Burnout in Pharmacy professionals during COVID-19 outbreak

Abstract

Background and aim:

COVID-19 pandemic has had a major global impact on the economic, social, and public health sectors. The most serious consequences were felt firsthand in health systems and by their professionals, exposing them to greater physical and mental health risks, which need to be properly evaluated. This study aims to assess burnout levels in pharmacy professionals in the context of the COVID-19 pandemic.

Methods:

We collected data (N = 250), in pharmacy professionals (mean age of 34.24 years) (SD=8.99) who working in different areas during the pandemic period using the Burnout Copenhagen Burnout Inventory (CBI).

Results:

There was an increase in the number of weekly working hours after the onset of the COVID-19 pandemic and a decrease in the number of rest days per month. Most participants believe that their health status after the start of the pandemic is a little worse (44.4%). According to the CBI, the dimension with the highest average value of the Burnout subscale is related to the customer/user dimension (53.07), followed by the Work (44.60) and Personal (44.22) dimension.

Conclusions:

The levels of Burnout of pharmacy professionals are more accentuated in the Burnout dimension related to the client/user and that the average values of the various Burnout subscales are higher in Pharmacy Technicians than in Pharmacists. (www.actabiomedica.it)

Appendix – Supplementary material

Table S1.

Distribution of respondent´s work hour, before and during the COVID-19 pandemic.

Question	Weekly working hours
	[20;35] n (%)	[36;40] n (%)	More than 40 n (%)
Before the COVID-19 pandemic	53 (21,2%)	159 (63,6%)	38 (15,2%)
Currently in COVID-19 pandemic	38 (15,2%)	151 (60,4%)	61 (24,4%)

Table S2.

Respondent´s perception of their health status.

Variable	Category	n	%
How do you rate your health	Poor Reasonable Good Very good Great	7 68 113 53 9	2,8 27,2 45,2 21,2 3,6
Current health status, compared to one year ago	Much worse A little worse About the same With some improvements Much better	15 111 115 5 4	6,0 44,4 46,0 2,0 1,6
	Total	249	99,6%

Table S3.

CBI-PT: age.

Dimensions	Age
	Correlation	p
Personal Burnout Work Burnout Client Burnout	r = - 0,007 r = - 0,068 r = 0,211	0,914 0,288 0,001

Table S4.

Mean values of all subscales of the CBI-PT.

Educational qualifications

	Licenciate degree		Master´s degree		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	45,09 45,28 54,07	19,12 18,12 23,66	41,67 42,63 50,26	19,15 18,11 24,27	0,217 0,314 0,272

Habitation with someone working on the frontline, during COVID-19 pandemic

	No		Yes		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	44,44 45,04 53,57	19,32 18,84 24,08	42,91 42,08 50,23	18,32 13,15 22,45	0,653 0,361 0,439

Professional title

	Pharmacy technician		Pharmacist (and others)		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	45,92 46,70 55,35	18,89 17,86 23,50	36,88 35,64 43,53	18,71 16,54 23,07	0,003 0,000 0,002

Table S5.

Mean values of CBI-PT.

Work during the COVID-19 pandemic

	No		Yes		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	45,26 45,39 52,54	20,35 19,12 25,02	43,51 44,06 53,44	18,32 17,45 23,05	0,481 0,572 0,772

Household

	Lives alone		One to three		Four to seven		p
	Mean	s.d.	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	42,02 41,95 51,90	15,59 16,64 24,08	45,18 45,10 52,01	19,95 18,19 22,93	43,33 45,57 57,40	19,81 19,30 26,19	0,523 0,599 0,244

Marital status

	Single		Married/ Cohabiting		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	44,01 44,60 50,80	19,27 18,69 23,52	44,58 45,25 55,31	19,07 17,43 23,39	0,951 0,434 0,305

Table S6.

CBI-PT: Period of time working in the current workplace and the age of the participants.

