From symptoms to solutions: A structured approach to alleviating burnout among critical care pharmacists.

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An Exploratory Qualitative Study of Student Pharmacist Perspectives on Leadership.

OBJECTIVES: The objectives of this study were to (1) explore student pharmacists' knowledge and perceptions of leadership characteristics and behaviors, and (2) identify where students have opportunities to observe and exhibit leadership. METHODS: Data were collected from 32 students participating in a pharmacy leadership elective. Students submitted reflections about leadership definitions, characteristics, observations of leadership, and times when they felt like a leader. An inductive constant comparative analysis was used to code and categorize text segments from the reflections using NVivo 1.7.1 (Lumivero; Denver, CO). Holistic consideration of the reflections was used to identify an overarching theme. RESULTS: Three categories were specified to organize the data from the qualitative analysis: (1) Leader Characteristics, (2) Leading Behaviors, and (3) Leadership Contexts. One overarching theme was proposed encompassing the categories and sub-categories: Leadership Contradictions. The theme is based on the finding that students seemed able to identify leadership characteristics but emphasized descriptions like holding titles and completing managerial or task-focused duties, suggesting contradictions between conceptual understanding of leadership and leadership behaviors. CONCLUSION: The contradictions between students' conceptual understanding of leadership and what they offered as examples of how and where leadership was observed or applied to practice suggest additional activities and experiences may be warranted to help students appreciate that leadership extends beyond formal roles and demonstrates the ability to influence and support the achievement of shared goals of a team. Additionally, a multi-modal approach may enhance leadership assessment.

Opening the Black Box: Agreement and Reliability of a Situational Judgment Test Across Multiple Institutions.

OBJECTIVE: The primary objective of this study was to examine the levels of agreement and reliability of a situational judgment test (SJT) using a diverse pool of pharmacy practice faculty as subject matter experts. Secondary aims included analyses to build support for test validity and fairness. METHODS: An SJT containing 18 scenarios and 118 responses assessing empathy, integrity, and teamwork was developed and delivered to pharmacy practice faculty at 5 schools of pharmacy across the United States. Reliability was assessed by examining internal consistency, inter-rater reliability, and split-half reliability. Only responses which attained an inter-rater agreement>0.7 were included in the final version of the SJT. All responses were scored using a near-miss system, allowing higher scores for answers more closely aligned with the key, which was determined by the faculty who completed the SJT. Test fairness was reported using descriptive statistics. RESULTS: Thirty-nine faculty across the 5 participating institutions completed the SJT. The final version of the SJT included 105 responses, achieving an inter-rater agreement of>0.7 (inter-rater reliability of 0.98). Split-half reliability was 0.72. The average score was 85.7%, and no differences in performance were observed based on demographic characteristics. CONCLUSION: An SJT designed to assess empathy, integrity, and teamwork achieved reasonable levels of reliability among pharmacy practice faculty across the United States, and the results provided initial support for test validity and fairness. These results support a pilot to assess this SJT among students representing multiple institutions.

Improving and Expanding Research on Burnout and Stress in the Academy.

Objective. To conduct an integrative review of existing literature evaluating burnout and stress to identify reliable, valid, psychometrically sound survey instruments that are frequently used in published studies and to provide best practices in conducting burnout and stress research within academic pharmacy.Findings. We reviewed 491 articles and found 11 validated reliable surveys to be most frequently cited in the literature that can be used in future burnout and stress research. We also noted frequent misunderstandings and misuse of burnout and stress terminology along with inappropriate measurement. Additionally, we identified a variety of useful websites during the review. Lastly, we identified a relative dearth of published research evaluating organizational solutions to burnout and stress beyond personal factors, ie, resilience.Summary. Burnout and stress among student pharmacists, faculty, and staff is an important research area that necessitates more robust, rigorous evaluation using validated reliable surveys with appropriate contextualization within psychological frameworks and theory. Future research evaluating organizational-level attempts to remedy sources of burnout and stress is also needed.

How Resilience and Wellness Behaviors Affected Burnout and Academic Performance of First-Year Pharmacy Students During COVID-19.

