An Assessment of Professional Burnout within Hospital Pharmacists: A Case Study of Abu Dhabi

Introduction

Burnout is a syndrome that results from unsuccessful stress management in the workplace.¹ It is characterized by three dimensions: energy depletion, reduced professional efficacy, and feelings of negativity. Burnout terminology was first developed by American psychologist Herbert Freudenberger in the 1970s to describe the consequences of severe stress in helping professionals, such as social workers, nurses, and psychologists^2,3 In 1982, Maslach defined burnout as a psychological syndrome related to emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment among those who work with others in challenging situations.⁴ Maslach et al. (2018) described burnout dimensions in detail, where emotional exhaustion was defined as feeling tired, emotionally drained, lacking drive, and irritable due to work.⁴ Depersonalization is defined as distancing oneself during interpersonal contact with customers, clients, or patients, and feelings of negativism.³ Low personal accomplishment indicates a feeling of reduced competency and efficiency.⁴

Burnout is included in the 11th revision of the International Classification of Diseases - 11 (ICD-11) as an occupational phenomenon; however, it is not considered a medical diagnosis.¹ According to Padgett and Grantner (2020), burnout causes are difficult to isolate because of their individual-specific nature and wide-ranging symptoms.⁵ Workload is considered a burnout risk factor, particularly if job requirements exceed reasonable human limits.³ Other burnout risk factors include having no establishment of an individual role within the work environment and insufficient rewards or the absence of a reward system.⁵ In addition, having minimal opportunities for social interaction, unfair workplace decisions, and inconsistent motivation among workers are all well-known risk factors. Other risk factors contributing to burnout in the healthcare sector include the challenges of clinical work, performance metrics, time constraints, conflict of leadership, technology limitations, and competing demands.⁵ To date, no studies have assessed burnout prevalence among hospital pharmacists in the United Arab Emirates. Consequently, this study aimed to measure burnout levels among hospital pharmacists in Sheikh Khalifa Medical City, Abu Dhabi, using a valid and reliable data collection tool to establish non-biased results.

Background

Many studies have shown the impact of burnout on the brain and health of those suffering from burnout.⁴ A study in which magnetic resonance imaging of 110 participants was analyzed, in addition to other psychological measures, concluded that burnout changed brain anatomy. Changes in the amygdala specifically affect negative emotion regulation in participants with high levels of burnout.⁴ Among Swedish healthcare workers, those with burnout reported anxiety, depression, neck and back pain, and memory impairment compared to Swedish healthcare workers without burnout.⁶ Another study confirmed a strong association between somatic symptoms, such as sleep disturbance and headache, in those reporting high degrees of emotional exhaustion. Furthermore, there is an elevated rate of general physical illnesses in people experiencing higher grades of burnout compared to those with lower stages of burnout.⁴ A study published by the American Psychological Association indicated that the impact of burnout on one’s health might be greater than expected.⁷ The researchers presented evidence supporting several mechanisms related to burnout and sickness, including metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis, sympathetic nervous system activation, systemic inflammation, impaired immunity functions, blood coagulation, fibrinolysis, and poor health behaviors.⁷ Another study concluded that burnout is associated with physical and mental health problems such as hypertension, gastrointestinal disorders, and insomnia.⁸

A systemic review conducted by Elbarazi et al. (2017), which evaluated 19 studies measuring burnout among healthcare professionals, claimed that burnout was assessed mainly among physicians, medical residents, nurses, social workers, surgeons, and physiotherapists, but not among pharmacists.⁹ The review included Middle Eastern countries such as Bahrain, Egypt, Jordan, Lebanon, Palestine, Saudi Arabia, and Yemen (9). This systematic review, which took place in 2017, indicated the need for future burnout research in Gulf countries to include a broader spectrum of healthcare professionals, such as dentists, dieticians, medical technicians, laboratory scientists, midwives, pharmacists, and radiographers.⁹

The availability of stress and burnout management materials may aid in reducing stress and burnout. A study evaluating burnout among hospital and health system pharmacists in North Carolina indicated that the decreased risk of burnout was associated with the availability and awareness of burnout resources.¹⁰

The American Pharmacists Association (APhA) and The American Society of Health-Systems Pharmacists (ASHP) provide resources for pharmacy teams to maintain pharmacy personnel’s well-being, resilience, and professional engagement. In addition to the programs offered by APhA and ASHP, pharmacy staff in the United States have access to a well-being index. The well-being index is a useful screening tool created by the Mayo Clinic to assess fatigue, depression, burnout, anxiety, stress, and mental/physical quality of life.¹¹

Methods

Results

The MBI-HSS MP questionnaire was distributed at five pharmacy sites and a pharmacy administrative office (the pharmacy sites involved were an outpatient pharmacy, inpatient pharmacy, discharge pharmacy, behavioral science pavilion pharmacy, and clinical pharmacy).

