Integration of Well-Being and Resilience Training

Integration of Well-Being and Resilience Training Into the Curriculum of a Pharmacy Residency Program

By: Dr. Anne C. Carrington Warren and Dr. Gwen J. Seamon

Background and Purpose

Burnout is defined by the Agency for Healthcare Research and Quality as a “long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.”1 In 2019, the World Health Organization classified burnout as an “occupational phenomenon” in the 11th Revision of the International Classification of Diseases (ICD-11).2 While previous research on rates of burnout focused primarily on physicians and nurses; emerging data shows that pharmacists experience the phenomenon at similar rates. A 2017 nationwide study of hospital clinical pharmacy practitioners found a burnout rate greater than 60%, largely driven by emotional exhaustion.3 As the profession continues to embrace advanced practice roles, rates of burnout are expected to increase with increasing clinical responsibilities.4 The American Society of Health-System Pharmacists (ASHP) Foundation Pharmacy Forecast 2019 found that the increasing pressure of clinical roles and the complexity of healthcare will increase the annual turnover rate amongst frontline pharmacists to at least 15%, an expected increase from 6.8% in 2014.4 In response, numerous pharmacy organizations including ASHP, the American Association of Colleges of Pharmacy, and the American Pharmacists Association developed well-being initiatives and task forces to address these concerns.5-7

The National Academy of Medicine (NAM) is currently addressing the issue of clinician well-being through the Action Collaborative on Clinician Well-Being and Resilience, or “Action Collaborative.”8 This initiative was launched in response to the expanding body of evidence that burnout is widespread and ultimately affects patient outcomes. The focus of the action collaborative goes beyond addressing the negative outcome effects of burnout. A key result is “to understand the broader phenomenon of clinician well-being, and to help clinicians achieve a state of personal fulfillment and engagement that leads to joy in practice, and ultimately, a connection to why one went into health care in the first place.”8

A new conceptual model for understanding the complexity of clinical well-being was proposed by NAM in 2018, titled “Factors Affecting Clinician Well-Being and Resilience” [Figure 1].8 Patient well-being is the center of the model, as, without a patient, there is no clinician.9 Patient well-being is enveloped by the clinician-patient relationship, followed by clinician well-being. Surrounding clinician well-being are a myriad of factors, divided into either external or individual, which are known to affect clinician well-being and resilience. The external factors are defined as “Society & Culture; Rules & Regulations; Organizational Factors; Learning/Practice Environment; and Health Care Responsibilities.” Individual factors are defined as “Personal Factors; and Skills & Abilities.” The 2019 Society for Academic Emergency Medicine Consensus Conference notably utilized this framework to further identify areas of needed study amongst physician wellness, identifying the distinct

The purpose of this paper is to describe a Well-Being and Resilience Curriculum developed for a Post-Graduate Year 1 (PGY-1) Pharmacy Residency in an Ambulatory Care Setting, utilizing NAM’s “Factors Affecting Clinician Well-being and Resilience” model as a framework.

Educational Activity and Setting

This PGY-1 pharmacy residency was established in 2018 within a family medicine clinic that serves a largely rural population. The main clinic includes family medicine physician and dental residency programs as well as PGY-2 pharmacy residency programs in ambulatory care and geriatrics. The PGY-1 residency program is taking a unique approach to addressing resiliency and potential burnout. Utilizing the innovative model from NAM as a framework, preceptors ensure that each internal and external factor is considered to provide a comprehensive resiliency experience. The ways each component is addressed and tasks the residents complete during residency are described in further detail below.

Wellness Components

External Factors

External factors are those influences, circumstances, or situations that may be beyond one’s control. External factors have also been shown to carry more weight in contributing to burnout than internal factors.9 These factors can be difficult for residents to navigate and usually depend significantly on the culture of the organization and the patient populations that are served. The pharmacy residency program directors and staff worked to address these factors for their residents within the curriculum.

As a Family Medicine residency site within an Area Health Education Center (AHEC), the organization has a long-standing tradition of training the next generation of healthcare professionals in various disciplines such as medicine, pharmacy, behavioral health, nursing, dentistry, and nutrition. The organization supports a “Culture of Civility,” which operates under three foundational principles: Civility, Inclusivity, and Empowerment. The human resources department has an Inclusion and Diversity Team to ensure all people are treated with respect and kindness, and the contribution of people of different backgrounds is valued. As part of the “Culture of Civility” initiative, seminars are held throughout the year on varying topics, including microaggression and systemic racism. Although not required, pharmacy residents are encouraged to embrace this culture and utilize the support throughout the year. Including a “Culture of Civility” at an organization or department level may provide the foundation necessary to introduce a Well-Being and Resilience Curriculum in outside programs.