Objective. To determine whether students' levels of resilience and self-reported wellness behaviors predicted burnout and grade point average at the end of the first fall semester of the COVID-19 pandemic.Methods. We measured first-year students' resilience, burnout (exhaustion and disengagement), and self-reported wellness behaviors (sleep, nutrition, social time, and self-care activities) at the beginning and end of the fall 2020 semester of pharmacy school. We also collected students' demographic information and end-of-semester grade point average from their academic records. Using multivariable regression, we assessed whether students' resilience and wellness behaviors predicted burnout and grade point average at the end of the semester. We also assessed for changes in burnout and wellness behaviors over time.Results. Resilience was positively associated with older age and was lower among students of color. Exhaustion and disengagement were high at baseline and continued to worsen over time. Students' self-reported wellness behaviors also decreased over time, except for ratings of sleep adequacy. Resilience predicted lower levels of disengagement at the end of the semester, but its relationship with exhaustion was inconsistent. The only wellness behaviors associated with lower burnout were nutrition and sleep adequacy. Students' end-of-semester grade point average was also related to nutrition and sleep adequacy but not resilience or burnout.Conclusion. Resilience offered some protection from burnout, but its relationship to immutable factors suggests that individual-focused interventions to improve student well-being (eg, wellness behaviors such as mindfulness meditation) should be complemented by organizational support, especially for younger students and students of color.

Break time: Examining pharmacy residency application deadlines and the potential impact of a proposed timeline shift.

INTRODUCTION: Many pharmacy residency programs set their application deadlines around the first of the calendar year, only weeks following the American Society of Health-System Pharmacists (ASHP) meeting in mid-December. This contributes to a condensed timeframe for applicants and reference writers to complete and submit materials over the winter holidays. This study examined pharmacy residency program application deadlines and respective timing of application and reference letter submissions. METHODS: This retrospective, observational study evaluated all residency programs within the ASHP residency directory. Several scenarios were examined for impact of a universal earliest deadline (UED) designation spanning early January. Subsequent analysis included compilation of application and reference submission dates from a sample of ASHP-accredited residency programs to determine timing of submission in regard to application deadline. RESULTS: A total of 2449 programs representing 4927 positions were identified for the 2018-2019 application cycle. The mean deadline was 5 January (± three days), and 11% of programs had a deadline prior to 1 January. Among the five first-year residency programs that provided application and reference submission data spanning the 2016-2020 application cycles, the average time from submission to application deadline was four days for applicants and 11 days for references. CONCLUSIONS: Most pharmacy residency programs have deadlines in early January. Implementation of a UED would cause a major shift for these programs but is only one component of change for the application process.

Association of lower urinary tract symptoms and diuretic adherence.

OBJECTIVE: To assess whether more severe urinary symptoms and poorer quality of life among patients on diuretic therapy are associated with decreased adherence to the diuretic regimen. METHODS: Participants were recruited via ResearchMatch.org and sent a REDCap survey. The Overactive Bladder Questionnaire-Short Form (OAB-q SF) was used to assess urinary symptom bother and health-related quality of life (HRQL). Participants were asked if they skip diuretic doses due to urinary symptoms with a bivariate (yes or no) outcome. Subgroup analyses of loop vs non-loop diuretic and those taking the diuretic for a cardiovascular indication (hypertension or heart failure) were performed. RESULTS: A total of 4029 surveys were sent, 285 were returned (7.1% response rate), and 279 were included in the study. Fifty-three participants admitted to skipping diuretic doses due to urinary symptoms. Lower HRQL scores were significantly associated with poorer adherence scores among all participants (P < .001), among participants taking a loop diuretic (P < .001), and among participants with hypertension and heart failure (P < .039). Association between symptoms and adherence remained significant after adjustment in the multivariate model for the whole cohort and loop diuretic subgroup but lost significance in the hypertension and heart failure subgroup. CONCLUSIONS: Worsening quality of life due to urinary symptoms may be associated with poorer adherence to diuretics, particularly loop diuretics.

Selection by design: Using job analysis to guide the selection of postgraduate pharmacy residents.

PURPOSE: To help ensure that we were accurately and consistently evaluating applicants to our postgraduate year 1 (PGY1) pharmacy residency program, we performed a job analysis to inform a redesign of our selection process. SUMMARY: A diverse panel of subject matter experts from our program was convened to develop a task inventory; a list of knowledge, skills, abilities, and other characteristics necessary for success in our program; and behavioral snapshots representing especially strong or weak resident performance (ie, critical incidents). After achieving a priori thresholds of consensus, these items were used to augment our application screening instrument (eg, development of anchored rating scales), build an online supplemental application consisting of a personality test and situational judgment test, develop a work sample consisting of a patient case presentation, and enhance the structure of our interviews (eg, by asking a consistent pattern of questions for all candidates). Preceptors reported that the redesigned process was more organized, easier to complete, and facilitated greater rating consistency. CONCLUSION: Job analysis represents an approach to designing selection processes that are more valid, reliable, transparent, and fair. Based on our experiences, recommendations for those who are considering changes to their selection process are provided.