Sixty-eight pharmacists participated in the study out of ninety pharmacists, with a response rate of 75.5%. Twenty-five pharmacists were from discharge, behavioral science pavilions, and emergency department pharmacies. This number is amalgamated as pharmacists rotate between pharmacy sites and are managed by the same pharmacy supervisor. Seventeen pharmacists were from inpatient pharmacies, 12 from clinical pharmacies, 11 from outpatient pharmacies, and the remaining three were from pharmacy administrations. Since the pharmacists practicing in emergency departments rotate between discharge pharmacies and behavioral science pavilion pharmacies, they account for most of the participating pharmacists (36.8%), followed by inpatient pharmacists (25%).

The majority of the participants were thirty-one to forty-five years old (48.5%), female (39%), and married (76.5%). The questionnaire showed that 4% revealed that their highest educational qualification was either a master’s degree or a diploma. The remaining 20% did not provide their educational level and left it blank. To address these missing data, analyses were conducted with and without these cases to check for consistency in the results. Additionally, such missing responses were excluded from statistical tests involving educational level to prevent any bias. Furthermore, most of the participants had practiced for approximately five years or less (41.2%). This was followed by six to fifteen years of practice experience (35.3%). See Table 2 for the demographic characteristics.

A breakdown of each MBI subscale, with the corresponding number of pharmacists who responded to a high, moderate, or low score, is shown in Table 3. The mean MBI-HSS MP score indicated a moderate level of emotional exhaustion (M = 22), depersonalization (M = 7), and personal accomplishment (M = 38). The majority of pharmacists had low emotional exhaustion (n = 30), low depersonalization (n = 32), and a high sense of personal accomplishment (n = 34). Furthermore, 15 pharmacists (22.1%) were identified as having a moderate level of emotional exhaustion, 14 pharmacists (20.6%) were found to have a moderate level of depersonalization, and 12 pharmacists (17.6%) had a moderate sense of personal accomplishment. Twenty-three (33.8%) and twenty-two (32.4%) pharmacists had high emotional exhaustion and depersonalization scores, respectively. While only twenty-two (32.4%) pharmacists were identified as having a low level of personal accomplishment.

Based on the definition of burnout, 17 pharmacists were considered to have high burnout (n = 17/68), as they had both high emotional exhaustion and high depersonalization scores. Moreover, 17 pharmacists were considered to have low burnout (n = 17/68) as they had both low emotional exhaustion and low depersonalization scores. Personal accomplishment scores were excluded when determining whether a pharmacist has high burnout, as a lower personal accomplishment subscale has low reliability in predicting burnout, as mentioned earlier by Kang and colleagues (2020).¹⁵

All pharmacists with high burnout were female, 16 of whom were educated to a degree level and one pharmacist did not reveal their education level. More than half of those identified as having high burnout were from outpatient pharmacies (n = 11) and the remaining were from discharge (n = 2), inpatient pharmacies (n = 2), and clinical pharmacies (n = 2). Nine pharmacists who were identified to have high burnout were married, two were divorced, and six were single. The minimum years of experience in SKMC for those with high burnout was one year and the highest number of years of experience as a pharmacist in SKMC was 19 years. Seventeen married pharmacists and one single pharmacist had low burnout because they had low emotional exhaustion, low depersonalization, and a high sense of personal achievement or satisfaction with their personal accomplishment, keeping in mind that the majority of the study population was married (76.5%). Two of the participating pharmacists had moderate burnout, emotional exhaustion, depersonalization, and personal accomplishment (married and divorced). Univariate analysis revealed that none of the factors (age, sex, marital status, practice settings, and years of practice) significantly affected the level of burnout (p > 0.05). See Table 4.