The pharmacy residency aligns the healthcare responsibilities of the PGY-1 with their current abilities and scope. Initial training within this residency program emphasizes teaching the residents to “practice at the top of their license” and to define their role on the healthcare team. Throughout the year, residency preceptor roles move from modeling to coaching to facilitating to grant timely autonomy and independence to residents. This process intentionally follows ASHP guidance on the roles of a preceptor so that residents will feel comfortable entering independent practice post-residency.13

The residency program director provides another level of support for residents by including weekly informal check-ins called “Coffee Rounds,” generally lasting around one hour on a weekday morning and involving all residents simultaneously. The aim is to promote an open-door policy for residents to seek advice whenever needed. The organization also encourages using an error reporting system to promote a culture of safety and transparency. Pharmacy residents, overseen by the residency program director and nursing manager, are responsible for evaluating and implementing at least one process change resulting from a reported error.

Additionally, for many new practitioners, the financial burden of maintaining licensure, accumulating required CE, and malpractice insurance are considered stressors. Pharmacists registered in North Carolina are required to earn 15 hours of CE per year for license maintenance. The organization offers free CE for their employees, including phar-

macy residents, when utilizing programs provided through the organization. Annual pharmacy state licensure fees and malpractice insurance are also covered.

The residency program created Primary Care Clinical Meetings (PCCM) for residents to feel more comfortable with various topics. These meetings are once-weekly, one-hour sessions led by a topic expert from the state. Attendees include all ambulatory care pharmacy residents in the area, and the meeting place is a conference room within this residency location. Topics include pharmacotherapy in chronic disease states; interdisciplinary topics including mental health, nutrition, and social determinants of health; transitioning from residency to pharmacy practice; and the business models associated with pharmacy administration and advocacy. Residents also gain insight through discussions about National/State Policies, litigation, and accreditation. The inclusion of periodic financial wellbeing seminars as well as advocacy discussions facilitated by state and local level organizations throughout the residency year may be a tangible way to assist residents in transitioning from a learner into a full-time career.

Individual Factors

While clinician burnout is widely viewed as a systems issue, NAM acknowledges the role individual factors can play in building capacity for resilience.8 This includes thoughtfulness around personal factors, as well as skills and abilities, to help individuals navigate changing landscapes and relationships. The residency curriculum intentionally incorporates personal and professional activities to support strengthening these individual factors.

Residents are supported in individual goals related to residency as well as that outside of pharmacy through creating a personalized development plan at orientation. At this time, an actionable plan for goal achievement is developed. The RPD meets quarterly with residents to support them in completing their goals and to update goals as needed. Additionally, time is spent throughout the year learning about various topics related to resilience, worklife integration, and well-being goals to support personal and professional goals.

Relationships and social support are known to be protective against burnout.1 This is especially important in a residency program, where many residents relocate and move away from friends and family. On day one of orientation, each resident is given “wellness coupons” that include coupons to trade in for items like emergency lunch delivery, a get-out-of-clinic pass for a half-day of administrative time, and group exertions for activities like pedicures and tubing the river (Table 1).

An annual retreat is held in July for the Pharmacotherapy Department. This allows the incoming residents to begin understanding their role and meaning within the care provided to patients in the organization. The retreat also sets the stage for building organic relationships with preceptor mentors. Following orientation, monthly opportunities to connect with preceptors and co-residents are scheduled throughout the year (Table 2).

To further expand the residents’ social network and opportunities for connection, residents from all other regional programs are incorporated into longitudinal opportunities to foster relationships (Table 3). Incorporating all residents within the region into required longitudinal learning activities was an intentional residency design to promote peerto-peer relationships both within and outside the program. When considering the inclusion of a Well-Being and Resilience Curriculum in one’s residency program, the authors strongly recommend allocating time on a regular basis for social and team-building activities.

In addition to relationships, NAM stresses the importance of personality traits, personal values, ethics, and morals contributing to well-being. Residency training allows individuals to reflect on these personal factors and how they affect their work. The leadership curriculum offered within the program formally incorporates these principles during once-monthly sessions and individualized, one-on-one leadership coaching. Residents are assigned a leadership coach at the beginning of the year and meet with them every other month for one hour. Leadership curriculum sessions meet monthly for three hours, and topics include personal leadership assessment, advocacy, servant leadership, interdisciplinary

communication, balance and time management, leadership book discussion, women in leadership, managing conflict, managing departments, supervising others, resiliency/burnout, and emotional intelligence. Sessions are led by leadership curriculum preceptors and pharmacy leaders within the community. Relevant skills and abilities are taught in this curriculum to familiarize residents with each topic and provide strategies for implementation in day-to-day life. Additional sessions on financial planning, transitioning from residency to practice, and best practices for job hunting are included in the PCCM curriculum.

