SCCMPod-544: Reducing Burnout in ICU Pharmacy Teams

Dr. Bulloch: Hello and welcome to the Society of Critical Care Medicines podcast. I'm your host, Dr. Marilyn Bulloch. Today I'll be speaking with Dr. Christy Forehand, PharmD, BCCCP, FCCM, discussing quality and safety in critical care and the importance of retaining highly skilled healthcare professionals. Dr. Forhan is a board-certified critical care clinical pharmacy specialist practicing in the Medical ICU at Wellstar MCG Health in Augusta, Georgia. She's also the PGY2 Critical Care Pharmacy Residency Program Director at Wellstar MCG Health in the University of Georgia College of Pharmacy and an Adjunct Clinical Associate Professor at the University of Georgia College of Pharmacy. Dr. Forhan is currently the Vice Chair for the Board of Pharmacy Specialties Critical Care Specialty Council and the Chair Elect for the SCCM CPP Sections Practice Advancement Committee. Welcome, Dr. Forhan. Before we start, do you have any disclosures to report?

Dr. Forehand: I do not, but I did want to start off by just saying thank you so much to the SCCM Quality and Safety Committee for recognizing and trying to bring awareness to this issue.

Dr. Bulloch: We appreciate you taking the time. I know you have a lot on your plate, it looks like, from your biography, and I know that you're probably one of the best people positioned to talk to us about retaining really some of these most valuable health care providers. Now today, we're really going to be focusing on the link of retaining critical care pharmacists because we know that when we retain these highly skilled pharmacists, it's really important to our ICUs in making sure that they can maintain this excellent quality and safety patient care that we're providing.

Can you talk to us a little bit on what you feel is the foundation for retaining these pharmacists in the ICU setting?

Dr. Forehand: Sure. I mean, I think it's really, really, really important that we do retain these highly skilled pharmacists in ICU settings. Having these pharmacists, particularly as part of multidisciplinary rounding teams, has been shown to impact many clinical and economic outcomes.

Just to name a few, adverse drug events, thromboembolic and infarction-related events, drug-drug interactions, sedation selection and ventilator days, door-to-needle time for thrombolytic administration and stroke, transitions of care, medication errors, just to name a few. And clinical pharmacist turnover is bad because it reduces productivity to have to constantly train new staff and it causes a decrease in morale among the pharmacists that remain at the institution. There's also economic consequences for replacing staff.

A recent estimate said that it costs about $60,000 to turn over one health care provider position. So, I think between the fact that pharmacists do have a strong link to improved outcomes, both clinical and economic, for ICU patients where they're involved in the care. And then also, you know, the cost of replacing staff, the morale hit that it takes when you have to constantly replace staff that have left, all tie together, demonstrating the importance of making sure that we do things as institutions that help retain staff.

Dr. Bulloch: I want to focus a little bit on why you think there might be so big of a problem with retention. I was reading a study earlier today, actually, that noted that hospitals, hospital pharmacies particularly, have a significantly higher rate of turnover intention, meaning hospital pharmacists have more intention to leave and go somewhere else in the near future than can community pharmacists do. Why do you think that is?

Dr. Forehand: I think this is multifactorial and professional organizations have looked at this as well. ASHP, or, you know, the American Society of Health System Pharmacists, they recommend that individual health systems develop retention plans for staff that include things like professional promotion, rewards, and recognition opportunities, as well as increased salary and benefits for staff. And then the American College of Clinical Pharmacy, or ACCP, has also published three different versions of a white paper on rewards, recognition, and advancement for clinical pharmacists.

In this document, the first version of this dates back to 1995, so this is not really a new problem, but the most recent version of that document was published last year. And that document is important because it addresses that by improving rewards, recognition, and advancement for clinical pharmacists, that that can help improve job satisfaction, reduce burnout, and increase job retention. And so I think specifically in critical care pharmacy, there is a high rate of burnout and attrition.

Folks are leaving critical care pharmacy to go do other things. Most notably, I think we're all aware of the large shift of critical care pharmacists leaving the bedside to go to industry. I think that's partly related to feeling underappreciated in your job.

There's a lack of career advancement opportunities within the clinical realm, and then just a lack of rewards, whether that be salary, benefits, or other non-monetary things to make you feel appreciated for doing your job. And so these documents are important that have been put out by professional organizations to highlight this issue and to offer guidance for administrators and other stakeholders when designing retention plans for staff. And we can go into some of those if you want to.

Dr. Bulloch: Absolutely. I'd love to hear those in just a minute, but I want to back up just a little bit. You mentioned that pharmacists in the ICU, they're burning out.

