Exploring the well-being of community pharmacy professionals, turnover intention and patient safety: Time to include operational responsibility

Background: The COVID-19 pandemic added significant occupational pressures on community pharmacists. The objective of this research project was to investigate the level of distress and burnout among community pharmacy professionals and its association with their retention within their occupation as well as patient safety outcomes. Method: We conducted a cross-sectional study on 722 community pharmacy professionals from all Canadian provinces using an online survey, including scientifically validated measures. The data were analyzed using multiple regression analysis. Results: In Canada, 85% of community pharmacy professionals reported their mental health had suffered since the COVID-19 pandemic. Younger pharmacy professionals and those paid hourly reported a worsening level of mental health and an increasing level of turnover intention. Pharmacists with more dynamic/disrupted work schedules and those working for a large pharmacy chain (more than 25 pharmacies in Canada) reported lower levels of mental health quality. Pharmacy professionals working in pharmacies that are open more than 70 hours a week reported a lower level of patient safety culture. Pharmacists’ mental health was the significant predictor of their turnover intention, implying a heightened risk to professional effectiveness and retention. Compassion satisfaction was positively associated with patient safety culture and safety behaviour, while compassion fatigue and secondary traumatic stress were significantly associated with pharmacists’ level of risk-taking behaviours. Conclusion: This study emphasized the importance of prioritizing the mental health and well-being of community pharmacy professionals and demonstrated individual and systemic factors predicting the well-being and turnover intention of community pharmacists, as well as patient safety culture within their pharmacy. This research makes a case to consider actions to shift the monitoring focus from community pharmacists (also known as “individual responsibility”) to community pharmacies (also known as “operational responsibility”) for managing patient safety. Additionally, community pharmacists should be provided with the professional autonomy to affect their working conditions and alleviate the stress that has the potential to negatively affect the delivery of care.


Method:
We conducted a cross-sectional study on 722 community pharmacy professionals from all canadian provinces using an online survey, including scientifically validated measures. the data were analyzed using multiple regression analysis.

Results:
In canada, 85% of community pharmacy professionals reported their mental health had suffered since the cOVID-19 pandemic. Younger pharmacy professionals and those paid hourly reported a worsening level of mental health and an increasing level of turnover intention. Pharmacists with more dynamic/disrupted work schedules and those working for a large pharmacy chain (more than 25 pharmacies in canada) reported lower levels of mental health quality. Pharmacy professionals working in pharmacies that are open more than 70 hours a week reported a lower level of patient safety culture. Pharmacists' mental health was the significant predictor of their turnover intention, implying a heightened risk to professional effectiveness and retention. compassion satisfaction was positively associated with patient safety culture and safety behaviour, while compassion fatigue and secondary traumatic stress were significantly associated with pharmacists' level of risk-taking behaviours.
Conclusion: this study emphasized the importance of prioritizing the mental health and well-being of community pharmacy professionals and demonstrated individual and systemic factors predicting the well-being and turnover intention of community pharmacists, as well as patient safety culture within their pharmacy. this research makes a case to consider actions to shift the monitoring focus from community pharmacists (also known as "individual responsibility") to community pharmacies (also known as "operational responsibility") for managing patient safety. Additionally, community pharmacists should be provided with the professional autonomy to affect their working conditions and alleviate the stress that has the potential to negatively affect the delivery of care. Can Pharm J (Ott) 2023;156:71-84.
Our research team is interested in the role of mental health in the workplace within the health care system and its connection with positive and negative individual, organizational and patient outcomes. Our goal is to help improve the sustainability, functioning and effectiveness of health care services.

