Purpose

To explore the interplay among burnout, moral distress, and moral injury; examine current trends and realities in pharmacy; and call for potential beneficial actions by individuals, the pharmacy profession, and healthcare systems.

Methods

A narrative review of recent events and research into challenges and problems in the pharmacy workplace indicative of burnout, moral distress, and moral injury among pharmacists, pharmacy technicians, and other pharmacy staff.

Results

Burnout in the workplace is caused by chronic stress and results in emotional exhaustion, feelings of cynicism/detachment from the job, and lack of accomplishment or a sense of ineffectiveness. A growing body of evidence indicates that what is termed burnout may in fact be moral distress, and this can lead to moral injury if not recognized and corrected. Indicators of moral distress are psychological distress, situational impact constraining an ability to act, and the effect of inaction upon doing what is deemed right. Over the long term, moral distress leads to moral injury, which is characterized by pain (psychological, existential, and/or spiritual) and resulting from dissonance from doing and/or seeing actions that violate deeply held moral beliefs and expectations. The intersectionality of burnout, moral distress, and moral injury can produce serious sequelae, including suicidality and death by suicide. In addition to burnout, stressful pharmacy job demands have been linked to patient safety concerns, especially medication errors that are worrisome for pharmacists and other pharmacy personnel, cause injuries to patients, and result in negative media attention focused on the individual and the profession.

Conclusion

Burnout has been well-characterized for healthcare professionals, and continued attention to this matter for pharmacists and pharmacy personnel is warranted. What is critical to deal with now is further consideration of moral distress and moral injury and their impact on the pharmacy profession, as burnout does not adequately characterize all of what pharmacists and pharmacy personnel are experiencing.

In October 2023, organized chain community pharmacy walkouts occurred in several cities across the United States in protest of untenable workplace conditions. Understaffing of pharmacist and pharmacy technician personnel, lack of well-trained pharmacy technicians, inability to take sick or vacation time, pressures created by time-measured productivity metrics, abuse from frustrated, angry, and sometimes violent patients, and employee burnout from all these factors were among the issues cited as causes of the walkouts.1-3 

Data generated from studies of the pharmacist workforce illustrate the extent of pharmacists’ stress and exhaustion.4,5  While much has been said about the level of burnout among healthcare providers, something different may actually be causing many providers’ distress.6,7  Pharmacists are healthcare professionals who take an oath to, among other things, “consider the welfare of humanity and relief of suffering their primary concern.” Yet, their ability to exercise professional autonomy for that purpose has eroded, particularly when supervised by nonpharmacists who do not respect or support the importance of the patient-pharmacist relationship (and sometimes by other pharmacists far removed from direct patient care who are similarly insensitive to professional commitments).

While these are not novel issues for or unique to community pharmacy, the negative impact of these long-standing workplace issues was amplified in the wake of the COVID-19 pandemic. This created an urgency around the need to deepen understanding of burnout, moral distress, moral injury, and other negative mental conditions (e.g., anxiety, depression, posttraumatic stress disorder), and how these factors combine to undermine the well-being of pharmacists and their staff. Clinician wellness is necessary for healthcare professionals to achieve other desired health outcomes, such as improving the health of populations, enhancing the patient experience of care, reducing the per-capita cost of healthcare, and achieving health equity.8-10 

In this article, we explore the interplay among burnout, moral distress, and moral injury; examine current trends and realities in pharmacy; and call for potential beneficial actions by individuals, the pharmacy profession, and healthcare systems.

Burnout is characterized from an occupational perspective and broadly described as exposure to chronic stress resulting in emotional exhaustion, feelings of cynicism/detachment from the job, and lack of accomplishment or a sense of ineffectiveness.11  The syndrome has often been reported to have a prevalence ranging from 52% to 61% for pharmacists, including those practicing in community and health-system settings.12-14 

Authors of a systematic review of burnout in pharmacists before the COVID-19 pandemic reported an estimated overall burnout prevalence range of 8% to 53%.15  The 2019 National Pharmacists Workforce Study reported pharmacist burnout (work exhaustion + personal disengagement) for the first time, and “a lot” or “totally emotionally exhausted” was reported by more than half of pharmacists working in large chain, mass merchandiser, or supermarket community pharmacy settings.4 

Pharmacists working full time reported having so much work to do that “everything cannot be done well” (43%) and even “fear that a patient will be harmed by a medication error” (35%). Almost 40% of pharmacists reported experiencing a change in their employment status, some of whom cited benefits such as better work environments, responsibilities, or conditions. Additional impacts of COVID-19 on pharmacists have been described elsewhere.16,17  Increasingly recognized is the need to take a systemic approach to address healthcare burnout that considers the system's structure, organization, and culture causing these problems.18-20 

Long considered a problem by the nursing profession, moral distress is generally characterized by the presence of 3 elements: psychological distress, situational impact constraining an ability to act, and the effect of inaction upon doing what is deemed right.21  Associated outcomes of moral distress are largely experienced as anger, frustration, guilt, and powerlessness.22  Furthermore, individuals may experience headaches, anxiety, insomnia, gastrointestinal problems (i.e., nausea, diarrhea), exhaustion, and depression.23  Moral distress has also been associated with occupational attrition and an intention to leave healthcare professions.24  There is also overlap with characteristics of burnout.11,22 

Moral injury appears to be a longer-term outcome of sustained moral distress described as pain (psychological, existential, and/or spiritual) resulting from dissonance developed from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”25  Moral injury is also noted to occur when an authoritative figure does not act in a just manner when the stakes are high.26 