	Time		Age
	Correlation	p	Correlation	p
Personal Burnout Work Burnout Client Burnout	r =0,013 r =-0,115 r =0,198	0,838 0,071 0,002	r =-0,007 r =-0,068 r =0,211	0,914 0,288 0,001

Introduction

Several cases of a new severe acute respiratory syndrome caused by a virus called SAR-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) were identified in earlier 2019. The disease caused by SARS-CoV-2 was then designated by the World Health Organization (WHO) as Covid-19 (Coronavirus disease 19) (1-3). The worldwide spread of the virus led the WHO Emergency Committee to declare a pandemic on March 11, 2020 (4). The pandemic caused economic consequences - drop in production, imports and exports, job losses, business closures and a drop in tourism; social consequences - increased poverty, restrictions such as isolation, quarantine, and new health habits (mask use, social distancing); and public health consequences - overloaded health systems (5,6).

Health care systems and health entities/ services were not prepared for the needs brought by the pandemic, which led to a lack of human resources and therefore overcrowding of pre-existing resources - increased work hours and increased amount of work (7). In this context, health care workers were the frontline of the fight against the new virus and are therefore at greater risk regarding their physical and mental health (8), and are directly exposed to the virus and to its psychological consequences, such as worry about infecting friends and family, lack of personal protective equipment, work overload, involvement in resource allocation decisions, and social discrimination (6,9). The emotional and work overload to which those professionals are exposed often results in occupational/professional stress and burnout syndrome. In this context, one study in China showed that a significant proportion of healthcare workers had symptoms of depression (50.4%), anxiety (44.6%), insomnia (34%), and discomfort (71.5%) (8).

Burnout syndrome (BS) affects the quality of people’s lives and puts individuals’ physical and mental health at risk. On the other hand, a health professional with BS does not have the same capacity to give patients the care they need, and the work performed loses quality. The effects of BS on the health and work performance of health professionals, and consequently on the good functioning of the health system, highlight the importance of increasing the prevention, diagnosis, and treatment of BS and appears in response to continued chronic, work-related stress (9-10). In several studies, BS is recognized as a serious problem among health professionals, patients, and the health care institutions, and can cause medical errors, depression, adverse effects on patients, and decreased safety (11-12). Over the years, due to high expectations and disappointments, the individual may develop a state of dissatisfaction and resentment. The work is less stimulating, and appear signs of fatigue, boredom, demotivation and discouragement, collapsing into the final stage of Burnout (12), women may have a more positive psychological attitude towards their personal perception and greater satisfaction with their work (13-15), and BS is more frequent in professionals who interact with clients and/or patients, or in an environment of extreme responsibility and precision (16-18).

Physicians and nurses in COVID-19 wards are exposed to a higher risk of psychological stress and its consequences compared to professionals in normal wards (8). However, other healthcare professionals may also suffer the effect of the determinants of this syndrome, namely pharmacy professionals, who underwent changes to their normal work with the onset of the pandemic.

Thus, this study aimed to assess the levels of burnout in pharmacy professionals in the context of the COVID-19 pandemic.

Methods

Data collection: Data was collected and applied by self-completion between April and June 2021 of pharmacy technicians in employment in either community pharmacies, hospital, or other area settings during the COVID-19 pandemic period.

Participants: A total of 250 participants [212 females (84.8%) and 38 males (15.2%) ] completed questionnaires that were usable for analysis. The average age was 34.24 ± 8.99 years, with the highest score between 20 and 30 years old (43.2%). Regarding marital status, 130 were single (52.0%), 110 were married/cohabiting (44.0%) and 10 are divorced (4.0%). Most of the participants has a degree (74.0%), followed by a master’s degree (24.0%). Regarding households, most of them were made up of one to three people (61.2%). 85.2% do not live with someone who works on the front line of the fight against the pandemic by COVID-19. There was a predominance of working in Community Pharmacies (55.6%), followed by Public Hospital (29.2%). Regarding professional title, 203 individuals are Pharmacy Technicians (81.2%), 44 are Pharmacists (17.6%), and 1 is a Pharmacy Assistant Technician (0.4%). Most of the participants (56.4%) have worked at their current workplace for less than 6 years, and most (59.6%) has worked for some time in the pandemic.