To promote physical well-being, residents are encouraged to participate in local intramurals or running groups. Additionally, the organization’s health plan includes discounts on local gym classes. Recognizing that mental health is just as important, the organization contracts with a local Employee Assistance Program to provide free behavioral healthcare services to employees. Sick time for residents can include both physical and mental illness.

Discussion

No previous publications described the creation of a Well-Being and Resilience Curriculum within a pharmacy residency utilizing a recognized framework to ensure both the internal and external components of wellness were addressed. While residents provide feedback for the Well-Being and Resilience Curriculum periodically throughout the year and during exit surveys, no formal evaluation currently occurs. Additional study is needed to determine the extent of perceived benefit to residents and the overall impact on feelings of burnout. The authors of this manuscript believe there is usefulness in both modeling new curricula on a validated framework as well as continual re-evaluation of current curricula to determine if all components are met. This process may be a promising strategy to meet the evolving needs of residents entering the healthcare workforce.

Little research has focused on the impact of stress and burnout on pharmacy residents. A nationwide study conducted in March 2016 found that roughly 40% of pharmacy residents who responded to the survey reported moderate-to-severe depressive symptoms, as measured by Patient Health Questionnaire – 9 scores, and the rate of severe depressive symptoms increased from around 3% in September to nearly 8% by March (p<0.05).11 Additionally, previous research identified discrepancies in perceptions of well-being between residents and residency program directors (RPDs). In one study, less than half of residents reported a “good” or “great” level of well-being as compared with 80% of RPDs assessing their resident’s well-being as “good” or “great” (p < .001).12 Given the known impacts of burnout on professional well-being, quality of patient care, and increased healthcare costs, it is prudent to develop strategies addressing well-being and resilience within not only health-systems but also residency programs to better Only one previous study evaluated resident perceptions of a resilience curriculum in a PGY1 pharmacy residency program utilizing a quarterly survey.14 Results of these surveys showed that most residents (90%) rated the Well-Being and Resilience curriculum as highly or extremely valuable and that the most valuable component was the creation of a sense of community. While the resilience curriculums within these two programs are modeled differently, the authors plan to adapt portions of this survey for longitudinal use within the curriculum. In the future, a formal, quantitative assessment of the Well-Being and Resilience Curriculum will be created to identify the most valuable components, opportunities to improve the curriculum, and significant sources of stress within the residency year.

This initial research was designed to discuss creating a Well-Being and Resilience program that utilizes an evidence-based framework to ensure all external and internal components of well-being are addressed. Research has shown that student pharmacists often do not acknowledge nor recognize health-system factors as impactful on well-being.15 Thus, the authors postulate that a baseline discussion of NAM’s framework should be introduced during residency orientation alongside the Well-Being and Resilience Curriculum so that residents may be better educated and understand the interplay between external

and internal factors on well-being. Recognition of the “Factors Affecting Clinician Well-Being and Resilience” may result in better articulation of feedback and needs amongst residents, particularly as stress and workload rise throughout the year. Plans for this research include utilizing the information from this informal research to create a formal exit survey evaluating the impact of the Well-Being and Resilience curriculum on residents’ attitudes and overall wellness. Quantitative data to collect include yearlong attendance to optional “Culture of Civility” and CE sessions.

Summary

As multiple leading pharmacy organizations take a stand to address well-being, residency programs should consider incorporating training strategies to manage internal and external factors that impact resilience. This PGY-1 Pharmacy Residency is taking steps to address these factors by integrating a Well-Being and Resilience Curriculum. Clinician well-being is important and should be a component of pharmacy residency training.

Authors: Anne C. Carrington

Warren, PharmD, BCPS, CPP is an Assistant Professor of Clinical Education at the Mountain Area Health Education Center, Inc., UNC Eshelman School of Pharmacy in Asheville, NC. Andy. warren@mahec.net. Gwen J. Seamon, PharmD, CPP is a Clinical Pharmacist at St Elizabeth Healthcare in Edgewood, KY. Re-

becca Grandy, PharmD, BCACP,

CPP is an Assistant Professor of Clinical Education at Mountain Area Health Education Center, Inc., UNC Eshelman School of Pharmacy in Asheville, NC.

References

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Quality. Physician Burnout (2017).

Accessed 4 March 2020. https:// www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index. html 2. World Health Organization. Burnout an “occupational phenomenon”:

International Classification of

Diseases (2019). Accessed 6 July 2020. https://www.who.int/mental_health/evidence/burn-out/en/ 3. Jones GM, Roe NA, Louden L, et al. Factors associated with burnout among US hospital clinical pharmacy practitioners: results of a nationwide pilot survey. Hosp

Pharm.2017;52(11):742-751. doi: 10.1177/0018578717732339 4. Vermeulen LC, Eddington ND,

Gourdine MA, et al. ASHP pharmacy forecast 2019: strategic planning advice for pharmacy departments in hospitals and health systems. AJHP. 2019;76(2):71-100. doi: 10.2146/ sp180010 5. American Society for Health-Systems Pharmacists. Wellbeing & You.