And you're a residency program director, so you're used to having people when they're fresh and they're young and they're very excited about clinical practice. I remember being a critical care pharmacy resident and having that same sort of passion. Do you think that maybe we as a profession and our professional organizations maybe have set our standards a little too high in terms of what to expect in practice and what to expect a reasonable clinician to be able to do in practice between patient care and scholarly activity and service for the long term?

Because when you look at our physician colleagues and our nursing colleagues and their postgraduate training programs, they really don't do as much as we do. And so I wanted to get your thoughts on that.

Dr. Forehand: Yeah, I think this is a really important discussion. I think ASHP, who sets the standards for residency accreditation and the activities that are expected to be accomplished during residency, is aware of this issue. And I think they're constantly kind of tweaking it a little bit.

I think it's a double-edged sword because residency is the time where you have mentored development or mentored guidance through these different types of activities that you're going to be expected to do after your residency is completed in your professional position. And so what better time to gain experience than when you have mentors and advisors all around you to help you learn how to do things efficiently and effectively. At the same time, residency is just a year.

And there's a reason that they say one year of residency is worth three to five years of clinical practice. Well, that's because we probably cram three to five years of activity into one year. I, you know, as an RPD, I have differing feelings on that.

We have to protect the health and well-being of our future generation of pharmacists, but we also have to have them prepared to take on the responsibilities that they're going to be expected to do in practice. I think one of the hardest things, though, related to this is not doing that PGY-3 after residency is done. That adjustment to real life, is what I like to say, after residency and not staying on that same trajectory.

Recognizing that your career is a marathon, not a sprint. Residency is a sprint, but your career after that is a marathon. And so while you are exposed to all these different activities and skill development during residency, that doesn't mean that you need to continue to apply and exercise all of those every year for the rest of your career.

I think also many of us, especially critical care pharmacists, are very type A. We're very high achieving. We want to do all the things.

And we have to show some restraint in that too, to protect ourselves and our own mental well-being.

Dr. Bulloch: That may be some of the best advice. I wish somebody had given that to me when I was coming right out of residency, because you're right, that PGY-3 mindset in a lot of ways, I feel like maybe contributes to some of the burnout that we see. I want to shift a little bit.

You were talking earlier about the importance of retaining, rewarding, good work, all of those things. Just over two-thirds of pharmacists in the inpatient setting, we don't have data for ICU specifically, they say they don't have defined criteria for career advancement. And of those who are thinking of their future, only 15% plan to stay at their own institution.

So what are some things that an institution can do to help their people plan for their future there and stay there and continue to grow there?

Dr. Forehand: Yeah, I think step one is that administrators and key stakeholders, they have to design retention plans for their institutions. I think that involves identifying rewards that their staff consider valuable and achievable, but it also needs to support the organization's mission and vision. They also have to establish clear criteria for achievement of rewards and advancement.

It doesn't need to be vague. It needs to be very clear and laid out, as well as having clear processes for identifying exceptional performance. There needs to be a structured timing of rewards that are done.

And then, of course, it doesn't matter if you're at the institution. So you have to create a process to ensure awareness about these programs. Other things that health systems can do would be to work towards improving patient-to-pharmacist ratios and practice models, adding in protected time for clinical activities, quality improvement, research and scholarship, and teaching and mentorship activities.

I think career planning is a large well that's untapped. Career ladders are well described in literature, but not as much for pharmacists as they are for maybe some other health care professions. But there should be structured, clear processes and mentorship around career planning.

And I think in the previous survey that you were citing, that's what pharmacists wanted. They wanted career planning, advancement, opportunities, and mentorship.

Dr. Bulloch: We always forget that even though you may be an independent practitioner now, you still want somebody to go to, even when you're mid-career. I feel like that that's important.

Dr. Forehand: Yeah, I agree. Other things that have been talked about are outside of pharmacists, other health care professionals often have opportunities for a stipend or for clinical buy-down models for taking on additional responsibilities, such as being a committee chair or a residency program director, whereas many pharmacists don't have this opportunity. And that leads to burnout and attrition of some of our most talented clinical pharmacists.

And I feel like ASHP has actually tried to help in this area for RPDs in the last several years by adding some verbiage in the standards around required dedicated time away from clinical responsibilities for residency program management activities. And so I think as an RPD, that is much appreciated from my viewpoint. And I think that's a step in the right direction from our professional organizations, but there's obviously more that can be done here.