Introduction
The COVID-19 pandemic has been the most significant public health event of the present era. It stress-tested the resiliency and safety of the Canadian health care system at various systemic, operational and individual levels. 1 Such added pressure exposed critical failures in various areas of our health care system and mandated that community pharmacists adopt a unique role in the preparation, preparedness and response within their pharmacy practice. While still managing medical and drug supplies, providing coverage and ensuring patientoriented safe use of medical/drug products, community pharmacies also provided more services in disease prevention and infection control than was typical before the pandemic. 2 A recent study showed that the number of patients seeking pharmacist care increased significantly during the pandemic, as people avoided other avenues of health care due to the fear of contracting the virus. 3 Such behaviour could have elevated exposure to community pharmacies without adequate coordination of workplace adaptations and frontline support in the pharmacy operating structures. Community pharmacists' unique position and service locations mean they are the most accessible frontline essential health care workers in every community. Community pharmacists are highly skilled at triaging conditions associated with mental health, quality errorfree pharmacological care and preventative measures, such as vaccination, chronic comorbidity monitoring and medication reviews. In Canada, there are more than 11,000 community pharmacies (1 for every 3500 Canadians). 4 This accessibility to highly skilled professionals has encouraged policymakers to expand community pharmacists' scope of practice from adjudicators of safe medication delivery to providers of diverse clinical services in collaboration with primary care physicians. Although there is little doubt that this expanded scope of service has been a change in a positive direction, a 2020 article found that 1 of every 4 pharmacists in Canada believed their work environment was not conducive to providing quality and safe clinical care. 5 Additionally, a study in the United States showed that 3 of every 4 community pharmacists were experiencing occupational burnout as a result of their job demands and working conditions, based on data collected after the COVID-19 pandemic. 6 Anecdotal evidence from the Canadian population has shown the negative impact of the pandemic on the well-being of community pharmacy professionals, raising concerns regarding their turnover intention and patient safety. 7,8 The objective of this research project was to investigate the level of well-being among community pharmacy professionals and its association with their turnover intention as well as patient safety outcomes. Therefore, we developed a broad survey, including scientifically validated measures that tap into the important psychological elements for medical professionals and provide community pharmacy professionals with an opportunity to reflect on how the pandemic has affected their abilities to provide safe, effective and sustainable health care.

KNOWLEDGE INtO PrActIcE
• In total, 85% of community pharmacy professionals in canada reported their mental health had become worse during the cOVID-19 pandemic. • this study emphasizes the importance of "securing your own mask before assisting others" within our health care system, to ensure we have a sufficient, effective and healthy workforce to lead community pharmacies and provide essential services to our communities. • Policy-makers, health care administrators and industry stakeholders must prioritize community pharmacy professionals' mental health and well-being. • regulatory oversight focus needs to shift to the pharmacies rather than the licensed pharmacists to ensure that occupational conditions, such as workload, work patterns and the work environment, meet obligations for safe health care delivery for staff and patients in accordance with legislated requirements.

Study design and participant recruitment
This was a cross-sectional survey study across Canadian provinces. The survey was available to participants in both English and French. Community pharmacy professionals were recruited through an e-mail sent by their respective pharmacy association or college of pharmacy as well as community pharmacy groups on social media. The data were collected from August 2021 to April 2022. A final sample included responses from 722 community pharmacy professionals in Canada.

Data collection instrument and data analysis
All respondents provided informed consent and their participation was completely voluntary. In terms of compensation, participants were entered into a drawing of ten $100 gift cards (participants' e-mail addresses were collected via a separate survey to ensure anonymity). Participants had the option to choose "prefer not to answer" for each item. No personal or identifiable information was collected in the main survey, except the IP addresses to control for duplicate entries from the same user. This study was approved by the Research Ethics Board of Dalhousie (2021-5518) and Saint Mary's University (21-106).
Collected data were analyzed using SPSS version 26. Descriptive statistics and correlations for all study variables are presented in Appendix 1 (available in the supplemental materials to this article.). Multiple regression analysis was used to explain the unique role of each predictor in explaining the variance in the outcome variable controlling for demographic (block 1), pharmacy-related (block 2) and pandemic-related variables (block 3). Variables were entered stepwise in their respective block to evaluate their unique association with the outcome variable by looking at the change in R 2 (reported in the tables). Participants with missing data were excluded listwise. Multivariate assumptions of normality and linearity and univariate/multivariate outliers were examined and addressed before data analysis.
The investigators invite all community pharmacy stakeholders to use these data iteratively for collaborative analyses. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Results
The results of regression analyses are indicated in Tables 2-4.