Measures: We used the Copenhagen Burnout Inventory Portuguese version (CBI-PT) (19-20). This measure quantify burnout in three scales: personal (regarding the respondent’s perception of their degree of physical and psychological exhaustion), work-related (perception of the degree of physical and psychological fatigue) and related to the work with clients/patients. The personal burnout scale consists of 6 items concerning general symptoms of exhaustion and can be applied to any worker; the work-related scale comprises 7 items and applies to all workers; the work with clients/patient’s scale comprises 6 items and can only be applied to people working with clients/patients. Each item has 5 available responses, which are quantified on a scale of 0-100 values (respectively 0,25,50,75 and 100). The final scores are calculated through the mean value of the items of each scale; the highest value corresponds to a higher level of burnout (19).

We designed a questionnaire composed of three parts Sociodemographic characterization (gender, age, nationality, marital status, educational qualifications, residence and household); Professional characterization (current workplace, professional title, working time at the current workplace, weekly working hours, and days off per month) and Health characterization (personal perception of health status).

Informed Consent Statement: Debriefing information appeared at the beginning of the survey. All subjects confirmed having read and understood and allow participate in the present study, and the protocol was carried out in accordance with the ethical and applicable regulations and guidelines.

Ethics Approval: This study received ethical approval from the Ethics Committee of the Polytechnic Institute of Coimbra with the refª “Parecer n.º 53_CEPC2/2021” and was carried out on a voluntary basis, without affecting any type of therapy or change in the lives of the participants, and all were informed them that this study was intended only for academic purposes, and be subject to analysis and discussion of results in the scientific community.

Data analysis: Statistical analysis was carried out using the software IBM SPSS® v.27. (IBM Corporation, New York, USA).

Results

Health status characterization: Regarding self-perception of health status, 45.2% of the individuals consider their health to be good, followed by 68 27.2%, who consider it to be reasonable and 21.2% who consider it to be very good. When comparing their current health with their health one year ago, 46.0 % consider their health status to be about the same, 44.4% consider it to be a little worse, and 6% think it is much worse.

Copenhagen Burnout Inventory (CBI-PT): Client related Burnout dimension presented highest mean followed by the dimension Work related Burnout and finally Personal Burnout. Although the mean values of Personal Burnout and Work Burnout are higher in the male gender, while those of Client Burnout are higher in the female gender, these differences were not significant (P>0.05) (Table 1 A and B).

Table 1A.

Characterization of the CBI-PT instrument.

Measure	Dimensions	Min.	Max.	Mean	s.d.	P25	P50	P75	95% C.I.
CBI-PT	Personal Burnout Work Burnout Client Burnout	0 4 0	100 93 100	44,22 44,60 53,07	19,15 18,11 23,83	29,17 32,14 37,50	43,75 42,8 50,0	54,17 57,14 70,83	41,67-46,55 42,46-47,03 50,09-56,14

s.d.: standard deviation; P25, P50, P75: percentiles 25, 50 and 75; C.I.: confidence interval

Table 1B.

CBI-PT: Gender.

Dimensions	Female		Male		p
	Mean	s.d.	Mean	s.d.
Personal Burnout Work Burnout Client Burnout	43,79 44,51 53,28	18,91 18,28 24,14	46,60 45,11 51,97	20,55 17,43 22,32	0,406 0,850 0,757

Personal Burnout and Work Burnout (PBWB): No significant correlations were found (P > 0.05), and PBWB was higher in participants who did not work during the pandemic period, while the value of Client Burnout was higher in participants who worked during this period. PBWB was higher for the group of married or cohabiting participants, while the mean value of Client Burnout is higher in the group of divorced/separated participants. However, such differences were not significant (P > 0.05).