Dr. Bulloch: One more thing on retention. You had talked a lot about rewards and we need to find the rewards that are valuable. Can you share maybe some of the rewards that you've seen in your practice, in your institution, or even that you know of from colleagues' institutions that have gone over really well?

It seems like the pharmacists there really appreciate them. They feel valued and it's like, yes, this is what I was wanting.

Dr. Forehand: Yeah, I think there are lots of different opportunities here. When surveyed, pharmacists responded that financial incentives were the most preferred option, and that was followed by personal or professional commitment changes. When it comes to what workplaces are currently offering, a lot of workplaces offer education days for attending conferences and meetings.

I really appreciate that. I like to be involved in professional organizations. I think it looks good for my institution as well, and so they support me by allowing off-campus leave for those types of activities where I don't have to use my vacation time to attend those, and that I appreciate a lot.

Some institutions will offer reimbursement for new credentials or certifications. They will do different methods of verbal or written employee recognition. Also, in this same survey, some institutions would offer dedicated office space for individuals who are high performers or going out of their way to do extra activities.

Some of the least commonly offered rewards in this survey were additional staffing support, routine project or off-service time, improved scheduling of shifts to accommodate the employee's preferences, career ladders, opportunity for mentorship into a management role, and then career development plans. So, a couple of things there. Improved scheduling of shifts.

I feel like what has been born out of the COVID-19 pandemic is the opportunity for more remote work, which I think some clinical pharmacists are really attracted to that, and I do know a couple of institutions that, for example, on their weekend staffing, they wanted to have more clinical pharmacists looking at patients on the weekends so that it was a closer model to the same level of care that patients received during weekday coverage.

But in order to get clinical pharmacists to kind of agree to that, because that's a huge personal time commitment to, you know, offer to work additional weekends, that's time away from family and other, you know, personal activities, they offered some of those shifts to be remote work so that the tasks could be accomplished wherever the pharmacist is. You don't have to come into the hospital to do those activities. And so, I think the COVID-19 pandemic, when we had to start trying to figure out how to do some things remotely, has really opened us up to these opportunities that I think more and more employers are looking into and more and definitely more employees are asking for these kind of hybrid staffing models.

Dr. Bulloch: I agree. I think the pandemic really changed the true outlook of how we work and where we work and what we can do. You mentioned earlier, you started to list off a long list of things that having an ICU pharmacist there does in terms of patient outcomes.

Let's talk about that a little bit more, and I'll start maybe even with a non-clinical one. I was reading an article that suggested our mere presence can actually maybe reduce our healthcare colleagues' burnout levels. Do you feel that that's accurate?

Dr. Forehand: I'm sure if he found a study that said it was, then it must be. But I think, you know, just thinking about my day-to-day practice, I do think having a pharmacist present on the unit can alleviate some stress from our colleagues because you're right there and able to answer some questions right there at the bedside rather than, you know, them having to pick up the phone and call Central Pharmacy. And, you know, Central Pharmacy is usually always very busy and stressed and may not be able to help them in the moment with what their specific issue is.

So I do think having a comprehensive and complete team at the bedside is important.

Dr. Bulloch: We were having a conversation earlier this week about how it's important to be who you are, you know, for you to be doctor forehand and not just pharmacy. And that kind of relationship comes with tenure and being there and getting to know the physicians and the nurses that you're working with. How do you think that retention in the ICU impacts patient care at the bedside?

I know you listed off a whole lot of things earlier, but in your actual practice, what are some things that you have seen that just having somebody who's been there for a while and they know the process has genuinely benefited patient care?

Dr. Forehand: Absolutely. I think working in the ICU is, you know, you're working in the trenches and going through those great patient situations where patient survives and you guys have worked together to help them have a successful outcome, but also going through the unfortunate situations where a patient may pass, but you still go through all of those interventions together. I think that builds camaraderie and also builds trust.

I think trust is very important because if I make a recommendation and I have a long-standing history with my team, I've developed rapport, trust with them, then I think that increases their likelihood of taking my recommendation. And likewise, the same thing with a physician or a nurse is telling me something about a patient and I've worked with that person for a while, then I'm more likely going to trust them and be like, okay, well, you know, this must really be true if they're telling me this. And so I think that increases efficiency.

It calms nerves in stressful situations when you have that known entity that you're working with. I think it also can increase efficiency in terms of once you build that familiarity with your team, they're going to reach out to you regardless of if you're at the bedside. So say I'm in my office working, or maybe I'm on my way home for the day, they may reach out to me because they know me and they know the kind of answer I'm going to give them in a certain situation.