Continuation Versus Interruption of Renin-Angiotensin System Inhibitors in Acute Decompensated Heart Failure: A Brief Report.

This article is temporarily under embargo.

Candidate reactions to a postgraduate year 1 pharmacy residency supplemental application.

PURPOSE: The purpose of this study was to gauge postgraduate year 1 (PGY1) pharmacy residency candidates' reactions to supplemental applications, as well as aspects specific to our process, including a personality test and situational judgment test (SJT). METHODS: After rank lists were submitted, applicants to our program were invited to complete an online survey. Outcomes of interest included candidates' perceptions of relevance and fairness. Whether candidates' attitudes differed based on the receipt of an interview offer was also assessed. RESULTS: Of 199 applicants to our program for the 2021-2022 training year, 48 applicants (24.1%) completed the survey, 15 of whom had received an interview offer. Most (64.6%) agreed that supplemental applications were useful, and nearly all (95.8%) indicated that they were willing to submit one for programs in which they were most interested. The process was seen as being fair, although ratings were higher among those who received interview offers. Most respondents believed that the personality test and SJT were relevant to the role of a resident, but attitudes towards the SJT were generally more favorable and less likely to vary according to whether candidates received an interview offer. Candidates believed that the personality test and SJT were not as representative of them as letters of reference or their curriculum vitae, but perceptions of academic performance varied. CONCLUSION: Applicants responded positively to our supplemental application and indicated that they would be willing to complete one for programs of interest. These findings should help assuage concerns about the use of supplemental applications, particularly when short-answer or essay formats are avoided.

Personality: A potentially untapped resource in the selection of postgraduate pharmacy residents.

PURPOSE: This study assessed whether personality testing of postgraduate year 1 (PGY1) pharmacy residency applicants was feasible and predicted important selection outcomes, including interview offers. METHODS: Applicants to the PGY1 pharmacy residency program at a large academic medical center were invited to complete a 50-item online personality test based on the 5-factor model (ie, the "Big Five"). Scores were sealed until after matching, at which point they were compared to screening, interview, and ranking and match outcomes. Endpoints of interest included the feasibility of the test (eg, time required for completion, completion rate) and whether personality predicted the odds of an interview offer. RESULTS: The personality test was taken by 137 PGY1 applicants (69.5%) and required a median of 6.8 minutes to complete. Openness to experience was associated with decreased odds of an interview offer (adjusted odds ratio [OR], 0.86; 95% confidence interval [CI], 0.75-0.98), whereas conscientiousness and extraversion were associated with increased odds of an interview offer (conscientiousness: adjusted OR, 1.26; 95% CI, 1.02-1.55; extraversion: OR, 1.16; 95% CI, 1.03-1.31). When combined with traditional screening criteria (eg, awards, leadership positions), openness to experience and extraversion remained predictors of an interview offer (in the directions specified above), whereas conscientiousness did not. In an exploratory analysis of interviewees, agreeableness was a negative predictor of interview score. Personality did not predict screening scores or final ranking. CONCLUSION: Personality testing, based on the traits desired at individual residency programs, could be a valuable addition to the methods used for selecting PGY1 pharmacy residents.

The Impact of Two Longitudinal Professionalism Courses on Student Pharmacists' Empathy.

Objective. To determine whether empathy increased in first-year student pharmacists after completing longitudinal professionalism courses at two schools of pharmacy, identify potential moderators, and assess whether students' conceptualization of empathy changed with time.Methods. Surveys to assess empathy and other variables were administered to student pharmacists at baseline and at the end of two professionalism courses. Baseline and follow-up scores were compared to detect changes over time. Multivariable analysis was used to identify predictors of empathy scores. Factor analysis was performed to ascertain changes in the dimensionality of empathy.Results. Students' demographics and baseline empathy scores differed between the two schools. Predictors of empathy at baseline included age, female gender, prior health care experience, and altruism score. A small increase in empathy was observed at one school but not in the combined cohort. Empathy was more likely to increase among female students, those with less health care experience, and those who did not work during the school year. Factor analyses suggested that students' conceptual clarity about empathy improved over time and became more consistent with existing models.Conclusion. Although an increase in empathy was not observed in the overall cohort, subgroups of students who may derive greater benefit from empathy-related interventions were identified. Factor analyses suggested that students' conceptual understanding of empathy improved, representing a potential alternative outcome assessment for affective domains. Given differences in demographics, instructional methodologies, and changes in empathy at each school, this study reinforces the importance of replication and multicenter studies to understand the generalizability of educational research.