Participants
The sample of this study consisted of 90.9% pharmacists (11.6% were owners, 22.6% managers, 54.1% staff pharmacists, 2.6% relief pharmacists) and 9.1% pharmacy assistants (unlicensed/unregistered), pharmacy technicians (licensed/ registered) and interns. The largest number of participants were from Ontario (51.6%), followed by Nova Scotia (17.2%), New Brunswick (10%) and Alberta (7.7%). Most of the participants were female (72%), Caucasian (65.1%), working full-time (74.3%) and coupled (77.6%), with an average age of 41.51 years (SD = 12.51). About half of the participants had dependents (49.6%) and were working with a mixed working schedule (56.8%). Only 19.7% of the participants were on salary, and the other ones reported different forms of compensation (i.e., hourly or contract). In terms of pharmacy operation, 32.9% of the participants were working in pharmacies in rural areas. A total of 1.6% of the participants were working in grocery/supermarket pharmacies and 43.4% of the participants were working in large pharmacy chains (i.e., having more than 25 pharmacies in Canada). Also, 59.3% of the participants were working in pharmacies that operate more than 70 hours a week. A total of 84.7% of the participants were working in a pharmacy that offered COVID-19 vaccine administration to the public.
In terms of occupational health and well-being, this study focused on general mental health, compassion satisfaction (pleasure you receive from your job), compassion fatigue (negative feelings of hopelessness and frustration in meeting job expectations) and secondary traumatic stress, as well as its connection with patient safety culture. Patient safety culture is the extent to which a community pharmacy promotes patient safety through the following subfactors: (1) physical space and environment, (2)   Psychological safety. Psychological safety was significantly associated with compassion satisfaction, compassion fatigue and secondary traumatic stress among community pharmacy staff. Participants working in pharmacies with a psychologically safe culture reported a higher level of compassion satisfaction and lower levels of compassion fatigue and secondary traumatic stress. Additionally, based on the correlation analysis, psychological safety was positively associated with patient safety culture and safety behaviours and negatively associated with risk-taking behaviours.
Social support. Although supervisor and peer support did not show a significant association with mental and occupational health variables based on the regression analyses, their bivariate correlations with mental and occupational health as well as patient safety culture were significant.
Moral distress. Participants were asked to rate how much they had experienced moral distress in their job based on the following definition: "Moral distress is a form of distress that occurs TaBle 2 Hierarchical regression models predicting mental and occupational health of community pharmacy professionals   TaBle 3 Hierarchical regression models predicting withdrawal behaviours of community pharmacy professionals

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Original research TaBle 4 Hierarchical regression models predicting patient safety culture and safety behaviours within community pharmacies  Original research when you believe you know the ethically correct thing to do, but something or someone restricts your ability to pursue the right course of action. " Based on the results, moral distress was significantly associated with secondary traumatic stress among community pharmacy staff.
Mental and occupational health. Employees' mental and occupational health was the significant predictor of their turnover intention. Compassion satisfaction was significantly related to patient safety culture and safety behaviour in community pharmacies. Compassion fatigue and secondary traumatic stress were significantly associated with employees' rate of risktaking behaviours in the workplace.

