.2190/ pm.43.2.b 9. Matheson C, Robertson H, Elliott A, Iversen L, Murchie P. Resilience of primary healthcare professionals working in challenging environments: a focus group study. British Journal of General Practice. 2016;66(648):e507-e515. doi:10.3399/bjgp16x685285 10. Cheshire A, Hughes J, Lewith G et al. GPs’ perceptions of resilience training: a qualitative study. British Journal of General Practice. 2017;67(663):e709-e715. doi:10.3399/bjgp17x692561 Maunder R, Lancee W, Mae R et al. Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training. BMC Health Serv Res. 2010;10(1). doi:10.1186/1472-6963-10-72 11. West C, Dyrbye L, Rabatin J et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism. JAMA Intern Med. 2014;174(4):527. doi:10.1001/jamainternmed.2013.14387 12. Bauer-Wu S, Fontaine D. Prioritizing Clinician Wellbeing: The University of Virginia’s Compassionate Care Initiative. Glob Adv Health Med. 2015;4(5):16-22. doi:10.7453/ gahmj.2015.042 13. Dyrbye L, Shanafelt T, Gill P, Satele D, West C. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians. JAMA Intern Med. 2019;179(10):1406. doi:10.1001/jamainternmed.2019.2425

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Well Being Index Questions

During the past month have you felt burned out by your work?

During the past month have you worried that your work is hardening you emotionally?

During the past month have you often been bothered by feeling down, depressed, or hopeless?

During the past month have you fallen asleep while sitting inactive in a public place?

During the past month have you felt that all the things you had to do were piling up so high that you could not overcome them?

During the past month have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?

During the past month has your physical health interfered with your ability to do your daily work at home and/or away from home?

Please rate how much you agree with the following statement: The work I do is meaningful to me.

Please rate how much you agree with the following statement: My work schedule leaves me enough time for my personal/family life.

Questions adopted from the Copenhagen Burnout Inventory and Patient Health Questionnaire-9 Since the start of the COVID-19 pandemic, how much do you worry about your family members and friends getting sick as a result of your exposure?

Since the start of the COVID-19 pandemic, how much do you worry about getting infected by COVID-19?

Response Options

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No Very strongly disagree Strongly disagree Disagree Neutral Agree Strongly agree Very strongly agree Very strongly disagree Strongly disagree Disagree Neutral Agree Strongly agree Very strongly agree

Response Options Not at all Mildly Moderately Highly, extremely

Almost never Once or a few times per month Once or twice a week Four or five times a week Almost every day

Since the start of the pandemic until now, how often have you had little interest or pleasure in doing things? Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you felt down depressed or hopeless? Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you had trouble falling or staying asleep or sleeping too much? Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you felt tired or had little energy? Not at all Several days More than half the days Nearly every day Since the start of the pandemic until now, how often have you had a poor appetite or overeating? Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you felt bad about yourself--or that you are a failure or have let yourself or your family down? Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you had trouble concentrating on things, such as reading the newspaper or watching television?

Since the start of the pandemic until now, how often have you been moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual? Not at all Several days More than half the days Nearly every day Not at all Several days More than half the days Nearly every day

Since the start of the pandemic until now, how often have you had thoughts that you were better off dead or of hurting yourself?

Not at all Several days More than half the days Nearly every day Before the pandemic, how often did you have little interest or pleasure in doing things? Not at all Several days More than half the days Nearly every day

Before the pandemic, how often did you feel down, depressed, or hopeless? Not at all Several days More than half the days Nearly every day

Before the pandemic, how often did you had trouble falling or staying asleep or sleeping too much?

Before the pandemic, how often did you felt tired or have little energy?

Before the pandemic, how often did you had a poor appetite or overeat? Not at all Several days More than half the days Nearly every day Not at all Several days More than half the days Nearly every day Not at all Several days More than half the days Nearly every day

Before the pandemic, how often did you have trouble concentrating on things, such as reading the newspaper or watching television?

Before the pandemic, how often did you move or speak so slowly that other people could have noticed or so fidgety or restless that you had been moving around a lot more than usual? Not at all Several days More than half the days Nearly every day Not at all Several days More than half the days Nearly every day

Not at all Several days More than half the days Nearly every day

Before the pandemic, how often did you have thoughts that you were better off dead or of hurting yourself?

Additional Survey Questions If a program was started to help promote resilience learning for our pharmacy team, which format would be best?

Before COVID-19 were you aware of your employer’s resources to cope with burnout? If yes, did you use the resources? Not at all Several days More than half the days Nearly every day Response Options Online app/website with resilience training tips and advice Half-day group workshop (with a blend of in person and online components Individual coaching sessions Other

Yes and I used the resources Yes but I did not use the resources Somewhat No

Rate how much you agree to the following statement: Decrease in working hours and/or income is a great contributor to COVID-19 related burnout.

Since the start of COVID-19, did your hours… Strongly agree Agree Neutral Disagree Strongly disagree Increase Decrease Stay the same