The Impact of Atherosclerotic Cardiovascular Risk on Graft Failure in Deceased-Donor Renal Transplantation.

INTRODUCTION: Pretransplant cardiovascular risk may be amplified after renal transplant, but little is known about its impact on graft outcomes. RESEARCH QUESTION: The purpose of this study was to determine if pretransplant cardiovascular risk was associated with graft outcomes. DESIGN: This retrospective study included deceased-donor renal transplant recipients from 2010-2015. Atherosclerotic cardiovascular disease risk for patients without prior disease was calculated and patients were categorized into high (score >20%), intermediate (7.5-20%), and low risk (<7.5%). Patients with and without prior cardiovascular disease were also compared. The main endpoint was graft failure at 3-years post-transplant. Other outcomes included major adverse cardiovascular events, biopsy-proven rejection, and mortality. RESULTS: In patients without prior atherosclerotic cardiovascular disease (N = 115), graft failure rates (4.5% vs 11.3% vs 12.5%; (P = 0.64) and major adverse cardiovascular events (9.1% vs 13.2% vs 5.0%; P = 0.52) were similar in the high, intermediate, and low risk groups. In those with prior disease (N = 220), rates of primary nonfunction (6.8% vs 1.7%; P = 0.04), major adverse cardiovascular events (7.3% vs 2.6%; P = 0.01), and heart failure (10.9% vs 3.5%; P = 0.02) were higher than those without cardiovascular; rates of major adverse cardiovascular events and heart failure were insignificant after adjusting for age, gender, and race. Other outcomes were not different. Outcomes did not differ based on pretransplant cardiovascular risk. DISCUSSION: Pretransplant atherosclerotic cardiovascular disease was associated with increased early graft failure but similar outcomes at 3-years, suggesting cardiac risk alone should not exclude transplantation.

Management of noncardiovascular comorbidities in patients with heart failure with reduced ejection fraction.

Patients with heart failure with reduced ejection fraction often have one or more noncardiovascular comorbidities. The presence of concomitant disease states is associated with worse outcomes, including increased risk of mortality, decreased quality of life, and increased healthcare resource utilization. Additionally, the presence of heart failure with reduced ejection fraction complicates the management of these comorbidities, including varying safety and efficacy of therapies compared to those without heart failure. This article will review the literature on the pharmacologic management of common noncardiovascular comorbidities-including chronic obstructive pulmonary disease, depression, diabetes mellitus, gout, chronic kidney disease, and iron deficiency-in patients with heart failure with reduced ejection fraction, as well as provide recommendations for appropriate treatment selection in this population.

Clinical Outcomes of Perioperative Desensitization in Heart Transplant Recipients.

BACKGROUND: Sensitization remains a barrier to heart transplantation (HT). Perioperative desensitization strategies have been described; however, a paucity of evidence exists to demonstrate efficacy and safety in HT. METHODS: This single-center, retrospective study consisted of adults who received an HT. Perioperative desensitization was initiated if virtual crossmatch or flow-cytometry crossmatch was positive. Therapy consisted of plasmapheresis, intravenous immunoglobulin, and rabbit antithymocyte globulin. Historical controls received standard immunosuppression or induction. The primary endpoint was survival at 12 mo. Secondary endpoints included freedom from acute rejection, cardiac allograft vasculopathy (CAV), and infectious complications. RESULTS: Of the 104 patients included, 48 received no induction, 46 received induction, and 10 underwent perioperative desensitization. No differences were observed in the primary endpoint at 12 mo (90.0% versus 97.9%, P = 0.25 for desensitization versus no-induction; 90.0% versus 100%, P = 0.72 for desensitization versus induction). Rates of acute rejection were lower with induction and desensitization compared with no-induction. There were no significant differences in CAV between the groups. Infectious complications were also similar among the groups (10.0% versus 16.7%, P = 0.62 for desensitization versus no-induction; 10.0% versus 30.4%, P = 0.34 for desensitization versus induction). CONCLUSIONS: This study suggests that a perioperative desensitization strategy triggered by positive virtual crossmatch or flow-cytometry crossmatch allows for successful transplantation of sensitized HT recipients and results in acceptable rates of survival, rejection, CAV, and infection at 12 mo.

