Assessment of burnout and pandemic fatigue among pharmacy leadership in the Veterans Health Administration healthcare system

Abstract Purpose Factors associated with burnout in Veterans Health Administration (VHA) pharmacy leadership positions were examined during the coronavirus disease 2019 (COVID-19) pandemic. Methods A questionnaire was distributed to all pharmacy executives of the VHA healthcare system. It collected demographic and employment characteristics, career satisfaction and work-related variables, indicators of burnout using validated single-item measures adapted from the Maslach Burnout Inventory, and the impact of the COVID-19 pandemic on psychosocial and work-related variables. A χ 2 test with Bonferroni correction was used to evaluate the data. Burnout was defined as a score of 4 or greater on either of the 2 single-item validated statements adapted from the Maslach Burnout Inventory to assess emotional exhaustion and depersonalization. Results In total, 407 (of 1,027; 39.6%) VHA pharmacy leaders representing Veterans Integrated Service Network pharmacy executives, chiefs of pharmacy, associate chiefs of pharmacy, and inpatient and outpatient supervisors completed the survey. The overall prevalence of burnout was 68.6% using the aggregate measure of emotional exhaustion or depersonalization. Pharmacy leaders who worked more than 60 hours a week reported significantly greater rates of burnout than those who worked 40 to 60 hours a week (86.7% vs 66.9%, χ2 = 7.34, degrees of freedom = 1, P < 0.05). Those experiencing increased workload related to COVID-19 also reported high burnout rates (72.1%, χ2 = 16.40, degrees of freedom = 1, P < 0.001). Burnout scores were similar across groups when respondents were stratified by leadership position, gender, age, or years in position. Conclusion As of March 2021, two-thirds of pharmacy leaders were experiencing burnout. It is important for healthcare system leadership to identify patterns of burnout among their pharmacy leaders to ensure a productive and sustainable workforce.

B urnout is described by the World Health Organization (WHO) 2019 International Classification of Diseases, 11th Revision, as a syndrome caused by prolonged working stress that has not been effectively handled. Emotions of energy depletion or weariness, mental detachment from one's employment, and pessimism or cynicism about one's profession are all signs of burnout.
The presence of burnout syndrome in healthcare professionals, including in physicians and nurses, has been well documented worldwide. In 2012, Shanafelt et al 1 reported that 45% of physicians in the US acknowledge having at least one symptom of burnout. Research has indicated that higher levels of emotional exhaustion and depersonalization among healthcare professionals are associated with lower levels of patient safety and quality of care. 2 Although these reports highlight the prevalence of burnout within healthcare systems before the coronavirus disease 2019 (COVID-19) pandemic, the demands of the pandemic on healthcare systems across the nation has led to greater stress and frustration among healthcare professionals. 3 Studies focused on the well-being of pharmacists and support staff have indicated burnout rates of over 50% with high levels of emotional exhaustion reported. [3][4][5] In a 2018 survey, 53.2 % of pharmacists experienced a high degree of burnout on at least one subscale of the Maslach Burnout Inventory (MBI)-Human Services Survey. 6 However, data are scarce on the incidence of emotional exhaustion and depersonalization among pharmacy leaders. When working to minimize turnover rates within a healthcare system, it is necessary to explore the impact of job satisfaction and workplace-related burnout for pharmacy leaders to optimize healthcare delivery. This descriptive study aimed to explore the factors associated with burnout in Veterans Health Administration (VHA) pharmacy leadership positions during the COVID-19 pandemic.
Methods design. This report describes the utilization of a cross-sectional survey to evaluate burnout and job satisfaction in Veterans Administration (VA) medical centers while also identifying potential barriers experienced by staff ascending in leadership responsibilities within the healthcare system. The survey was conducted from February 5 to March 19, 2021. The institutional review board of the Edward Hines Jr VA Hospital/ Captain James A. Lovell Federal Health Care Center completed a formal review and granted the study exempt status before data collection.
sample. All Veterans Integrated Service Network (VISN) pharmacy executives (VPEs), chiefs of pharmacy, associate chiefs of pharmacy, and pharmacy supervisors were included. All 1,027 potential participants were identified through VHA pharmacy leadership email groups, which included all medical centers across a total of 23 VISNs.