Limited study of moral injury outside the military-associated context has suggested this as the root cause of daily negative experiences of physicians rather than burnout, particularly those who work for corporate entities, though some argue that moral distress is the core problem.6,7,27  In healthcare, unresolved moral distress can lead to moral injury when a health professional repeatedly encounters dilemmas that they cannot prevent or see occurring around them.27-30  Analysis of themes of lived experiences of pharmacists infer occurrences of distress and suffering and seem to map well to elements associated with the varied definitions of moral distress and moral injury.31 

Thus, there is ample room for investigation to determine the intersectionality of burnout, moral distress, moral injury, and potentially related outcomes such as death by suicide. Death by suicide has been estimated to be higher for health professionals versus the general population—including pharmacists—and problems in the workplace have been notably associated with suicide in pharmacists.32  September 20 has been designated as Pharmacist Workforce Suicide Awareness Day to acknowledge that pharmacists are at an increased risk of death by suicide. This recognition is increasing attention to the need for the prevention of suicide among our pharmacy colleagues.

The Workplace Change Collaborative has created a national framework to address burnout and moral injury in the health and public safety workforce (Figure 1).33  It outlines numerous and intersecting factors that contribute to burnout and moral injury and includes environmental factors that contribute to breakdowns in operations and relationships.

Figure 1.

Depiction of Burnout and Moral Injury for Workforces in Health and Public Health

Source: The Workplace Change Collaborative at the Fitzhugh Mullan Institute for Health Workforce Equity; Institute for Healthcare Improvement; Moral Injury of Healthcare; AFT Healthcare. Burnout and Moral Injury in the Health and Public Safety Workforce. Washington, DC: George Washington University, 2023. wpchange.org. Reprinted with permission.

Figure 1.

Depiction of Burnout and Moral Injury for Workforces in Health and Public Health

Source: The Workplace Change Collaborative at the Fitzhugh Mullan Institute for Health Workforce Equity; Institute for Healthcare Improvement; Moral Injury of Healthcare; AFT Healthcare. Burnout and Moral Injury in the Health and Public Safety Workforce. Washington, DC: George Washington University, 2023. wpchange.org. Reprinted with permission.

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Operational breakdowns include lack of safety (i.e., abusive behaviors by employers, peers, or patients), chronic understaffing, excessive clinical and nonclinical practice demands, and administrative burdens. Distrust of employers and supervisors, insufficiently trained pharmacy personnel, and lack of professional autonomy are reflective of relationship breakdowns. A review of moral distress and moral injury in the health professions outlines distinctions and psychological consequences, and commonalities among the professions, including guilt, anguish, blaming, and powerlessness.27 

Application of the Workplace Change Collaborative framework for pharmacists has the potential to advance the recognition and organization of factors contributing to moral injury. Developing operational and relational strategies can lead to implementing solutions across the spectrum of stakeholders in our profession and all of healthcare.

In addition to burnout, stressful pharmacy job demands have been linked to patient safety concerns, especially medication errors that are worrisome for pharmacists and other pharmacy personnel.34,35  A core cause of this stress is the fear that pharmacists face—fear of committing a medication error because of exhaustion and distraction, fear of retribution when helping patients with women's health issues that are not currently clear from a legal standpoint, or fear of speaking up about unsafe working conditions. Pharmacists and other healthcare workers are also fearful of reprisal in today's corporate healthcare world; most of the published articles in mainstream media are laden with interviewee requests not to be identified for fear of retaliation by employers.2,3 

Based on the definition of moral distress, many pharmacy situations could be contributing factors for those practicing pharmacy. However, whether any of them result in moral injury and for whom is not currently known. This unanswered question warrants further investigation. Among these situations are these examples:

  • Does working toward health equity over time for myriad people with diverse characteristics and health challenges (e.g., age, gender, gender identity, disease condition, veterans’ status) contribute to moral injury?

  • What has been the impact on pharmacists and pharmacy technicians who supported the walkouts in fall 2023 and on those who decided not to participate because of their strong desire to fulfill their responsibilities to patients’ well-being and health?36 

  • To what degree have job problems and related moral distress or mental health conditions (e.g., anxiety and/or depression) led to moral injury, suicidal ideation, and completed suicides?

  • What impact have state and national laws and regulations had regarding the employment situations of pharmacists, increasing the fines on corporations that put profits ahead of patient safety, and dictating what pharmacists are allowed to do in difficult situations?

  • Are pharmacists and pharmacy technicians in different practice settings experiencing varying degrees of moral distress and injury based on their roles, responsibilities, and limitations?

Burnout has been well-characterized for healthcare professionals, and continued attention to this matter for pharmacists and pharmacy personnel is warranted. What is critical to deal with now is further consideration of moral distress and moral injury and their impact on the pharmacy profession, as burnout does not adequately characterize all of what is being experienced by pharmacists and pharmacy personnel.

Learning from other sectors and applying definitions, understanding contributing factors, identifying differences across work settings, and characterizing outcomes will advance strategies to address moral distress and moral injury on the individual and system levels so that work settings can be improved to ensure the health of the pharmacists and pharmacy technicians who care for patients and communities. Additionally, positive media campaigns are needed to illustrate the vital role that pharmacists have in rural and urban communities, combat pharmacist invisibility, and support consumer confidence that might otherwise be eroded by negative attention to untenable workplace conditions.37,38 

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Conflicts of interest: The authors report no relevant conflicts of interest with the material presented in this article.