Spearman’s rho was used to identify the correlation between the study variables and high burnout. It revealed that there is a weak negative association between marital status and having high burnout, and between gender and high burnout, as well as between practice settings and burnout (see Table 5).

Although a weak negative association was identified, the correlation between all variables and high burnout was not significant (p > 0.05). Multivariate regression analysis was used to identify how study variables affect the level of burnout. None of the variables significantly affected high levels of burnout. Refer to Table 6.

Discussion

The aim of this study was to assess burnout presence/levels among SKMC pharmacists using the validated MBI-HSS (MP). The results of this study showed that 17 pharmacists had a high burnout status; all of those pharmacists were females. Based on the statistical analysis, there was no significant relationship between being female and high burnout. Previous studies failed to find a significant correlation between gender differences and burnout rates¹⁵; however, this study confirmed that female medical residents have higher burnout levels than their male colleagues. Burnout was assessed among hospital and health-system pharmacists in North Carolina, and it was revealed that more than half of the pharmacists were at a high risk of burnout. Being female was among the three factors significantly associated with increased burnout among pharmacists with high burnout and working in hospitals and health system pharmacists in North Carolina.¹⁵

In 2004, a MONICA study (Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study was conducted in northern Sweden to assess the prevalence of burnout. Researchers have used the (SMBQ) as a burnout instrument to evaluate burnout among active workers. The study concluded that women had higher burnout levels than men. According to Norlund et al. (2010), the difference in burnout levels between each gender is explained by work-related stressors and situational life factors, where the level of education, socioeconomic status, work object, and varying working hours are the main factors affecting female tolerance to burnout.¹⁶

A recent study during the COVID-19 pandemic supported the statement of different burnout levels among both sexes, where female workers had a higher burnout rate. A previous study conducted in Kuwait by Alsairafi et al. (2021) showed that the prevalence of severe depression is higher among females. The authors explained that females were at a higher risk of severe depression and anxiety due to hormonal fluctuation.¹⁷

Moreover, a study published by Alanazi et al. (2020) assessing burnout showed that burnout was higher in all parameters in females than in males.¹⁸ Another cross-sectional study that included hundred and two pharmacists in Saudi Arabia to evaluate burnout among pharmacists during the COVID-19 pandemic revealed that 59.1% of pharmacists were categorized as having burnout. Univariate analysis revealed that burnout levels were significantly higher among younger female pharmacists.¹⁹ Studies from Montreal University have disclosed an increasing gender gap in workplace burnout. Additionally, data from the mental well-being platform illustrated that female workers are 23% more likely than men to struggle with poor work-life balance and 45% more likely to suffer from work stressors. Bowling (2022) explained that an unequal share of work-life tasks, having less time for self-care, and being less promoted compared to males contributes to a higher prevalence of burnout in women.²⁰

Although all previous studies concluded that females had a higher level of burnout compared to males, an analysis of seventy-eight studies among nurses revealed that male nurses had a higher rate of burnout in general and a higher rate of depersonalization compared to female nurses. This affects the quality of patient services. Additionally, it negatively affected their attitudes toward their colleagues.²¹

This study did not find a significant association between burnout among SKMC pharmacists and different age groups. However, 11 pharmacists with high emotional exhaustion and high depersonalization were between thirty and forty-five years old. Seventeen pharmacists had low burnout, low emotional exhaustion, low depersonalization, and high satisfaction with their personal accomplishments. Excluding three pharmacists, two of them were more than forty-five years old and one pharmacist did not reveal their age; thus, confidentiality will not be breached, and identity will remain anonymous.

There are various published data on age and burnout. According to a new survey, COVID-19 worsened employees’ feelings of burnout, especially those working from home, due to prolonged working hours.²² The average age of workers who reported a higher level of exhaustion and burnout was thirty-two years old.²² During the COVID-19 pandemic, one study reported a higher burnout rate in those aged twenty-nine years old and younger with chronic conditions compared to other healthcare professionals without chronic conditions from the same age group.¹⁷ The same study concluded that, in general, the incidence of burnout was higher among females aged < 50 years. At the same time, a study from Saudi Arabia reported a higher incidence of burnout during COVID-19 among those younger than forty years old.¹⁸