Measurements. The 23-question inventory was developed through literature review. The first section of the inventory included 2 single-item validated statements adapted from the MBI to assess emotional exhaustion (MBI-EE) and depersonalization (MBI-DP). MBI-EE ("I feel burned out from my work.") and MBI-DP ("I worry that this job is hardening me emotionally.") were registered on a Likert scale from 0 (never) to 6 (every day). Burnout was defined as a score of 4 or greater on either the MBI-EE or MBI-DP (once weekly or more). Validation and utilization of these abbreviated burnout assessment tools has been described by previous literature. 7,8 The series of statements intended to determine the impact of the COVID-19 pandemic on the emotional well-being of VHA pharmacy leaders was answered using a 7-point Likert scale (from 1 [strongly disagree] to 7 [strongly agree]).
The questionnaire also requested respondents to provide demographic information. Additionally, respondents could assess their career satisfaction and respond to questions regarding the work environment at their institution. The items assessing career sustainability were as follows: "My work schedule takes me away from my personal/family life," "I wonder how long I will be able to continue working/ leading my staff," "I feel a sense of dread when I think about the work I have to do," and "My work is satisfying and meaningful to me." Each item of work-and career-related satisfaction was measured on a 7-point Likert scale (from 1 [never] to 7 [every day]) and was treated as its own metric (ie, a summary score was not calculated). The items to assess career and work environment were identified as critical through a review of the current literature on pharmacists' career satisfaction, turnover, and job stress.
The inventory was peer reviewed by pharmacists from the VA Pharmacy Benefits Management Services Clinical Pharmacy Practice Office and the VA Central Iowa Health Care System. The investigators pilot tested and revised the survey before it was distributed to all active VHA pharmacy leadership virtually using the REDCap online survey tool. 9 REDCap is hosted through the VA Informatics and Computing Infrastructure and is accessible only through the VA Intranet. implementation.
A preliminary email outlining the objective of the survey was sent, followed by the survey link 2 days later; 3 biweekly reminder emails were sent automatically using REDCap to nonresponders. Investigators were blinded to the survey participants and responses.
Analysis. To achieve 80% power, with a Bonferroni-corrected α of ≤0.005 across 10 categories and a moderate effect size (Cohen's f = 0.25), the minimum number of participants needed was determined to be 264. However, no limits were placed on the number of participants allowed to complete the survey. A χ 2 test was used to compare the overall frequency of burnout and each characteristic of interest. The a priori level of significance was 0.05. For variables with statistically significant differences, Bonferroni correction was used for familywise multiple comparisons to avoid type 1 error inflation. Statistical analysis involved use of Python (version 3.8.8) with pandas (version 1.2.4), NumPy (version 1.19.2), and SciPy (version 1.2.1). Descriptive statistics were used to report the respondents' answers to career satisfaction and work environment statements.
When asked about work satisfaction, most pharmacy leaders indicated feeling a sense of fulfillment once a week or more (72.3%; 293/405) ( Figure  2). When asked about feeling a sense of dread when considering the work for which they are responsible, 46.6% (189/405) of pharmacy leaders reported concerns once a week or more. Additionally, 60.6% (246/406) of pharmacy leaders reported being taken away from personal and family life due to work responsibilities. When asked about their degree of concern about the sustainability of working and leading their staff in their current position, 45.6% (184/403) of respondents indicated being concerned once a week or   Figure 3 shows the top items the respondents noted as a major factor resulting in increased work stress, including workload (62.6%), resolving interpersonal/staff conflicts (22.6%), technology issues/stressors (6.9%), maintaining day-to-day operations (4.9%), balancing competing priorities (1.7%), surveyors (1%), and unforeseen issues (0.3%).