COVID-19 pandemic
Perceived risk. Participants were asked to rate their level of concern regarding 4 factors (i.e., patients, colleagues, workspace and work policies) that could potentially increase their exposure to the COVID-19 virus. Based on the results, the perceived risk from work policies had a significant negative association with pharmacy staff 's mental and occupational health. Perceived risk from patients had a significant positive relationship with patient safety culture, signalling that the more concerned the respondents were about being exposed to the virus from their patients, the better patient safety culture was in place. Conversely, the respondents reported a lower level of patient safety culture when they were concerned about being exposed to the virus due to high-risk work policies.
Infection control. Employees' perception of the level of infection control in their pharmacy was a significant predictor of their level of mental health, occupational well-being and turnover intention. More specifically, employees who reported a high level of infection control within their pharmacy reported higher levels of mental health, compassion satisfaction, patient safety culture and safety behaviour and lower levels of secondary traumatic stress, risk-taking behaviours and turnover intention. The higher amount of infection control activities was positively associated with compassion fatigue, suggesting a negative impact of this extra task resulting from the COVID-19 pandemic.

COVID-19 vaccine administration.
There was no significant difference between participants who administered the COVID-19 vaccine in terms of their mental health, occupational wellbeing, turnover intention, safety behaviours or patient safety culture compared with those who worked in the pharmacies that did not offer this service.

Pharmacy operation
Type of pharmacy. Staff working in pharmacies that were open more than 70 hours a week reported a lower level of patient safety culture compared with the pharmacies that operated for fewer than 70 hours a week.
Size. Pharmacy staff working at large pharmacy chains (more than 25 pharmacies) reported lower levels of mental health compared with the ones who worked for small or mediumsized pharmacy chains.
Location. Pharmacy staff working in urban areas reported a higher level of presenteeism (i.e., working when feeling unwell) compared with community pharmacy staff working in rural areas.
Job characteristics Job status. There was no significant difference in any variables between full-time and part-time community pharmacy staff.
Compensation. Pharmacy staff who received hourly pay reported lower levels of mental health and compassion satisfaction and higher levels of compassion fatigue and turnover intention compared with their colleagues who received a salary. Additionally, employees receiving hourly pay reported a lower level of patient safety culture compared with their salaried counterparts.
Work shift. Participants were asked to identify whether they had fixed work shifts (i.e., always mornings, always afternoons, always nights) or mixed work shifts. Community pharmacy staff with mixed working schedules reported lower levels of mental health and patient safety culture and higher levels of compassion fatigue and turnover intention.

Demographics
Sex. There were 3 people in our sample who identified themselves as nonbinary. Due to the small size of this group in our sample, our analysis of sex included only the individuals self-identifying as male/man or female/woman; however, those identifying as nonbinary were included in all other measures. There was no sex-related effect difference in terms of reported mental and occupational health, turnover intention or patient safety culture. However, male/man-identified participants reported a higher level of risk-taking behaviours in their workplace.
Age. There was a significant negative association between age and mental and occupational health variables, suggesting that a younger generation of community pharmacy staff reported lower mental health perceptions and compassion satisfaction and were more susceptible to compassion fatigue and secondary traumatic stress. Additionally, the younger generation of community pharmacy professionals reported a higher level of turnover intention, presenteeism and absenteeism. Moreover, younger pharmacy professionals reported a lower level of patient safety culture, a lower rate of safety behaviour and a higher rate of risk-taking behaviours within their work environment.

Original research
Marital status. There was no significant difference between participants who were coupled (i.e., married or common-law) and those who were single (e.g., single, separated, divorced, widowed) in any variable of this study.
Ethnicity. In terms of ethnicity, racial minorities reported higher levels of compassion satisfaction and lower levels of compassion fatigue. There was no significant difference between majority and minorities in terms of mental health and turnover intention. Regarding safety variables, minorities reported higher levels of patient safety culture and safety behaviours.
Dependents. There was no significant difference in any variables of this study between the participants who had dependents and those who did not (i.e., children under 22 years old or adults who are financially and physically dependent upon you).

