Background
In accordance with a paradigm shift towards a patient-focused rather than a disease-focused approach in clinical medicine, pharmacists are trained in both traditional drug-oriented services, such as pharmacy compounding, and patient-oriented services [
1]. In modern pharmaceutical care, which is focused on improving safety, therapeutic outcomes, and patient quality of life [
1], pharmacists may face new psychological challenges. Pharmacists may be exposed to the emotional responses of angry patients with aggression [
2], be required to provide direct patient care under the direction of a physician [
3], and facilitate the distribution of information and advice between patients and other healthcare practitioners [
4]. Healthcare professionals, such as radiologists who have little contact with patients, have occupational stress, such as effort/reward imbalance, high job demands and limited autonomy, and low social support [
5]. Therefore, pharmacists may suffer from the same type of occupational stress. Health professionals dealing directly with patients who are facing challenging medical conditions are often subject to strong emotional interactions in their work setting, and thus are likely to experience chronic emotional stress that can induce burnout [
6]. As with other healthcare professionals, high requirements regarding interpersonal communication can impose physical and psychological burdens on pharmacists.
Based on recent developments in the field, we believe that burnout and compassion fatigue (CF) in pharmacists need to be reconsidered. These conditions can represent overwhelming psychological burdens, and can cause physical, mental, and emotional health difficulties [
7]. Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job [
8]. Compassion fatigue describes the caregiver cost of caring for patients with chronic illness (i.e., patients who will never fully recover) [
9]. A previous study reported that CF in pharmacists may be associated with medical errors, such as errors in management of medicines [
10]. For medical staff in a cancer care center, as many as 44 % of inpatient workers were at high risk of burnout, while 37 % were at high risk of CF [
7]. Psychological distress among medical staff is correlated with high levels of burnout and CF [
11].
With regard to pharmacy staff, the need for better burnout prevention strategies and clarification of burnout-prone behaviors were established in the 1980s [
12]. However, investigations of the prevalence of burnout, related factors, and associated neuropsychological traits among pharmacists have been limited. Several factors associated with burnout of pharmacists have been identified, including age, marital status, work experience, work contentment, and workload [
13]. However, knowledge of the associations between burnout and specific behavioral or neuropsychological traits related to communication, which may induce burnout/CF, is lacking.
Therefore, in this study, we investigated two psychological traits that may be associated with burnout and CF, in addition to demographic variables. The first trait was the presence of autistic-like traits (ALTs), which can resemble a milder form of autism spectrum disorder (ASD). ALTs can signal individuals who might have difficulty with sociality and communication [
14], but are within the “normality” spectrum [
15]. The second trait was attention deficit hyperactivity disorder (ADHD). Individuals with ADHD often encounter problems with interpersonal relationships in their youth. The tendencies characteristic of ADHD are thought to remain into adulthood, and the adult prevalence of ADHD ranges between 3.4 % and 4.4 % [
16]. Those with ASD or ADHD in their youth may later have impaired social adjustment [
17,
18], but there are limited studies on this issue.
However, as a result of recommendations by the Ministry of Health, Labour and Welfare in Japan, the demand for a change to a patient-oriented service from drug-oriented work in the role of the pharmacist has become stronger. Additionally, a medical fee is charged when hospital pharmacists perform face-to-face explanations of the need for medication or injection of anti-neoplastic agents to patients with cancer under physicians’ instructions. A fee is also charged when pharmacists perform 20 h or longer a week of drug-related work in the hospital, including answering consultations from other health workers or explaining risks to patients. Therefore, we were concerned that this drastic change imposes a great deal of stress on pharmacists, particularly on those with these two psychological traits. We hypothesized that hospital pharmacists with ALT-and/or ADHD-like tendencies are less socially adaptive with respect to their work environment, and thus are especially susceptible to burnout/CF.
To the best of our knowledge, few reports have evaluated psychological distress, burnout, and the associated risk factors in hospital pharmacists. Accordingly, this study aimed to investigate the following: 1) the prevalence of psychological distress and burnout/CF among hospital pharmacists; 2) the extent of correlation of specific demographic characteristics (e.g., sex and years of experience) with psychological distress and burnout/CF; and 3) whether high levels of ALT-and ADHD-like symptoms contribute to psychological distress and burnout/CF in hospital pharmacists. More information on these issues could contribute to enhanced risk assessment. Additionally, new data may facilitate environmental adjustments and early educational prevention interventions in hospital pharmacies. High stress in pharmacists may endanger not only the physical and mental health of practitioners, but also patients’ safety [
19].
Discussion
Our data indicate that there is a relatively high prevalence of psychological distress and burnout/CF among hospital pharmacists. To the best of our knowledge, this is the first report to investigate the association between characteristics that are hypersensitive to interpersonal communication and psychological distress among hospital pharmacists.
