Impact of Working Environment on the Level of Occupational Burnout among Community Pharmacists – a Pilot Study

Introduction: The disorder known as burnout develops as a reaction to the damaging impacts of workplace stress. When occupational stress is poorly managed, it can result in burnout, which has a detrimental impact on workers’ performance and emotional and physical well-being. Those who work in the helping profession are the most vulnerable. Pharmacy practitioners are among the most vulnerable groups in the healthcare industry. Aim: The aim of the study was to look into how community pharmacists’ work environments affect their levels of occupational burnout. Materials and methods: The current survey included 127 pharmacists holders of a Master of Pharmacy degree who practice in Bul-garia’s northeast. A paper-based questionnaire with details about the workplace of these pharmacists and the Maslach Burnout Inventory (MBI-HSS-MP), a validated assessment instrument, were used to conduct the survey. Results: The majority of those surveyed (53%) had a medium to high degree of burnout at work. The highest percentage of pharmacists (51%) received high scores on the depersonalization scale, which is associated with a lack of motivation for providing patient care. The degree of burnout was found to be unaffected by the kind of community pharmacy – chain or individually owned. Burnout was more prevalent among responsible and non-responsible pharmacists than among pharmacy owners. Conclusion: It was determined that pharmacists needed training and preventative measures to avoid occupational burnout, even though there was no evidence of a statistically significant relationship between the job position and burnout.


INTRODUCTION
The workplace is one of the primary determinants of health.It is essential to worker well-being and contributes to 17%-20% of health issues, along with factors of the physical environment. [1]It is commonly known that working conditions including exposure to potentially harmful chemical, phys-ical, and biological agents have a direct impact on employees' health at the workplace. [2]The goal of employee health initiatives is to guard against each of these, but it is important to recognize the impact of workplace stress.
In recent years, many studies have focused on how occupational stress influences employee health and what factors contribute most to raising its level.The complex intertwin-Folia Medica I 2024 I Vol.66 I No. 4   ing of occupational stress and personality traits is fundamental for developing the condition known as burnout. [3]urnout, or occupational burnout, is a term describing severe emotional, mental, and physical exhaustion directly related to the working environment that affects healthy people.It was first observed in healthcare workers. [4]harmacists are healthcare professionals who interact with a large number of patients on a daily basis.Their duties involve intensive interpersonal communication as well as operating with cash flows and inventory management.They actively participate in the management of patients' pharmacotherapy.While performing their duties, they often neglect their own wellbeing and put patients' needs above their own. [5]The pharmacist's job is dynamic and responsible, with constantly increasing requirements for professional competence and communication skills, which is a predictor of high-level burnout. [6]ultifactorial analyses of burnout have identified several causes contributing to occupational burnout, such as insecurity caused by healthcare reform, a heavy administrative workload, many non-pharmaceutical duties, difficult relationships with colleagues, and the feeling that their performance is underestimated. [7,8]ther factors related to occupational burnout among pharmacists are the working environment, working hours, number of patients served per hour, and stress resilience. [9]n the United Kingdom, a number of issues were identified in the pharmacy sector after surveying 722 pharmacists. [10]ome 80% of employee pharmacists reported experiencing stress at work, which indicated a six-percent increase from 2015.The problems in chain pharmacies were linked to pressure from management for 75% of employee pharmacists, compared with 40% of those employed in independent pharmacies.At the same time, pharmacists working in independent pharmacies or small chains reported an increase in stress of 11% for the period 2015-2017. [10]

AIM
To explore the influence of working environment on the level of occupational burnout among community pharmacists in the northeast region of Bulgaria.

Study sample
The research sample included the pharmacists holding the degree of Master of Pharmacy who work at community pharmacies in Varna.Inclusion criteria: participants were required to be members of the Regional Pharmaceutical Association in Varna, complete an informed consent form, and work in community pharmacies under contract with the National Health Insurance Fund (NHIF).We re-stricted ourselves to master pharmacists only since, under current Bulgarian legislation, they have the authority to prescribe drugs and supervise patient care, whereas assistant pharmacists do not.This distinction renders the two groups incomparable according to the established criteria.As of March 2021, 301 pharmacists had met the inclusion criterion.

Survey execution
The study was conducted from March 2021 to December 2021 using a direct, anonymous questionnaire.The paper-based questionnaires were distributed to pharmacists with the assistance of the Regional Pharmaceutical Association of Varna, either when they visited its office or at association-organized events and meetings.

