peer-to-peer
Burnout, Moral Distress, and Moral Injury Meet
in a Pharmacy: The Need to Learn From the
Interplay Among Them
Nancy A. Alvarez and Michael J. Negrete
Abstract
Purpose
To explore the interplay among burnout, moral distress,
and moral injury; examine current trends and realities
in pharmacy; and call for potential beneficial actions by
individuals, the pharmacy profession, and healthcare
systems.
Methods
A narrative review of recent events and research into
challenges and problems in the pharmacy workplace
indicative of burnout, moral distress, and moral injury
among pharmacists, pharmacy technicians, and other
pharmacy staff.
Results
Burnout in the workplace is caused by chronic stress and
results in emotional exhaustion, feelings of cynicism/
detachment from the job, and lack of accomplishment or
a sense of ineffectiveness. A growing body of evidence
indicates that what is termed burnout may in fact be
moral distress, and this can lead to moral injury if not
recognized and corrected. Indicators of moral distress are
psychological distress, situational impact constraining an
ability to act, and the effect of inaction upon doing what is
deemed right. Over the long term, moral distress leads to
moral injury, which is characterized by pain (psychological,
existential, and/or spiritual) and resulting from dissonance
from doing and/or seeing actions that violate deeply
held moral beliefs and expectations. The intersectionality
of burnout, moral distress, and moral injury can produce
serious sequelae, including suicidality and death by
suicide. In addition to burnout, stressful pharmacy job
demands have been linked to patient safety concerns,
Introduction
In October 2023, organized chain community pharmacy
walkouts occurred in several cities across the United
States in protest of untenable workplace conditions.
Understaffing of pharmacist and pharmacy technician
personnel, lack of well-trained pharmacy technicians,
inability to take sick or vacation time, pressures created
by time-measured productivity metrics, abuse from
frustrated, angry, and sometimes violent patients, and
employee burnout from all these factors were among the
issues cited as causes of the walkouts.1-3
Data generated from studies of the pharmacist
workforce illustrate the extent of pharmacists’ stress and
exhaustion.4,5 While much has been said about the level of
burnout among healthcare providers, something different
California Pharmacist | vol. 71, no. 1 | www.CPhA.com/CaliforniaPharmacist
especially medication errors that are worrisome for
pharmacists and other pharmacy personnel, cause injuries
to patients, and result in negative media attention focused
on the individual and the profession.
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Conclusion
Burnout has been well-characterized for healthcare
professionals, and continued attention to this matter for
pharmacists and pharmacy personnel is warranted. What
is critical to deal with now is further consideration of moral
distress and moral injury and their impact on the pharmacy
profession, as burnout does not adequately characterize
all of what pharmacists and pharmacy personnel are
experiencing.
Calif Pharm. 2024(spring);71(1):35-39.
doi: doi.org/10.37901/cpha24-01
Nancy A. Alvarez, PharmD, BCPS, CPCC, FAPhA, is
Associate Dean, Academic and Professional Affairs–
Phoenix Campus; Associate Professor of Pharmacy
Practice and Science; and Director of Diversity, Equity,
and Inclusion–Phoenix and Tucson Campuses, R. Ken Coit
College of Pharmacy, University of Arizona. Michael J.
Negrete, BS, PharmD, is Speaker, Teamwork & Leadership
Trainer, Executive Coach, ExecOnline, Oakland, California.
Conflicts of interest: The authors report no relevant
conflicts of interest with the material presented in this
article.
ORCID identification: Alvarez: 0000-0002-8952-9765,
Negrete: 0009-0002-3668-6449
may actually be causing many providers’ distress.6,7
Pharmacists are healthcare professionals who take an
oath to, among other things, “consider the welfare of
humanity and relief of suffering their primary concern.”
Yet, their ability to exercise professional autonomy for
that purpose has eroded, particularly when supervised
by nonpharmacists who do not respect or support the
importance of the patient-pharmacist relationship (and
sometimes by other pharmacists far removed from direct
patient care who are similarly insensitive to professional
commitments).
While these are not novel issues for or unique to
community pharmacy, the negative impact of these long-
standing workplace issues was amplified in the wake of the
COVID-19 pandemic. This created an urgency around the
need to deepen understanding of burnout, moral distress,
35
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Figure 1. Depiction of Burnout and Moral Injury for Workforces in Health and Public Health

www.CPhA.com/CaliforniaPharmacist | vol. 71, no. 1 | California Pharmacist

Source: The Workplace Change Collaborative at the Fitzhugh Mullan Institute for Health Workforce Equity; Institute for Healthcare Improvement; Moral Injury
of Healthcare; AFT Healthcare. Burnout and Moral Injury in the Health and Public Safety Workforce. Washington, DC: George Washington University, 2023.
wpchange.org. Reprinted with permission.