As expected, GHQ-12 values were large (54.7 % of our participants obtained a score that was higher than the cutoff point) in our sample population (Table
1). Previous studies using the GHQ-12 have shown various values. In one study, 68.8 % of nurses in general hospitals in Japan [
32] obtained a score that was higher than the cutoff point, and first-year medical residents in Japan had a mean score of 4.8 ± 3.2 [
33]. However, studies in other countries have reported a lower prevalence of psychological distress as measured by GHQ-12 scores, such as nurses in a Nigerian tertiary health institution (44.1 %) [
34] and randomly sampled community pharmacists in New Zealand (40.7 %) [
35]. Reports from Japan show a tendency of a high GHQ-12 score. Therefore, cultural differences may exist. We found a relatively high level of burnout/CF, where 49.2 % of the individuals in our sample were facing a high risk of burnout, and 29.2 % were at high risk of CF (Table
1). This result has important implications for the prevalence of psychological distress, and is comparable with previous investigations of other professional groups, such as inpatient oncology staff who have a burnout rate of 44 % and a 37 % rate of CF [
7]. The high prevalence of psychological distress, as measured by the GHQ-12, may have been caused not only by interpersonal work, but also by other work-related and daily personal stress. Therefore, we used the GHQ-12 in combination with the Pro.QOL, which specializes in work-related stress. Similar results are obtained from these two measures. Therefore, many pharmacists might be considered to have the risk of a psychological crisis, possibly due to work-related interpersonal stress in addition to conventional occupational stress [
5].
GHQ-12 scores were significantly negatively correlated with years of experience (Table
2). This finding is consistent with a study reporting that work-related stress in healthcare workers decreases with years of experience [
36]. Therefore, burnout may be prevented through experience and education. However, because this study was a cross-sectional survey, we cannot make statements about causality. Pharmacists without these traits might be more likely to continue to work, while pharmacists who have experienced burnout leave the profession. Because years of experience showed no correlation with burnout, preventive interventions for burnout should target all hospital pharmacists.
As expected, ALT and ADHD symptoms were significantly associated with psychological distress (Table
3). This finding may reflect difficulty not only with work-related stress but also with everyday life stress. Additionally, while the strength of ALT symptoms significantly affected burnout/CF severity, the number of ADHD symptoms only affected CF among hospital pharmacists (Table
4). The reason for this finding may be because ASD is associated with more severe deficits in social cognition [
37]. We are confident that our findings regarding burnout and CF reflected psychological stress specific to the workplace because we clearly questioned the participants about their work-related burden as pharmacists (Pro.QOL). Furthermore, we believe that our measure of CF was specific to the interpersonal component of work because the number of hours of interpersonal work per week had a positive, but not significant, effect on CF, while this was not the case for burnout.
Designing burnout preventive interventions specific to individuals with the traits highlighted in this study may be possible. Mindfulness-based interventions are effective burnout protective interventions for primary care physicians [
38]. Future research is required to determine whether interventions specific to those with ALT or ADHD symptoms are especially effective.
Individuals with ALTs are often super-moral and have been known to strongly value fairness [
39]. Additionally, they generally have an intact capacity to care about others, regardless of their lack of “theory of mind” [
39]. Individuals who are vulnerable to burnout in medical practice are also thought to be those who are highly motivated, dedicated, and emotionally involved in their work [
40]. Therefore, further research is needed to examine the relationship between occupational burnout and altruistic traits because such characteristics are indispensable for providing high-quality care for patients. More information may lead to the development of programs to help professionals maintain such useful personality traits while avoiding burnout.
This study has several limitations that must be acknowledged. First, in this study, we collected independent and dependent variables by self-report measures without behavioral observations. Therefore, our results might have been strengthened by common method variance. Second, all of the data were collected from one geographic area. Additionally, the sample population was small and the response rate was lower than 50 %. Therefore, selection bias may have occurred. Accumulation of more data from multiple areas is necessary. There may be a limitation to the interpretation of our results, caused by differences between participants and non-participants in the present study. Third, this was a cross-sectional study. In the future, we need to consider the longitudinal turnover rate of pharmacists with ALT or ADHD symptoms. Fourth, we used self-report questionnaires as an index for ALT or ADHD symptoms. Although these scales were validated, the objectivity of answers could have been biased and we did not make definite diagnoses. Fifth, the AQ is considered to reflect static aspects of personality traits or behavior. Therefore, a high level of burnout/CF or depression may influence answers provided in the AQ. Finally, we did not investigate the presence of personal problems for the consideration of privacy. Therefore, our results of the GHQ-12 may have been greatly affected by daily stress unrelated to pharmacists’ work.
Acknowledgements
The authors thank the Okayama Society of Hospital Pharmacists and all of the study participants. The authors would also like to express their sincere gratitude to Shoko Yoshimoto for funding management, and Yifei Tang and Kyoko Hageshita for excellent data management. This study was supported by the Research for Promotion of Cancer Control Programmes (H26-Gan Seisaku-general-002 and H25-Seishin-general-001), and Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare, Japan.