Furthermore, a study evaluating the relationship between age and burnout in Canadian workers showed that burnout symptoms differed significantly according to the different life stages of working females and males. Males and females aged between twenty to thirty-five and fifty-five years and older were at a higher risk for burnout.²³ Moreover, among pharmacists working in different Singaporean hospitals, the burnout rate was higher among young pharmacists aged thirty-two years old and less than those thirty-five years and older.²⁴

In this study, the majority of pharmacists reporting high burnout were married (53%), and there was no significant relationship between being married and high burnout. Furthermore, most pharmacists with low burnout were married. This can be explained by the fact that the majority of participants in this study were married (76.5%). Similarly, many studies have claimed that marital status is unrelated to burnout dimensions. For instance, a survey to check community pharmacist resilience and burnout in Lebanon found that being married or single was not significantly related to burnout and resilience.²⁵ Another study assessing burnout among hospital pharmacists in Qatar claimed that marital status was unrelated to burnout.²⁶ On the other hand, a higher level of burnout was reported in unmarried hospital pharmacists and in unstable relationships in the United States. Moreover, single pharmacists working in Singapore reported a more elevated level of burnout, and in Turkey, it was established that marital status strongly affects burnout and resilience.²⁷ In addition, a published study assessing burnout among nurses confirmed that marital status is strongly related to a high level of burnout, with unmarried nurses being the most affected.²⁸

Participants were not asked about their working hours, as all pharmacists working in SKMC worked for eight hours, in addition to one hour of mandatory breaks. The main difference was in the evening and night shifts. There was no statistically significant correlation between practice settings and burnout among pharmacists working in SKMC. Different published papers have demonstrated that long work hours are a risk factor for psychological and work-related stress. Working ten hours or more per day, 40 hours of overtime per month, and 60 hours or more per week increased stress levels.²⁹ A study conducted in one of the Taiwanese medical centers among healthcare workers revealed a nonlinear association between working hours and burnout. The odds ratio was doubled in those hours exceeding 60 hours compared to those working 40 hours per week, tripled when hours exceeded seventy-four, and quadrupled when hours exceeded eighty-four.³⁰

Hospital pharmacists generally work eight hours per day, while retail pharmacists work around 12–14 hours per day.³¹ In contrast, National Health Service hospital pharmacists work around thirty-seven and half hours a week, and additional hours may be required in specific situations. Hospital pharmacists may be part of an on-call rota.³² The Manitoba Pharmaceutical Association (2004) confirmed that one of the pharmacy department’s responsibilities is to provide clinical drug information services—i.e., non-laboratory, advisory support to healthcare professionals regarding medications—twenty-four hours a day, seven days a week.³³ As a result, when staffing is unavailable after working hours, on-call pharmacists usually provide this service. As per the study by Padgett and Grantner (2020), it was confirmed that pharmacists working more than forty hours per week had a higher burnout level than those working less than forty hours per week.⁵

This study did not evaluate whether the number of dispensed items and prescriptions were related to higher burnout among SKMC pharmacists. The number of patients seen by outpatient pharmacists decreased during the COVID-19 pandemic, and even after COVID-19, the hospital was designated as a COVID-19 hospital, and patients were followed up in other non-COVID-19 hospitals. Nowadays, outpatient pharmacists verify hundred and thirty prescriptions per month with an average of thousand and four hundred items. Inpatient pharmacists verify approximately 70 orders per hour per shift and approximately fifty thousand medications are verified per month. Based on studies by Peat et al. (2022) and Bookwalter (2021), an increased volume of daily prescriptions is associated with higher burnout among community pharmacists.^11,34

While trying to assess the undergraduate level, four pharmacists left the question blank, nine pharmacists answered yes or no, and nine pharmacists answered higher or lower educational level. All pharmacists identified as having a high burnout were bachelor’s degree holders, except for one who did not reveal the educational level. In a study that evaluated burnout among hospital and health system pharmacists in North Carolina, 95% of the pharmacists had a graduate level degree and only forty-nine (13.7%) had an additional advanced degree other than Pharm D. However, education level, additional advanced degree, or obtaining certification through the Board of Pharmacy Specialties did significantly affect burnout subscales.¹⁵

