The US health care system continues to rapidly change to provide better care, reduce costs, and improve the health of an aging population. With these changes come added pressures on health care professionals, which have harmed mental health and contributed to high rates of burnout, a syndrome characterized by emotional exhaustion, depersonalization, and loss of meaning in work. The diminished well-being of health care professionals is concerning, as burnout has been associated with increased medical errors, decreased patient satisfaction, increased turnover, higher health care costs, and a higher likelihood of substance use or suicidal ideation.1 Although burnout has been a topic of conversation for physicians and nurses for decades, there has been a push to address the extent of burnout found in pharmacists—specifically pharmacy residents—in recent years.
More than 5000 pharmacists are seeking residency training in more than 2000 programs accredited by the American Society of Health-System Pharmacists (ASHP) each year.2 Pharmacy residents rotate through various practice settings throughout the year while managing several additional assignments. In addition to patient care responsibilities, successful completion of a residency program often includes a research or quality improvement project, a medication use evaluation, a staffing component, topic discussions, precepting and mentoring of pharmacy students, and providing continuing education programs and in-service presentations. Many of the tasks assigned are longitudinal and may overlap with daily requirements. The intensive nature of a residency program has resulted in an increased risk of stress leading to high rates of depression and burnout among pharmacists pursuing this path.3
Evaluating the Extent of Burnout Among Pharmacy Residents
A cross-sectional study was conducted in February and March 2012 to examine stress and negative affect levels among 643 PGY-1 and PGY-2 pharmacy residents. This was the first study conducted to evaluate the experience of stress pertaining to pharmacy residents. Researchers utilized an institutional review board–approved questionnaire that surveyed participants utilizing the 10-item Perceived Stress Scale (PSS10) and the Multiple Affect Adjective Checklist–Revised (MAACL-R). Results demonstrated that the number of hours worked per week was a significant predictor of perceived stress, with those who worked more than 60 hours per week being significantly more likely to have higher stress levels than those who worked between 40 and 60 hours per week (P = .001). Additionally, PGY-2 pharmacy residents had a significantly higher MAACL-R hostility score than PGY-1 pharmacy residents (P = .017). Compared with previous studies including medical residents, pharmacy residents experienced similar PSS10 scores (20.3 ± 7.4 vs 19.06 ± 5.90, respectively).4
To evaluate the rate of depressive symptoms among pharmacy residents, a time series study utilizing web-based surveys assessed 678 pharmacy residents completing their training during the 2015-2016 cycle in ASHP-accredited programs. The surveys included 38 questions relating to demographic information, regional location of the residency programs, residency-specific environmental factors (ie, hours worked, preceptor support, number of coresidents, type of residency program), and the 9-item depression screening component of the Patient Health Questionnaire (PHQ-9). Data were gathered in September 2015, December 2015, and March 2016. This study revealed that rates of depressive symptoms (PHQ-9 ≥ 10) did not significantly increase over the course of the year (September 2015: 34% vs March 2016: 39.9%; P > .05); however, severe depressive symptoms (PHQ-9 ≥ 20) increased significantly from 2.9% to 7.3% (P < .05). The proportion of participants who reported PHQ-9 scores below 10 significantly decreased throughout the year, and by March 2016, approximately 40% of pharmacy residents scored 10 or higher on the PHQ-9, indicating at least moderate depressive symptoms with a strong likelihood of major depression.3
The Switch to a "Quadruple Arm"
For decades, health care has focused on achieving the “Triple Aim” of enhancing patient experience, improving population health, and reducing costs. Studies have demonstrated burnout’s negative impact on patient care, resulting in the adoption of a fourth aim. The “Quadruple Aim” encompasses all previous aims, with an additional goal of promoting care team well-being.5 ASHP has recognized the importance of prioritizing well-being and resilience among pharmacy residents, which is crucial to their success, overall health, and ability to provide high-quality patient care. The ASHP Strategic Plan refers to a pillar called “Our Patients and Their Care,” which aims to “improve patient care by enhancing the well-being and resilience of pharmacists (including pharmacy residents), student pharmacists, and pharmacy technicians.” This goal comprises 5 key objectives, one of which is to actively seek opportunities to enhance the well-being and resilience of pharmacists who pursue postgraduate residency training. Furthermore, ASHP has incorporated language regarding well-being and resilience into the Accreditation Standard for Postgraduate Residency Programs since 2023. To promote this concept, ASHP established the Well-Being Ambassador (WBA) Program with funding from the Health Resources and Services Administration.
The ASHP WBA Program certificate is a virtual, curriculum-based program designed to increase one’s knowledge and skills to implement practices enhancing well-being and resilience in their personal lives and within professional practice. ASHP has established a resource guide, highlighting the importance of incorporating WBAs or initiatives into a pharmacy residency program.6
WBAs are dedicated individuals tasked with advocating for and supporting pharmacy residents’ mental, emotional, and physical well-being. They serve as an approachable point of contact for residents to express concerns about their well-being and are knowledgeable about all available resources, nationally and locally. WBAs should undergo comprehensive training, including education on mental health and crisis intervention. WBAs are responsible for organizing activities and events to reduce stress and promote self-care, which may include mindfulness sessions, stress management workshops, and social events to foster a sense of community and support within the department.7
Integrating Well-Being Into a Residency Program
The first step in establishing a wellness initiative within a residency program is identifying risks to well-being and resilience. It is also important to measure baseline well-being using at least 1 validated tool (eg, Maslach Burnout Inventory, Mayo Well-Being Index, Stanford Professional Fulfillment Index, Mini Z burnout assessment). Although each tool may vary slightly, they have all been created to assess stress, meaningfulness from work, depersonalization, and emotional exhaustion.8 The 2023 ASHP Accreditation Standard for Postgraduate Residency Programs updated the requirements of individualized development plans to include a well-being and resilience component, which remains in place today.9,10 Assessment and documentation of resident well-being are required during the initial developmental plan and at least every 90 days thereafter. Validated screening tools may provide a subjective assessment of resident burnout and allow program directors or preceptors to identify changes in burnout throughout the year.9