Methods
We used the following methods in the study: I.A documentary research method: this was used to research official documents and literature sources on the development of pharmacy profession and the concept of occupational burnout.
II.A sociological research method: a survey questionnaire was designed to gather information from the respondents.The questionnaire included demographic questions as well as the validated assessment tool Maslach Burnout Inventory (MBI), specifically adapted for medical personnel.
Maslach Burnout Inventory (MBI-HSS-MP) [11] was purchased from an official representative specifically for the present study.
MBI-HSS-MP consists of three subscales: The level of emotional exhaustion was measured by adding up the points from statements 1, 2, 3, 6, 8, 13, 14, 16, and 20 on the following scale: over 30 points: a high level.The level of depersonalization was measured by adding up the points from statements 5, 10, 11, 15, and 22, using the following scale: over 12 points: a high level.The level of personal accomplishment was calculated by adding up the points from items 4, 7, 9, 12, 17, 18, 19, and 21, where a score of 0-33 points was a low level.
Emotional exhaustion is defined as feeling emotionally drained as a result of workplace activities.It is characterized by a lack of energy, health problems, mental exhaustion and depletion, and difficulty concentrating for no apparent reason.
As for depersonalization, everything is perceived with negativity.A feeling of detachment appears, irritability and intolerance towards others, and job dissatisfaction, all of which gradually affect interpersonal relationships. [12,13]he reduced personal accomplishment is associated with a perceived lack of confidence in one's own efficiency and professional competence, along with a feeling of failure and inability to cope with tasks. [12,14]ccupational burnout is observed in high scores on the EE and DP scales and low scores on the PA scale.
III. Statistical analysis Descriptive analysis: It presents quantitative variables as mean and standard deviation (±SD), while categorical variables are number and percentage (N, %).
The statistical reliability of the questionnaire was assessed using the Cronbach's alpha reliability coefficient.By calculating this coefficient we confirmed the homogeneity of the entire questionnaire (MBI) and of each subscale.Data showed a good factor structure and a very good level of reliability coefficients (Cronbach's alpha for subscale emotional exhaustion was α=0.929, for subscale depersonalization -α=0.733, and for subscale personal accomplishment α=0.791).The reliability coefficient for the entire questionnaire was α=0.808.The correlations satisfy the requirements.
Analysis of variance: ANOVA was used to analyze the effect of independent variables (job position, working environment) on the dependent variables (DP, PA, EE) in a regression study.
Ethics approval: The presented data are part of a study approved by the Research Ethics Committee at the Medical University of Varna (No. 101/24.03.2021).
Study limitations: The study was undertaken in the midst of the COVID-19 epidemic.Although not our major purpose, this has clearly had an impact and should be considered when reviewing the data.

RESULTS
The current survey included 127 pharmacists with Master of Pharmacy degrees who satisfied the criteria for inclusion requirements, expressed an interest in participating, and completed informed consent forms.The sample size exceeded one-third of those who met the inclusion criteria.The demographics and social profile of the sample is presented in Table 1.
The number of female participants was 101 (80%), compared to 26 (20%) men.A previous study demonstrated that sex distribution and mean values did not have an impact on the three scales. [15]The majority of survey respondents were between the ages of 25 and 45 (73, 58%).The 46-55-year age group consisted of 26 respondents (20%), while those over 55 were 28 (22%).The largest group of pharmacists had less than 5 years of experience (44, 34%).This is accounted for by the greater number of survey respondents who fall into the 25-40 age group.The percentage of respondents with job experience of 16 to 25 years and over 35 years was the same: 21 (16%); the pharmacists with experience of 5 to 15 years were 30 (24%); and those with experience between 25 and 35 years were 11 (9%).
The distribution of the respondents showed that the majority were non-responsible pharmacists (72, 57%), fol-lowed by responsible pharmacists (40, 31%), and the smallest proportion was that of the pharmacists who owned pharmacies (15, 12%).
The pharmacists were almost evenly distributed according to the type of community pharmacy: 75 (59%) worked in chain pharmacies, whereas 52 (41%) were employed in independent pharmacies.Survey data showed that 95 (75%) of the participants had at least one scale result associated with a high level of burnout while 67 (53%) demonstrated a medium-to-high level of occupational burnout.An analysis was performed and the study subjects were grouped according to the high values on the three scales.
The largest group of the study sample had high values for the DP scale (51%), followed by the EE scale (43%), and low values for the PA scale (31%).

Impact of the type of community pharmacy on the level of burnout
For the purpose of studying the impact of the workplace on the level of burnout, we divided the participants into two groups: respondents working in a chain pharmacy and those employed in an independent pharmacy.The results are shown in Table 2. Chain pharmacies and independent pharmacies have similar mean values across all three scales.Analyses showed that the type of pharmacy did not have a statistically significant impact on the three scales.For chain pharmacy employees, the values for the EE scale were M=26.88, for DP -M=12.84,and for PA -M=30.99.For independent pharmacy employees, the values were M=25.38,M=12.58,M=31.62 for EE, DP, and PA, respectively.