Personal, Work, and Client (PWC): The mean values are higher in Pharmacy Technician participants compared to participants with a pharmacist title or other and those differences were significant (P ≤ 0.05). PWC was higher in participants working in the pharmaceutical industry, compared to the other locations. Such differences were not significant for the Personal Burnout subscale. However, for the Work Burnout and Client Burnout subscales, the differences were significant (Private Hospital/Community Pharmacy; Community Pharmacy/Pharmacy and Public Hospital/Community Pharmacy, respectively (Table 2).

Table 2.

CBI-PT: Current workplace.

		Personal Burnout	Work Burnout	Client Burnout
Regional Health administration (ARS)	Mean	44,44	61,90	52,78
	s.d.	4,81	14,43	29,27
State Hospital	Mean s.d.	44,63 19,39	46,04 18,46	60,67 24,62
Private Hospital	Mean s.d.	51,60 17,48	52,20 15,67	57,37 8,19
Community pharmacy	Mean s.d.	42,45 19,41	41,35 17,85	47,42 23,71
Para pharmacy	Mean s.d.	50,00 13,82	53,57 12,30	55,95 16,16
Pharmaceutical industry	Mean s.d.	75,00 5,89	66,07 7,58	72,92 38,30
Other	Mean s.d.	38,33 23,08	47,14 23,61	66,67 19,98
P =		0,209	0,012	0,001

Working Hours Increase: 13.2% of the individuals who worked up to 35 hours per week before the pandemic now work more than 40 hours per week. In the group of participants who before the pandemic worked between 36 and 40 hours per week, 17.0% now work more than 40 hours. As for the group of participants who before the pandemic worked more than 40 hours per week, 71.1% remained in this range.

Age: No significant correlations were observed for the subscales Personal Burnout and Work Burnout (P > 0.05). However, a significant correlation was found (P = 0.001) in the Client related subscale. Regarding the values of time working at the current workplace, no significant correlations are observed for the Personal Burnout and Work Burnout subscales (P > 0.05). For the subscale Client Burnout, a significant correlation was found (P = 0.002).

Discussions

Regarding Personal and Work, male participants have higher average levels of scores than females. Whereas, in the Client Burnout subscale, the female gender has higher scores. These results are in line that females who have a professional activity have better levels of physical and psychological well-being than those who do not have any activity (7,13-14). Women may have a more positive psychological attitude towards their personal perception and greater satisfaction with their work (13-15). The higher values for females in the Client Burnout subscale agree with the results obtained by a study in an Intensive Care Unit, in which female professionals reported higher levels of Burnout than males (7,15).

Concerning Client Burnout, a significant correlation regarding the association of the mean values of the subscales with the increasing age and period working ate the current location was found. The years of work should also increase and with this comes a state of dissatisfaction that may lead to Burnout (11). Workers go through several emotional stages regarding their perception of work, starting with a “honeymoon phase”, in which the work is ideal and exciting, they show high productivity and positive attitude (15). However, over the years, due to high expectations and disappointments, the individual may develop a state of dissatisfaction and resentment. The work is less stimulating, and appear signs of fatigue, boredom, demotivation, and discouragement, collapsing into the final stage of Burnout (16,18). Thus, professionals with more time at work show higher levels of Burnout.

Regarding Personal Burnout, Work Burnout and Client Burnout, pharmacy technicians shown higher values than pharmacists. These values are reflected in the exhaustion and motivation of workers, with the increase in work, and increased exposure. The percentage of workers working 20 to 30 hours and the days for rest decreased before the pandemic, explained by the increased demands for pharmacy activities. The needs brought by the pandemic led to increased working hours, decreased rest time, and consequently decreased leisure time and socializing time for professionals. COVID-19 pandemic has the potential to adversely affect the mental health of healthcare workers (24). Health care systems and health entities/ services were not prepared for the needs brought by the pandemic, which led to a lack of human resources and therefore overcrowding of pre-existing resources - increased work hours and increased amount of work (11).

