Changing patterns of the prevalence of burnout and secondary traumatic stress in health‐system pharmacists throughout the COVID‐19 pandemic

Abstract Introduction The demands posed during the coronavirus disease 2019 (COVID‐19) pandemic have led to greater stress and frustration, which in turn can fuel exhaustion, cynicism, secondary traumatic stress (STS), and burnout. More evidence is needed regarding the prevalence of burnout and STS throughout the pandemic. Objectives The aim of this study was to describe the changing pattern of the prevalence of burnout and STS in health‐system pharmacists throughout the pandemic (early to 20 months into the pandemic). Methods A cross‐sectional, listserv‐based online survey was conducted in health‐system pharmacists. The survey was administered between April and May 2020 (early group) and again between October and December 2021 (20‐month group). The survey questionnaire included demographics, employment characteristics, COVID‐19‐related questions, survey of respondent's perceptions of prevalence and severity of burnout, and Professional Quality of Life Scale (ProQOL) which assessed compassion satisfaction and fatigue (burnout and STS). Results A total of 1126 health‐system pharmacists completed the survey (484 in the early group and 642 in the 20‐month group). Based on respondents' self‐rating of burnout, significantly more respondents reported feeling burned out in the 20‐month group vs the early group (69% vs 47.7%; P < .001). Based on ProQOL, significantly more respondents were identified with moderate–high likelihood of burnout (83.8% vs 65.3%; P < .001) and moderate–high probability of STS (63.2% vs 51.4%; P < .001) in the 20‐month group vs the early group. Approximately 99% of respondents in both groups were identified with moderate–high probability of compassion satisfaction. Conclusion Twenty months into the COVID‐19 pandemic, almost 83% of health‐system pharmacist respondents were identified with burnout, 63% with STS, and 99% with compassion satisfaction. These rates are significantly higher compared with rates early in the pandemic. Unfortunately, the development of burnout and STS in these pharmacists may lead to several work‐related consequences (eg, increase risk of medical errors); therefore, further studies are critical to develop and assess effective interventions to address the long‐term effects of the pandemic and well‐being of health‐system pharmacists.

effective interventions to address the long-term effects of the pandemic and wellbeing of health-system pharmacists. that 38% reported anxiety and depression, 43% suffered from work overload, and 49% had burnout (high or very high). 4 Allied health care professionals (speech therapists, occupational therapists, and social workers) reported the highest rates of burnout compared with other health care professionals. The prevalence of burnout and STS in pharmacists during the COVID-19 pandemic had been described in recent studies. One survey study showed that over half of health-system pharmacists were identified with burnout, half with STS, and three fourths with compassion satisfaction during the early period of the COVID-19 pandemic. 5 Another survey study conducted in pharmacists (42.2% in hospital and 39.9% in community setting) during the early period of the pandemic showed that emotional exhaustion and depersonalization scores were higher during the pandemic compared with pre-pandemic, which indicated increased burnout. 6 One survey study in pharmacists during the early period of the pandemic showed that about half of pharmacists reported increased feelings of physical and emotional exhaustion at work, 40% reported experiencing anxiety, and 25% reported more sadness or depression. 7 Based on these studies, the COVID-19 pandemic has put significant pressure and stress on health care professionals, especially pharmacists.
The demands posed during these unprecedented times perhaps have led to greater stress and frustration, which in turn can fuel the exhaustion, cynicism, and inefficacy of burnout. 3 This process has also been described as compassion fatigue, STS, and vicarious traumatization. Unfortunately, compassion fatigue, which includes burnout and STS, can lead to medical errors, impact standards of patient care and relationships with other co-workers, and lead to physical and mental health conditions. 3 Additionally, compassion satisfaction can also be present which occurred when a person is professionally satisfied with their position. The goal is for a person to have more compassion satisfication to increase the chance to overcome compassion fatigue related to their job. 3 Therefore, it is crucial to evaluate the extent of compassion fatigue and satisfaction in health care professionals, especially health-system pharmacists, throughout the COVID-19 pandemic. Currently, there are no studies that evaluated the changing pattern of the prevalence of burnout and STS, and perception related to burnout in health-system pharmacists throughout the COVID-19 pandemic. This study evaluated the prevalence of burnout and STS in health-system pharmacists early in the pandemic compared with 20 months into the pandemic.

| Study design
A cross-sectional, professional pharmacy organization listserv-based online survey was conducted with a target group of health-system pharmacists across the US. The local institutional review board approved the study prior to initiation. The primary objective of this study was to compare the prevalence of burnout and STS in health-system pharmacists early in the COVID-19 pandemic (early group) to 20 months into the pandemic (20-month group). The survey was sent out to five communities that include health-system pharmacists through the American Society non-health-system pharmacists and therefore would not represent healthsystem pharmacists who responded to the survey. Pharmacists who indicated that they practice in a U.S. health-system were included in the study. Incomplete survey responses were excluded from the study. The survey was initially sent to the members of the listservs between April 21, 2020 and May 20, 2020, which assessed the initial prevalence of burnout and STS in health-system pharmacists early in the pandemic. The same survey was sent to the same listservs between October 15, 2021 and December 31,2021, which assessed the prevalence of burnout and STS in these pharmacists 20 months into the pandemic. The methods of the initial study have been described in a previous publication. 5