Impact of job position on the level of burnout
In order to determine the factors influencing occupational burnout, we studied the relationship between respondents' job position and the scores on the three scales.We searched for a statistically significant relationship between the job position and the Maslach scales.
Table 3 presents the mean values for the three scales and the impact of the job position on each scale.
There is no statistically significant influence found of job position on the three scales.Pharmacy owners demonstrated a lower level of EE (М=23.13)and the lowest level of DP (М=10.80),and their level of personal accomplishment was the highest (М=35.00).The mean values for the EE scale were the highest (М=27.00)for the groups of responsible pharmacists.The DP scale showed the highest values in the group of the non-responsible pharmacists (М=13.63).

DISCUSSION
Women continue to make up the majority of community pharmacists.This pattern is consistent with data from a research conducted in Bulgaria on community pharmacists, which shows that the ratio of women to males in the Varna region is 84% women to 16% men. [16] medium-to-high level of occupational burnout was observed in more than half of the surveyed subjects (53%).This also corresponds to the results of other studies. [17]Occupational burnout has to be studied, and measures need to be developed for its prevention, as it can seriously affect employees' health.Associations between burnout and metabolic syndrome, disturbed sleep, and hypertension have been confirmed by various studies. [18]There is evidence in the literature that occupational burnout starts with emotional exhaustion, followed by depersonalization, and the last stage is a reduced professional satisfaction.For instance, in a study including 412 community pharmacists, findings indicate a predominance of respondents with high values for EE (68.9%), followed by depersonalization (50.4%), and reduced personal accomplishment (30.7%). [19]The pharmacists in our study demonstrated mostly high values on the DP scale, which suggests different dynamics in the process of occupational burnout.Depersonalization is related to a lack of motivation to interact with the patient, withdrawal from the consultation process, and reduced quality of pharmaceutical care [20] , which might lead to adverse patient outcomes [21] .
Other studies show that one of the risk factors for burnout is working in chain pharmacies. [22]The findings of the present study show that workplace is not correlated with the level of occupational burnout.The mean values of both groups, employed in chain pharmacies or individual pharmacies, are very similar and show no significant differences for the three scales.
Pharmacy owners, who also function as responsible pharmacists, are the group most involved in the work process, according to a comparison of the mean values of the respondents based on their job position.On the EE and DP scales, they have low values, and on the PA scale, they have high values.Studies conducted on pharmacists reveal that those who manage pharmacies have a higher likelihood of experiencing burnout in their line of work.Another predisposing factor is the increasing obligations. [23,24]In this study, both non-responsible and responsible pharmacists showed high values in the EE scale, low-to-moderate DP values, and low values for the PA scale.These results are the closest to the profile defined by Maslach as 'an overextended' . [24]e can summarize that non-responsible pharmacists and responsible pharmacists are most vulnerable and prone to occupational burnout.Despite the differences in the mean values of the three scales, no statistically significant differences were found between the respondents in relation to their job positions.Other studies also prove the lack of statistically significant influence of the job position on the level of occupational burnout. [25]any factors, such as job overload and administrative difficulties, contribute significantly to the development of occupational burnout; thus, it is critical to investigate the characteristics of the work environment and their impact on the level of occupational burnout. [26]

CONCLUSION
This study demonstrated that community pharmacists are among the most at-risk healthcare professionals for occupational burnout.The unpleasant effects of workplace stress can have a significant influence on employees' mental and physical health.
Burnout has been demonstrated to have an impact on the healthcare system by reducing productivity, increasing employee absenteeism, and negatively affecting patient health outcomes by lowering the quality of care and services, which increases the chance of medical errors.
In the current survey, the majority of respondents had high levels of DP, which is associated with low motivation to offer pharmaceutical care to patients.This is a prerequisite for depriving the patient of an effective consultation, which could jeopardize the therapeutic outcome.Non-responsible and responsible pharmacists have been recognized as the most vulnerable to occupational burnout.Employers must take preventative efforts against burnout by giving specialized stress management training.
Efforts to reduce burnout and assist pharmacists manage with stress will improve their quality of life and the care and services they deliver.

Table 1 .
Demographic characteristics of the study sample (N=127)

Table 2 .
Distribution of mean values for EE, DP, and PA as related to the type of community pharmacy

Table 3 .
Distribution of mean values for the three scales in relation to the job position *One-way ANOVA is used