Discussion
A conceptual summary of the key findings of this research project is presented in Figure 1. This study demonstrated a strong relationship between community pharmacy staff 's mental health and their turnover intention, as well as safety behaviours and patient safety culture. The findings support the previous limited and anecdotal evidence from news, social media and word of mouth suggesting a concerning level of well-being and turnover intention. Moreover, the impact on the younger professionals risks extending harm with pandemic resolution due to habituation, which could be exacerbated by premature workforce exit by experienced professionals. This would have substantive negative impacts across the community pharmacy sector from an industry perspective, as human resources and collective effectiveness will not be replaced by incumbent professionals. Based on the findings of this study, 85% of community pharmacy professionals in Canada reported their mental health had become worse than usual since the COVID-19 pandemic. Since the COVID-19 outbreak, despite introduction of a number of new policies and procedures on how to deliver care and services to patients, there has been no official guideline for community pharmacy professionals or owner/ operators on how to engage with self-care activities and manage their own mental health and well-being, particularly with at-work policies/practices. To ensure we have an effective and healthy workforce to lead community pharmacies and provide essential services to our communities, policy-makers, health care administrators and industry stakeholders must prioritize the mental health and well-being of community pharmacy professionals. The findings of this study emphasize the importance of the airline adage of "securing your own mask before assisting others" within our health care system. Community pharmacists should be provided with the professional autonomy to affect their working conditions and alleviate the stress that might have been caused operationally (by pharmacy practices or corporations and government policies) or situationally (by unprecedented circumstances). Job stress as a risk factor has the potential to drive up the costs of care, reduce access to health care services and increase strain across the health care spectrum, including causing patient harm directly and indirectly. Based on the findings of this study, the worsening status of well-being among community pharmacy professionals, their high level of turnover intention and the poor patient safety culture present immediate and looming concerns that are not about individual pharmacists but are more about the system (the system that expects presenteeism and increases the workload without offering adequate staffing). Thus, a regulatory focus needs to be directed more toward the pharmacies rather than the pharmacists to help manage the conditions under which pharmacists operate. We recommend that government authorities shift their focus from monitoring "community pharmacists" to monitoring "community pharmacies" and hold pharmacy owners and corporations accountable for not Original research providing a safe work environment for community pharmacy professionals, where detected. Equally, this accountability also requires payers (private and public) to participate proactively in the underlying provision of essential services equitably to meet legislated obligations and occupational expectations of the community pharmacy. This should be patient-centred but also requires an understanding of logistical needs underlying service delivery and continuity. This shift in agenda will potentially improve the well-being of community pharmacy professionals, which will consequently increase their retention within the profession as well as the patient safety culture within their pharmacy.

Limitations
This was a cross-sectional survey study, meaning that no causal relationship can be interpreted. Although this study had a large sample size, the generalizability of the findings is somewhat limited since about half of the participants were from Ontario and we did not have an equally distributed sample from all the Canadian provinces and territories. Additionally, the spread of COVID-19 and the number of active cases changed rapidly during the data collection phase of this study, which means some participants in our sample may have responded to this survey when the number of active cases was low, whereas others had to deal with many active cases in their community. Most of our participants were recruited through our community partners (pharmacy associations or colleges of pharmacy). This may have created a sampling bias that might influence the generalizability of our findings, as some community pharmacy professionals are not members of pharmacy associations or they might have opted out of receiving research invitations from their respective colleges of pharmacy and were not included in our recruitment strategy. Although we tried to address this limitation through snowball sampling and social media recruitment, the sampling bias might still be present. Additionally, although we could not estimate how many community pharmacy professionals saw our advertisement, we believe the response rate was fairly low and the results are biased toward the ones who chose to participate in this study. However, because this study was focused on exploring the relationship between different variables rather than reporting their absolute values, we believe this limitation should not weaken the strong validity of our findings.

Conclusion
Community pharmacy professionals are an integral part of our health care system and are legislated essential workers. If industry stakeholders and government authorities fail to support the well-being of pharmacists, they will consequently leave their profession which will endanger the quality and continuity of care within our health care system. This study indicated worsening well-being among community pharmacy professionals and a significant impact of this trend on their turnover intention and patient safety, with potentially lasting effects, particularly among younger pharmacy professionals, that could negatively impact the health care system and the pharmacy industry. ■