Recent studies that assessed burnout, depression, and anxiety during the COVID-19 pandemic did not correlate this with healthcare professionals’ education level or examine the relationship between educational level and burnout or depression subscales.^17,18,35 However, the degree of burnout assessed among graduate pharmacists of Mercer University Southern School of Pharmacy from 1973 to 1983 showed that pharmacists holding a Pharm D degree experienced a lower degree of burnout than those holding a bachelor’s degree only.³⁶ A study assessing the impact of burnout on the academic achievement of Saudi female students enrolled in the College of Health Sciences confirmed that there was no association between burnout and academic achievement. There was no relationship between burnout and academic level of study. Students of pharmacy colleges were the only students among all other health sciences colleges to suffer from high burnout.³⁷ Moreover, a study assessing the job satisfaction among hospital pharmacists in Tikur Anbesa specialized hospital in Addis Ababa revealed that almost half of the pharmacists were poorly satisfied with their current job thinking that their formal education overqualified them for the current job they are practicing.³⁸

Additionally, the Abu Dhabi Health Services Company (SEHA), including its hospitals, is undergoing privatization. Privatization and changing the pharmacist’s contracts, including the housing and end of services, are of concern for many pharmacists, and this leads to job insecurity. A study conducted in Turkey by Aybas et al. (2015) confirmed an association between job insecurity and burnout, which is worth further investigation among SKMC and SEHA pharmacists.³⁹

The correlation between years of experience and high burnout was not significant. Among pharmacists identified as having high burnout, there were pharmacists who worked for more than 15 years and pharmacists who worked in SKMC for less than five years. To date, no study has specifically examined the correlation or association between years of experience and level of burnout. However, a study conducted among teachers of special education revealed that years of work experience is an important predictor of burnout and is significantly correlated with exhaustion and depersonalization.⁴⁰ A meta-analysis conducted by Brewer and Shapard (2004) illustrated that prolonged years of experience are associated with a lower level of burnout among employees working in some fields in the United States, including social workers, educators, nurses, psychologists, and mental health workers. Additionally, a small negative correlation between years of experience in the field and emotional exhaustion has been identified.⁴¹

Many preventative strategies suggested by Padgett and Grantner (2020) can be followed to reduce the risk of burnout in those with a low level of burnout, including encouraging a work-life balance by offering a flexible working schedule, enhancing organizational promotion and rewarding systems, defining wellness and burnout to the team, and communicating plans to the team. Furthermore, the same resource encourages pharmacists with high burnout levels to seek help and personal care, including emotional health, fitness, and nutrition.⁵

At the organizational level, in addition to offering a wellness program by the SKMC psychologist team, a progressive strategy to mitigate employees in general and pharmacists in specific needs to be implemented. In Stanford Medicine in California, a position was created years ago, called the chief wellness officer.⁴² As per Flemings and Desselle (2021), the chief wellness officer’s responsibility is to create initiatives to combat physician burnout; the same approach can be adopted toward combat burnout in SKMC.⁴² Additionally, SKMC can consider expanding or implementing access to mental health and self-care resources other than stress management resources as part of annual compliance exams and increasing the number of seats in the wellness program so that more pharmacists and SKMC healthcare professionals can join.

Conclusion

Burnout is a psychological syndrome related to emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment.⁴ Burnout has been assessed among hospital pharmacists in many Gulf countries but not in the United Arab Emirates. This study is the first to evaluate burnout among hospital pharmacists working in SKMC and SEHA. The study used the MBI-HSS for medical professionals to assess burnout among SKMC pharmacists. Sixty-eight pharmacists participated in the study, with a response rate of 75.5%. 25% of pharmacists working at SKMC had high burnout rates. Although statistically insignificant (P > 0.05), all pharmacists with high burnout were female and working in different pharmacy settings. Moreover, an additional 25% experienced low burnout, and 3% had moderate burnout levels. The remaining items were difficult to classify because they did not fit the Maslach definition of high, moderate, or low burnout. Moreover, marital status, age, and level of education were statistically insignificant in relation to burnout level. The research methodology did not allow the identification of the causes of burnout, and further investigation is required to identify burnout causes among SKMC pharmacists. Moreover, assessing burnout among pharmacy residents, interns, pharmacy store workers, and technicians is another area for future research.

Author contributions

Wadha Mohammed, Beth Fylan, and Liz Breen contributed equally to the study design, data collection, analysis, and writing of the manuscript. All authors reviewed and approved the final version of the manuscript.