| Survey design and data collection
The survey questions were developed through Qualtrics Survey Software, Version 2020 (Qualtrics, Provo, UT) by investigators, reviewed by pharmacists and managers, and modified based on feedback. The survey was also tested on 10 internal health-system pharmacists and further revised the survey based on results and feedback from these pharmacists. This established face and content validity of the survey.
The survey questionnaire included 62 items assessing demographics, self-rating of burnout. 8 The ProQOL was used to measure the negative and positive effects of helping others who experience suffering and trauma. 9,10 This tool has been used to assess both compassion satisfaction and fatigue in health care professionals in extremely stressful events. the low likelihood of the specific ProQOL category, a score between 23 and 41 indicated the moderate likelihood of that category, and a score of 42 or more indicated the high likelihood of that category.
More details regarding the ProQOL assessment tool were described in the published initial study. 5

| Study outcomes
The primary outcome of the study was the prevalence of burnout and STS in health-system pharmacists 20 months into the COVID-19 pandemic (20-month group) compared with early in the pandemic (early group

| RESULTS
The survey was started by 1421 health-system pharmacists and com-  Table 1 summarizes the demographics and characteristics of respondents and employment between the two groups.
As for the impact of the COVID-19 pandemic on employment status and other related factors (see Table 2), all COVID-19-related factors significantly decreased in the 20-month group compared with the early group.
There was a reduction in the number of respondents with decreased salary or benefits (17.1% vs 8.4%), respondents who have lost childcare There was a significant increase in the percent of respondents reporting that they have burnout based on the PWLS self-rating in the 20-month group compared with the early group (69% vs 47.7%, respectively; P < .001). There were more respondents in the early group who reported having a history of burnout compared with the 20-month group (81% vs 69.9%, respectively; P = .006). Of respondents who reported burnout, significantly more respondents in the 20-month group indicated that burnout was related to the pandemic compared with the early group (78.3% vs 51.2%, respectively; P < .001). As for duration of burnout when experienced, most respondents reported having burnout last for up to 12 months (81.3% in the early group vs 70.9% in the 20-month group). However, there were significantly more respondents in the 20-month group who reported having burnout last between 1 and 5 years (26.5% vs 17.7%; P < .001). Additionally, the perception of percent of pharmacists who are burned out in their institution increased by approximately 20% in the 20-month group compared with the early group (60.9% vs 43.3%; P < .001), which is similar to their own self-perceived burnout. The top five reasons and main drivers respondents believe pharmacists who are burned out were similar in both group and were due to: (1) workload, (2) efficiency and resources, (3) culture, (4) work-life integration, and (5) lack of rewards. Table 3 summarizes respondents' self-ratings, perception, and description of burnout.
Based on the ProQOL (see Table 4

| DISCUSSION
Several studies have shown that pharmacists are burned out during the COVID-19 pandemic. 5-7 A recent study (n = 439) showed that pharmacists reported increased feelings of physical exhaustion at work (45%) and of emotional exhaustion at work (53%) during the pandemic. 7 Additionally, approximately 40% of pharmacists reported feeling more anxiety and 25% feeling more depression or sadness.
Another recent study in pharmacists (n = 647) showed that the mean Maslach Burnout Inventory (MBI) scores for emotional exhaustion (28.5) and depersonalization range (7.98) were higher than reported pre-COVID-19 scores, which may indicate increased burnout. 6 Pharmacists reported that working overtime, medication supply and T A B L E 3 Description of self-reported burnout There are limitations with our study which included that the length of the survey perhaps caused fewer responses; but almost 80% (1126/1421) of respondents completed the survey. Although an accurate response rate could not be calculated, the response rate would most likely be low which increases risk of selection bias and would limit generalizability of the study results. Additionally, about 50% of the respondents were in management positions which would also limit generalizability of the results. However, the strengths of our study included having a comparator group (early in the pandemic vs later in the pandemic) to assess the changing patterns and effects of burnout and STS throughout the pandemic. To our knowledge, this is the first study that assessed the changing patterns of the prevalence of burnout and STS in health care professionals, especially health-system pharmacists, throughout the COVID-19 pandemic.
Overall, our study is unique compared with previous studies in health-system pharmacists because we identified the changing patterns and impact of burnout, STS, and compassion satisfaction throughout the COVID-19 pandemic. Additionally, we reported that the overall prevalence of burnout in health-system pharmacists is over 80% of respondents and for STS is over 60% of respondents 20 months into the pandemic. These rates are significantly higher compared with rates early in the pandemic. Unfortunately, we know that the development of burnout and STS may lead to work-related consequences such as decreased productivity, quality of patient care and patient satisfaction, increased employee turnover, and more concerning, increased risk of medical errors, substance abuse, depression and suicide, and disrupted relationships. 3 Therefore, it is crucial to develop and assess effective interventions to address burnout and STS in these health-system pharmacists.

| CONCLUSION
Twenty months into the COVID-19 pandemic, almost 70% of healthsystem pharmacist respondents identified as being burned out, and this is reflected by the high percentage of pharmacists with moderate-high likelihood of burnout based on the ProQOL. Additionally, a high percentage of health-system pharmacists had moderatehigh likelihood of STS, but compassion satisfaction scores were lower later in the pandemic. This shows that we are seeing increased rates of burnout and STS, and compassion satisfaction may be impacted the further we are into the COVID-19 pandemic. Further studies are critical to develop and assess effective interventions to address the effects of the COVID-19 pandemic and the well-being of healthsystem pharmacists.