Pharmacy Staff Burnout Impacts Patient Safety, Outcomes

Aislinn Antrim: Hi, I'm Aislinn Antrim with Pharmacy Times, I'm here with George MacKinnon, founding dean of the Medical College of Wisconsin School of Pharmacy and a professor there, to discuss burnout in the pharmacy and how it can ultimately impact patients. And so, burnout has become a particularly front of mind issue in pharmacies over the last couple of years, but it certainly existed before the pandemic. Can you just tell us what you've seen from pharmacies dealing with burnout lately?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, I think it's an excellent observation that the challenges and work environment associated with burnout has existed long before the pandemic. And some of the factors that have implicated the pharmacy work environment have not gone away. In fact, they've probably been exacerbated through the pandemic.

The American Pharmacy Association CEO executive, Scott Knoer, identified 3 major themes that we need to address in pharmacy practice, that being payment reform, provider status, and then work conditions. And they're all linked together such that if we had reimbursement models that actually are commensurate with the clinical care provided by pharmacists, that would be afforded through provider status, then pharmacists could be paid for the clinical care they're delivering to patients as opposed to dispensing only products and being paid for that. And that's where the volume issues come in, by shrinking margins as the effects of PBM management principles. And so, they're all linked together, coupled with now the pandemic, and that had certainly placed in a good sense, pharmacy at the center of many of our communities.

For health care during the pandemic, people were seeking out care, COVID testing was being done at pharmacies, as we well know. And then the vaccines became available. But what we didn't have was an upsurge in FTE allocation in that work environment, that could also balance the existing work that was occurring. And right in the precipice of the pandemic, I believe it was the early part of January of 2020, the New York Times had an article that came out about challenges in community pharmacy, in particular, and the wellbeing of patients and medication errors that happen. And every pharmacist will tell you, that's the worst feeling ever, if they in fact think that they've been involved with a medication error. And what we need to go back to is what's the root cause analysis of these medication errors in the work environment.

And so, I think that's where a lot of the work needs to begin. But once we identify a root cause, then we have to provide the solutions. And I think those are the tough challenges, because oftentimes, these solutions involve costs such as new technologies and costs such as people—FTEs. And that's both pharmacists and pharmacy technicians and other support personnel. So, kind of a long response there, but I think it's so linked, and the pandemic has only exacerbated where we are with it today.

Aislinn Antrim: Absolutely. And as you mentioned, in addition to impacting pharmacy, staff burnout can have impacts on patients. Can you go into these impacts a little bit more?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, certainly, every pharmacists I know for the most part went into pharmacy to help patients. And when that opportunity to interact with patients is diminished or taken away altogether, you limit that. And so, if we're directing patients to models of practice where they have limited interaction with the pharmacist or no interaction whatsoever, that challenges the patient, and so they're not going to get the experience, they're not going to get the counseling interaction with the pharmacist that they sorely need and want. And so that impacts them.

And when you add in the issue of burnout, in terms of a work environment, where you don't even have the time to address a patient concern—and sometimes it's just listening to patients to hear what their concerns are, that helps you identify what the best treatment plan is. And you know what, it may not be a pharmaceutical, and as a result, we may not get reimbursed because the pharmaceutical wasn't dispensed. Again, back to the point that everything's linked together, that if we had the ability to be paid for that cognitive service to a patient, that would be something we could bill for just like any other health care provider does.

Aislinn Antrim: Absolutely. And with such widespread burnout among pharmacy staff, how does this issue ultimately become a public health and safety issue for patients?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, certainly it does. And I think most recently, if I'm not mistaken, APhA and NASPA (National Association of State Pharmacy Associations) had a document that they put out in terms of the rights of pharmacists, and NAPB signed on to that most recently here in January. So, I think that shows leadership recently with NAPB in recognizing that the purpose of Boards of Pharmacy are to protect the public health. And we need to make sure that there are ongoing processes, whether that be statutorily defined or rules defined by each state that ensure that patient safety is maintained. And we have to abide by those areas that we've defined as such.

I hate to see that at many Boards of Pharmacy in some states they've already all but eliminated state pharmacy board inspectors. And so we don't have people coming through. We don't have the secret shopper coming through and seeing what's happening. But certainly paramount is patient safety. And I think the one thing that we have to do, on the education side again, I'm a dean of pharmacy. And we've had certainly an upswing in the number of schools of pharmacy but these recent past 8 years, we've had a downturn in number of applicants to our PharmD programs. And why is that? And I think we have to examine that is it because of the work environment? Is it because of the potential burnout that individuals are seeing there and work conditions that they do not want to go into that's resulting in a reduction in our workforce? I think it does have some correlation. But at the same time, we want to address the situation of making sure we have the requisite number of pharmacists and pharmacy personnel, ie pharmacy technicians, if that's what they're defining in the respective states that are involved in the work environment. We have a significant shortage of pharmacy technicians right now, we also have a breadth of pharmacy technician training. That is the gamut of what it takes to be considered a pharmacy technician. So, we have shortages in both areas and that's not a good recipe for positive outcomes. So again, using appropriate technologies, using appropriate workforce, I think will help address some of the challenges associated with public safety, medication errors, and negative outcomes.