Comparing Diuresis Patterns in Hospitalized Patients With Heart Failure With Reduced Versus Preserved Ejection Fraction: A Retrospective Analysis.

BACKGROUND: Congestion predominates in exacerbations of heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF), but evidence suggests that excess volume may be distributed differently in these 2 subgroups. METHODS AND RESULTS: In this retrospective study, diuretic efficiency (DE, or net urine output per 40-mg of intravenous furosemide equivalent) during the first 72 hours was compared between patients hospitalized with HFrEF (n = 121) versus HFpEF (n = 120). Multivariate analysis was used to compare the 2 groups based on expected baseline differences (e.g., demographics, heart failure etiology, concomitant therapy). During the first 72 hours, mean daily diuretic doses were higher in patients with HFpEF versus HFrEF (172.0 vs. 159.9 mg, respectively, P = 0.026) but urine output was not significantly different (2603.3 mL vs. 2667.5 mL, respectively, adjusted P = 0.100). Similarly, mean cumulative DE did not differ (-673.5 vs. -637.8 mL/40-mg in the HFrEF and HFpEF groups, respectively, adjusted P = 0.884). An exploratory analysis of propensity-matched cohorts yielded similar findings. Correlations between the components of DE varied considerably and only became weak to moderately correlated toward the end of the observation period. CONCLUSIONS: Although cumulative DE did not differ between patients with HFrEF and HFpEF, variable correlations in the components of DE suggest there may be differences in diuretic response that warrant future analysis.

Novel Use of Tamoxifen to Reduce Recurrent Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices.

Gastrointestinal bleeding (GIB) is a frequent complication in patients with continuous-flow left ventricular assist devices (LVAD). We retrospectively evaluated eight patients implanted with a HeartWare LVAD between July 2017 and June 2020 who experienced at least one episode of GIB and were started on tamoxifen 20 mg once daily for secondary prevention. Tamoxifen was associated with a significant decrease in major GIB from a median of 3 (IQR 1.4-7) events/patient-year pre-tamoxifen initiation to 0 (IQR 0-0.9) events/patient-year post-tamoxifen initiation (p = 0.02). Transfusion of packed red blood cells also decreased from 16.8 (IQR 9.9-30.6) units/patient-year pre-tamoxifen initiation to 1.5 (IQR 0-7.5) units/patient-year post-tamoxifen (p = 0.04). Tamoxifen was well tolerated and no thromboembolic complications were observed. This small cohort study suggests that tamoxifen is associated with reduced GIB and transfusion requirements, with no apparent increase in thrombotic risk. A larger, randomized study is warranted to confirm the results of this exploratory analysis. Graphical abstract.

A Systematic Review of Leadership Definitions, Competencies, and Assessment Methods in Pharmacy Education.

Objective. To characterize leadership definitions, competencies, and assessment methods used in pharmacy education, based on a systematic review of the literature. Findings. After undergoing title, abstract, and full-text review, 44 (10%) of 441 articles identified in the initial search were included in this report. Leadership or an aspect of leadership was defined in 37 (84%) articles, and specific leadership competencies were listed or described in 40 (91%) articles. The most common definitions of leadership involved motivating others toward the achievement of a specific goal and leading organizational change. Definitions of leadership in some articles required that individuals hold a formal leadership position whereas others did not. Only two leadership competencies were related to specific areas of knowledge. Most of the competencies identified were interpersonal and self-management skills. In terms of assessment, only one (2.3%) article assessed leadership effectiveness, and none assessed leadership development. Of the remaining 24 (55%) articles that included some type of assessment, most involved behavioral-based tools assessing individual attributes conceptually related to leadership (eg, strengths, emotional intelligence), or self-assessments regarding whether learning objectives in a leadership course had been met. Summary. Definitions for leadership in pharmacy varied considerably, as did leadership competencies. Most conceptualizations of leadership resembled a combination of established approaches rather than being grounded in a specific theory. If leadership development is to remain a focus within accreditation standards for Doctor of Pharmacy education, a consistent framework for operationalizing it is needed.