Accessed 4 Mar 2020. https://wellbeing.ashp.org/ 6. American Association of Colleges of

Pharmacy. Wellness and Resilience in Pharmacy Education. Accessed 4 March 2020. https://www.aacp. org/resource/wellness-and-resilience-pharmacy-education 7. American Pharmacists Association.

Well Being. Accessed 4 March 2020. https://www.pharmacist.com/ well-being 8. National Academies of Sciences,

Engineering, and Medicine. 2019.

Taking Action Against Clinician

Burnout: A Systems Approach to Professional Well-Being. https:// doi.org/10.17226/25521. Reproduced with permission from the

National Academy of Sciences,

Courtesy of the National Academies

Press, Washington, D.C. 9. Brigham T, Barden C, Dopp AL, et al.

A journey to construct an all-encompassing conceptual model of factors affecting clinical well-being and resilience. NAM Perspectives (2018). Discussion Paper, National

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Medicine. 2020;27(4):317-332. doi:10.1111/acem.13937 11. Williams E, Martin S, Fabrikant A, et al. Rates of depressive symptoms among pharmacy residents. Am J

Health-Syst Pharm.2018;75(5):2927. doi: 10.2146/ajhp161008 12. LeDoux H, Bowers R, Shapiro M, et al. Perceptions of well-being among pharmacy residents and residency program directors. JAACP. 2020;3(3):623-629. doi: 10.1002/ jac5.1197 13. document for the ASHP accreditation standard for postgraduate year one (PGY1) pharmacy residency programs. Accessed 4 March 2020. https://www.ashp.org/-/media/ assets/professional-development/ residencies/docs/guidance-document-PGY1-standards.ashx 14. Swanson S, Schweiss S. Resident perceptions of a resilience curriculum in a postgraduate year 1 (PGY1) pharmacy residency program.

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Table 1: Wellness Coupon Template

Welcome Wellness Coupons

Class of 2023 - Ambulatory Care PGY1

***Be sure to plan ahead and coordinate schedules for redeeming group wellness coupons

Mani, Pedi, or Facial Courtesy of ____

Redeemable as time with preceptor or as preceptor-free time – based on resident preference

Lunch at the School of Pharmacy

Courtesy of ___

Redeemable for one lunch on campus

One free admin half-day Courtesy of your MAHEC RPDs

Redeemable x 1 (please provide 1 day heads up to your preceptor)

One home-cooked meal Courtesy of ___

Redeemable for 1 dinner

“I forgot my lunch?!”

Courtesy of __

Redeemable for one lunch at MAHEC (please notify __ by 11:30am if same day)

Coffee and breakfast treat from Starbucks Courtesy of ___

Redeemable x 1

Raid office chocolate drawer Courtesy of ____

Redeemable for repeated PRN use (no need to present coupon at time of transaction)

***Evening Lake Cruise with Wine OR Waterfall Hike (weather dependent) Courtesy of _____

Redeemable for 1 activity above

*** “Float or Hike the Stress Away”

Courtesy of ____

Redeemable for 1 tube, paddleboard, or hike excursion

Decorate your space! Courtesy of ____

Redeemable for one piece of office “flare” of your choosing (send link to item and she will order)

***Wine and Cheese Night Courtesy of ____

Redeemable for an outing to the Biltmore Wine Bar for wine and cheese

Treats from Free Clinic

Courtesy of ____

A Free Friday off to start an early weekend/ holiday or self-care day (no PTO necessary) A free breakfast from McFarlands.

Month Event

July

Pharmacy Department Retreat August Baseball Game September Beach Trip (includes former residents) October Halloween Party November Self-Care Sunday December ASHP Midyear Networking Dinner (includes former residents)

January February March April May June Holiday Party Galentine’s Day Dinner Game Night Regional Residency Conference Outing Bowling River Float Trip

Table 3. Required Learning Activities to Promote Regional Networking Among Residents

Learning Activity Description Residency Programs Included

Primary Care Clinic Meeting (PCCM) One hour, weekly lunch meetings focused on topics pertaining to ambulatory care Regional outpatient-focused residencies

Evidence-Based Medicine (EBM)

One hour, monthly journal clubs Diabetes Didactics Four hour, monthly intensive review of recent literature related to diabetes care Regional outpatient-focused residencies Regional outpatient-focused residencies

Teaching and Learning Curriculum (TLC)

Four hour, monthly sessions as part of the teaching certificate curriculum Global Health Curriculum Two week experience in Honduras All regional residencies

Pharmacy students and residents Medical students and residents

Dual publications: Yes, some portion of the results/data/figures in this manuscript has been published and written permission to reproduce or adapt previously published material has been obtained from the original copyright holder.