With regard to the impact of COVID-19, the majority of respondents reported increased workload due to COVID-19 (89.2%) ( Table 3), while 10.6% reported no change and 0.25% reported a decrease in workload. Because only one respondent reported a decrease in work hours secondary to COVID-19, their data was not included in the analysis due to the low sample size. Respondents who reported increased workload also reported significantly more burnout than those who did not (72.1% vs 41.9%, χ 2 = 16.40, df = 1, P < 0.001). No subgroup analysis was performed on the number of hour ranges worked per week as this was already addressed in the analysis above. Figure 4 shows the impact of COVID-19 on leadership practices. Across the study, respondents agreed that the concept of well-being for those affected by COVID-19 is strong within VHA (52.9%; 215/406) and most respondents agreed to some extent that VHA evaluates the challenges related to COVID-19 in a manner that considers the complexities of patient care (54.9%; 223/406). More than two-thirds of respondents remained neutral or disagreed that they had experienced new or increased feelings of inadequacy regarding their leadership abilities (67.8%; 274/404), while 74.8% (304/406) of respondents remained neutral or disagreed that the impact of COVID-19 had made them question their leadership abilities. Figure 5 shows the changes VHA leaders have enacted to adapt to the pressures of the COVID-19 pandemic, including new telework agreements (50.9%), a split workforce (22.9%), reallocation of staff to areas of need

discussion
Our research revealed that 68.6% of VHA pharmacy leaders are experiencing symptoms of burnout at least once a week, and those who reported increased workload due to COVID-19 indicated a higher occurrence of burnout symptoms. This multicenter report describes the largest and first national study on pharmacy leadership burnout thus far. Utilization of the MBI-EE and MBI-DP in this inventory ensured a validated assessment of burnout. This report characterized burnout trends across major VHA pharmacy leadership executive positions: VISN VPEs,    Pharmacy leaders serve as a vital part of all healthcare systems. The complexity of the job of every VPE, chief of pharmacy, associate chief of pharmacy, and pharmacy supervisor has increased significantly over the past decade. The COVID-19 pandemic has added a further layer of complexity, requiring more from every pharmacy leader in the organization. This survey aimed to explore the factors associated with burnout in VHA pharmacy leadership positions during the COVID-19 pandemic and identify potential workplace factors resulting in burnout among pharmacy leadership. In 2018, a survey among healthcare executives found that nearly 60% of healthcare leaders felt at least some degree of burnout, which is similar to the findings in our study. 10 Further, nearly 65%  The concept of concern for the well-being of those affected by COVID-19 is strong at my organizaƟon (n=406)  of pharmacy leaders in our study had a high score for emotional exhaustion, which is the subscale most commonly reported in studies evaluating burnout in pharmacists. 11 It is especially concerning that half the respondents met the criteria for burnout in depersonalization, which is congruent with previously published data in pharmacy staff, providing further support for the sustained and prolonged professional burnout observed in pharmacy. 4,6,12 The impact of burnout on healthcare systems is staggering and has led to calls to action to address burnout in healthcare professionals. 13 The number of direct reports assigned to each leadership position will vary greatly depending on a variety of factors, including the medical facility's complexity. However, supervisory positions often have the most direct reporting, with the number of direct reports decreasing as associate chiefs of pharmacy, chiefs of pharmacy, and VPEs assume more leadership duties. Despite this, burnout rates were similar across characteristics such as gender, age, and leadership position. The similarity in burnout rates between female and male pharmacy leaders provides further support for WHO's definition of burnout syndrome, which states that employment factors are more related to burnout than individual characteristics. 14 Although the respondents were predominantly female, the percentage of female respondents (55.3%) was still somewhat lower than the overall percentage of females in the VHA pharmacist workforce (67%), which may have falsely impacted our results. Interestingly, there was also no difference in burnout rates when stratifying by the number of years respondents had worked in their current leadership position. However, a lack of assessment of the total number of years respondents had worked in VHA may have falsely skewed our results. This could be a potential area for future study to identify long-standing burnout risk and the impact of emotional well-being on career decisions. Nearly three-quarters of our pharmacy leaders indicated that they had been in their current position for 9 years or less, further supporting the need to proactively protect the well-being of our healthcare system leaders to retain high-functioning individuals in their positions.