The third element though, is I think we need to do some education on our behalf to 2 key stakeholders, and that's our prescribers—for the most part, our physician colleagues and other prescribers of medications—and our patients, that they need to bear with us. This is not going through a drive thru and getting an order of fries with your order. This is health care. This is a medication that can extend your life. This is a medication that can make you mobile and have higher quality of life. It's also medication that could have some negative outcomes if not taken properly with appropriate instruction. And so, this is not get in as quickly as you can, it's not get it as cheaply as you can. And that's some education we need to do.

Most recently, we've seen pharmacies that have gone to allowing pharmacists to take a lunch break. Wow, here we are in 2022. And we actually have that occurring and it's making news. I heard from actually a colleague of mine, a pharmacist, who said, yes, my significant other went to the pharmacy to pick up a prescription and they said they'd have to come back in half an hour because the pharmacist was on lunch break. And they were not appalled by that but were surprised by it. And I said, “Well try calling your doctor's office between noon and 1 and trying to get an appointment or someone answer the phones.” It doesn't happen. And we've educated the public to realize that our health care providers get commensurate time off as well. There's work that's been done in this space.

Krasinski at the American Medical Association has brought up the concept with others of this issue, the issue of the quadruple aim, where certainly the triple aim of was population health issues, engagement of patients in their care, and cost of care. But the fourth element, and that's the health care provider, assuming the quality of the life of the health care provider. And that's paramount. And we have work that has actually demonstrated that physicians working in tandem with pharmacists helps to increase their quality of care, their work productivity, but also their quality of life as a health care provider. And why is that? Well, I think why it is, is because we have a unique knowledge base that helps that physician provider in challenging situations with chronic medications that we can assist and in many cases, take over the management of that medication therapy, and they can essentially go to bed at night knowing that their patients have gotten good therapies, great management that day, and we're good to go, but someone else on the team is managing that. And so, I think that's an example of where we need to work in tandem. But the education needs occur both the providers and patients alike.

Aislinn Antrim: Absolutely. And what can really be done to fight burnout among pharmacy staff?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: So, I think one of the things is we need is data. And the American Pharmacy Association has a wellbeing index now that they are utilizing, and people can go there—pharmacists, I should say, not people—pharmacists can go there and complete the wellbeing index with respect to that. It is a document tool, I believe that was developed by Mayo Clinic, and it looks at overall distress of pharmacists. And if I'm not mistaken, most recently, they had almost 9000 pharmacists reported within a recent survey here in March that 32% had a distress level that was concerning. That's a third of the profession. A third of respondents reporting at significant distress. So, we have the data. Now what do we do with it?

And again, certainly some might argue that's anecdotal. That's an n=1. We've got 9000 pharmacists reported out of over 300,000 pharmacists. Okay, I realize that and I also want to bear in mind that stress not only occurs, burnout not only occurs in community-based pharmacy situations, but it occurs in the health systems, ie our hospitals, and those pharmacists that serve in long term care. So, it's throughout all our environments of health care delivery where we have pharmacists that burnout can occur. So, part of it is obtaining the data to demonstrate what the issues are.

I think also it’s advocating for your profession. I've also said with respect to therapy, there is no acceptable delay in therapy, just as there is no acceptable error rate. And so, we have to drive those down to nil, to zero. And we need to ensure that we have systems in place and processes in place where we have the right personality and technologies that drive us to those zero rates. And pharmacy is paramount to that. And so we need to be at the table, we need to be pounding our fists when we're meeting with administrators that are proven FTEs and other areas of health system, that we need the commensurate uptick in pharmacists.

We likewise need to be making sure our executive leaderships realize that at the chain pharmacy level, that certainly there's external stakeholders, but no external stakeholder, ie a stockholder, ever wants to encounter a medication error. And so, we need to make sure that they also realize we are providing the highest quality care with your commensurate staff that we need. We are way understaffed in terms of community pharmacy, and where our numbers are, we probably need an additional 1.5 to 2 pharmacy FTE allocations across the board. And if you look back years ago to independent pharmacies, that's how they ran their pharmacies, they had 2 pharmacists and there was an overlap. And that was not atypical that you’d encounter that at many small community pharmacies. And the reason was the independents knew it made good sense—not only business sense, but customer sense and patient care and outcomes. At that time, there was different margins at work in terms of prescriptions. That's now has all been eliminated. So yes, we do need to think about different ways by which pharmacists can be compensated for their clinical skills and outcomes.

Basically, at the end of the day, we need to walk home, go home, and not say how many prescriptions that I feel, but rather how many lives that I touch. That's where we need to be as a profession and we also need our colleagues and administrators also accept that as well.