Now, on the flip side, that could also increase burnout because providers and nurses work different hours usually than clinical pharmacists, at least in my experience. You know, they work more 12-hour shifts, whereas the pharmacists at my institution work eight-hour shifts, but sometimes I think they think I work 12-hour shifts. And so if I'm getting paid or called on my personal cell phone after hours, that can also lead to increased burnout.

But at the same time, I want what's best for the patient. So I feel like I need to and want to answer that call and help them. I also know that I'm much more efficiently going to be able to answer their question than, for example, if I weren't to answer my phone and I've left for the day and they have to call maybe Central Pharmacy or something to ask them the same question.

What my institution has done that has helped this particularly is we've hired PGY2-trained, board-certified critical care pharmacists who work on second shift, and I would hope eventually that would extend to third shift as well. And so I have noticed that I've received less phone calls after I leave work for the day regarding issues that are going on in my ICU, and I think that's because they're contacting our excellent second shift critical care clinical pharmacists. And so that has helped me personally from a burnout perspective, not feeling guilty about not answering a call when technically my hours have ended for the day.

Dr. Bulloch: That's such a good point because you also get a little bit of fulfillment too, right? Knowing that your team trusts you that much, that you have commitments to your family and to other things that you may be doing. Now, some of the rewards you mentioned were monetary, whether they were direct salary support or something else.

We know that that can't always happen, but there are ways to foster a supportive work environment to help promote job satisfaction and retention. So what are some of those strategies you have found really do provide that good work environment?

Dr. Forehand: My institution, for example, has instituted that clinical pharmacists will get one admin day per month. And so that's a day that you're off service, there's someone else that's covering your patients, and you're free to work on, you know, quality improvement projects. Maybe you're teaching a lecture at the College of Pharmacy.

In the near future, you could work on that or education for staff. So a day that you're not trying to balance everything at once, it's a day that's completely dedicated to admin time. Some days it feels like I could probably have one of those types of days per week and still have more things to do.

But I think I'm not going to complain about it because I know many pharmacists don't have that opportunity. But I really appreciate that my employer recognizes how important that is in terms of preventing burnout and job satisfaction, because I love taking care of patients, but I also really like teaching, mentoring, working on quality improvement projects, working on research. And I think that having a balance between my clinical responsibilities and those other kind of indirect patient care activities to me has really helped me from getting burnout in my career.

So I've been a pharmacist for just over 14 years, and I've worked 12 of those in the ICU. And so I consider myself, I guess, early mid-career practitioner. And I feel like it's around this time that people start burning out, leaving clinical practice to go to other employment opportunities.

And I don't feel like I'm quite there yet. And I really do owe a lot of that to having a nice balance between my clinical responsibilities and other activities that I do that are very fulfilling for me professionally.

Dr. Bulloch: Sounds like you've got a really good model for a lot of our younger trainees and early practitioners that are coming up. As we close today, I want to just give you an opportunity to maybe touch on anything we didn't have a chance to talk about already that maybe is important to you on this subject.

Dr. Forehand: Sure. I mean, I think kind of take home points from this are that recognition and rewards, I think, are important components in job satisfaction, and that can reduce burnout and improve retention. I think rewards and recognition, career advancement, those can look like a lot of different things. There are many things that could be considered rewards recognition or career advancement.

I think it's up to institutions to develop pathways for these, structured processes for how these are done so that they're done in an equitable way among staff. I think that's really important, too. I think that recent publications that are highlighting burnout and attrition of highly skilled, particularly critical care clinical pharmacists, should be a call to action to administrators and other stakeholders to develop and advocate for more opportunities to provide their staff with these rewards recognition and career advancement opportunities.

And I would encourage people to reference some of the ASHP resources that are out there. Also, I referenced this earlier, but ACCP has a white paper that was just updated last year regarding this topic. Again, I'm just very thankful that the SECM Quality and Safety Committee recognizes that this is a quality and safety concern if we're losing our highly skilled pharmacists because of burnout and attrition and just bringing this issue some awareness and beginning the conversation about how we can improve this in the ICU setting.

Dr. Bulloch: You mentioned ASHP and ACCP. I would also just reference listeners to our own organization. SCCM has launched this LEAD initiative.

Dr. Forehand: Great point. 

Dr. Bulloch: Well, Dr. Forehand, thank you so much for being here and being our guest today to our audience. This concludes another episode of the Society of Critical Care Medicine podcast.

If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I'm Marilyn Bullock. Thank you for listening.

Announcer: Marilyn N. Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama Birmingham School of Medicine.

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