The number of hours worked per week was associated with burnout: pharmacy leaders who self-reported working more than 60 hours a week were found to have a significantly higher rate of burnout than those who worked 40 to 60 hours a week. When factors impacting burnout were considered, our respondents indicated that workload and resolving interpersonal/ staff conflicts were related to burnout in pharmacy leaders, as also supported by previous studies. 5,12 Research has also shown work overload to have a consistent relationship with burnout, with a critical point occurring when individuals are unable to recover from the demands of their work. 14 Avoiding task redundancy, limiting professional work hours, promoting mentor-mentee relationships, and employing cognitive behavioral and relaxation methods have all been found to help prevent and minimize burnout. 15,16 The COVID-19 pandemic forced pharmacy leaders to adapt their departments rapidly to avoid impact on the quality of patient care. In a recent study, 47% of pharmacists in a healthcare system reported currently having burnout, of whom nearly half  indicated that their burnout was related to the pandemic. 12 In our survey, respondents who reported an increased number of hours worked per week due to COVID-19 had significantly more burnout than those who reported no impact on their workload. The top 3 most common changes in response to COVID-19 to VHA pharmacy departments across the nation were an increase in or establishment of telework agreements, splitting of the workforce, and reallocation of staff to areas of need. This finding aligns with previously reported increased pharmacist workloads during the COVID-19 pandemic. Furthermore, pharmacy leaders may have been more frequently reassigned to other responsibilities than usual, resulting in less time for tasks expected to provide professional fulfillment, such as mentor-mentee relationships, quality improvement projects, or the development of new clinical services. Over half of the surveyed VHA pharmacy leaders agreed that VHA's response to COVID-19 sustained their trust in their employer. Similarly, when asked about the effect of the COVID-19 pandemic on their confidence levels, over half of VHA pharmacy leaders disagreed that the pandemic had caused them to question their leadership skills, further demonstrating their resilience and confidence in VHA. Although the survey had a 39.6% response rate, it is crucial to note that several people on the email list did not meet the inclusion criteria. The investigators were unable to sort the list before delivering the survey instrument because they were blinded to the identity of the individuals on the list. One of the first questions on the survey required participants to select their leadership position from a list of options. They were unable to complete the survey if their current title did not meet the inclusion criteria. As this questionnaire was voluntary, both selection bias and response bias are plausible; respondents who were concerned about their risk of burnout may have been more likely to complete the survey than those who were not. On the other hand, pharmacy leaders not participating in the survey because of a high level of burnout may have resulted in underreporting. Nevertheless, assessing burnout rates to monitor the mental well-being of our healthcare leaders is critical, especially in a workforce that was already experiencing shortages before the COVID-19 pandemic.
Identification of institutional and employment characteristics that may be driving burnout in pharmacy leadership is an important consideration as burnout undoubtedly has a significant impact on pharmacists, patients, and the healthcare system. Future work is required to identify optimal interventions to prevent and reduce burnout in our pharmacy executives. This report adds to the growing literature supporting recent calls within the pharmacy profession to address burnout much earlier in a pharmacist's career through the promotion of resilience and well-being.

Conclusion
According to the findings of this national survey, as of March 2021, twothirds of VHA pharmacy leaders were experiencing burnout. These findings emphasize the need to prevent and decrease burnout among healthcare executives. Continuing the conversation to highlight the prevalence of burnout among our healthcare professionals is critical to retaining valuable health-system pharmacy leaders and improving the care we provide to our patients.
disclosures Dr. Ourth serves as an associate editor for AJHP. The other authors have declared no potential conflicts of interest.

Additional information
The views expressed are those of the authors and do not necessarily reflect the views or policies of the Department of Veterans Affairs.