As a response to the work and the factors that may trigger increased levels of Burnout, changes such as feelings of fatigue, sleep/eating disorders, anxiety, and depression may appear (16). Although the majority of the participants consider themselves to have good health today, pharmacy workers consider this state to be worse than it used to be before the beginning of the pandemic by COVID-19. Probably due to the consequences it brought to the lives of all individuals and the changes it implied in their work. A total of 61.2% of the individuals reported living with one to three people, a fact that may increase personal and professional stress levels due to the fear of transmission to family members, friends, and co-workers. This fact can be reflected in the performance of work functions and leisure activities. On the other hand, the existence of emotional support may minimize the impact of stress on the psychological health of individuals. These differences in the response of individuals can be attributed to individual personality factors (15). Occupational stress has become a public health problem, with both professional and personal consequences. These consequences are a direct result of professionals’ perceptions of the demands of the job, the demands caused by clients/patients, and their ability to overcome them (15,19). As a result of these demands, people are forced to adapt and resist these types of pressures.

BS is more frequent in professionals who interact with clients and/or patients, or in an environment of extreme responsibility and precision (15,20). COVID-19 pandemic has had a significant impact on the emotional wellbeing of mental healthcare professionals, resulting in anxiety and distress (19-20). The incidence of psychological distress in the general population has significantly increased during the pandemic due to the direct impact of the virus and the socioeconomic consequences of lockdown measures (21-25). It is possible to conclude that pharmacy professionals have high levels of burnout in the dimension related to the client/patient (mean value of the subscale higher than 50 percentage points); the same is not true for the remaining dimensions. These results differ from those obtained in the assessment of the levels of Burnout in mid-level professionals using the CBI-PT instrument, who obtained high burnout levels in all subscales (Personal Burnout = 72.35; Work Burnout = 72.39; Client Burnout = 73.63) (15). However, due to the cross-sectional character of the study, the results obtained are correlational and therefore, it is not possible to establish causal relationships.

It is important to highlight some limitations in the development of this study, namely the length of the questionnaire, which may have reduced the number of responses obtained. On the other hand, the professional associations contacted did not allow the distribution of the questionnaire as we would have liked.

Conclusions

With the onset of this pandemic, the consequences and demands on both the economic, social and health sectors were visible early on. Demands for which the world was not prepared. At these times, due to their constant exposure with other workers and patients, the mental and physical health of health professionals is at great risk. Therefore, this study was undertaken to evaluate the levels of burnout experienced by pharmacy technicians during the course and professional experience of this COVID-19 pandemic related to the individual’s perception of themselves, their work, and their work with patients. The results showed that not all participants feel equally affected by their work in a pandemic context.

The results of this study showed that female individuals may present more positive attitudes towards themselves and their work, however they have more difficulty when it comes to working with patients, reflected by the higher values in the Client Burnout scale (mean=53.28). Professionals with more time at work were correlated with higher Burnout values. The increase in weekly work hours and the decrease of rest days demonstrate an increase in demands on pharmacy professionals, with a decrease in leisure time and socializing. Values that should be considered with the high percentage of respondents who consider their current health status to be worse than it used to be before the beginning of the pandemic by COVID-19 (44.4%).

There is a growing need for further studies to test new models at the individual and professional/institutional level to prevent and reduce levels of burnout in pharmacy professionals. Research in pharmacy professionals is scarce worldwide and is extremely important.

Conflicts of Interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

Author Contributions:

EC, APA, CR, RC, SBC: conceptualization, methodology, software, validation, formal analysis, investigation, data curation; EC, RC, SBC: original draft preparation; APA, RC, SBC: review and editing.