36
moral injury, and other negative mental conditions (e.g.,
anxiety, depression, posttraumatic stress disorder), and
how these factors combine to undermine the well-being
of pharmacists and their staff. Clinician wellness is
necessary for healthcare professionals to achieve other
desired health outcomes, such as improving the health
of populations, enhancing the patient experience of care,
reducing the per-capita cost of healthcare, and achieving
health equity.8-10
In this article, we explore the interplay among burnout,
moral distress, and moral injury; examine current trends
and realities in pharmacy; and call for potential beneficial
actions by individuals, the pharmacy profession, and
healthcare systems.
Burnout
Burnout is characterized from an occupational perspective
and broadly described as exposure to chronic stress
resulting in emotional exhaustion, feelings of cynicism/
detachment from the job, and lack of accomplishment or
a sense of ineffectiveness.11 The syndrome has often been
reported to have a prevalence ranging from 52% to 61%
for pharmacists, including those practicing in community
and health-system settings.12-14
Authors of a systematic review of burnout in pharmacists
before the COVID-19 pandemic reported an estimated
overall burnout prevalence range of 8% to 53%.15 The
2019 National Pharmacists Workforce Study reported
pharmacist burnout (work exhaustion + personal
disengagement) for the first time, and “a lot” or “totally
emotionally exhausted” was reported by more than half of
pharmacists working in large chain, mass merchandiser,
or supermarket community pharmacy settings.4
Pharmacists working full time reported having so
much work to do that “everything cannot be done well”
(43%) and even “fear that a patient will be harmed by
a medication error” (35%). Almost 40% of pharmacists
reported experiencing a change in their employment
status, some of whom cited benefits such as better
work environments, responsibilities, or conditions.
Additional impacts of COVID-19 on pharmacists have
been described elsewhere.16,17 Increasingly recognized
is the need to take a systemic approach to address
healthcare burnout that considers the system’s structure,
organization, and culture causing these problems.18-20
Moral Distress and Moral Injury
Long considered a problem by the nursing profession,
moral distress is generally characterized by the presence
of 3 elements: psychological distress, situational impact
constraining an ability to act, and the effect of inaction
upon doing what is deemed right.21 Associated outcomes
of moral distress are largely experienced as anger,
frustration, guilt, and powerlessness.22 Furthermore,
individuals may experience headaches, anxiety, insomnia,
gastrointestinal problems (i.e., nausea, diarrhea),
exhaustion, and depression.23 Moral distress has also been
associated with occupational attrition and an intention to
leave healthcare professions.24 There is also overlap with
characteristics of burnout.11,22
California Pharmacist | vol. 71, no. 1 | www.CPhA.com/CaliforniaPharmacist
Moral injury appears to be a longer-term outcome of
sustained moral distress described as pain (psychological,
existential, and/or spiritual) resulting from dissonance
developed from “perpetrating, failing to prevent, bearing
witness to, or learning about acts that transgress deeply
held moral beliefs and expectations.”25 Moral injury is also
noted to occur when an authoritative figure does not act in
a just manner when the stakes are high.26
Limited study of moral injury outside the military-
associated context has suggested this as the root cause
of daily negative experiences of physicians rather than
burnout, particularly those who work for corporate
entities, though some argue that moral distress is the core
problem.6,7,27 In healthcare, unresolved moral distress can
lead to moral injury when a health professional repeatedly
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encounters dilemmas that they cannot prevent or see
occurring around them.27-30 Analysis of themes of lived
experiences of pharmacists infer occurrences of distress
and suffering and seem to map well to elements associated
with the varied definitions of moral distress and moral
injury.31
Thus, there is ample room for investigation to determine
the intersectionality of burnout, moral distress, moral
injury, and potentially related outcomes such as death by
suicide. Death by suicide has been estimated to be higher
for health professionals versus the general population—
including pharmacists—and problems in the workplace
have been notably associated with suicide in pharmacists.32
September 20 has been designated as Pharmacist
Workforce Suicide Awareness Day to acknowledge that
pharmacists are at an increased risk of death by suicide.
This recognition is increasing attention to the need for the
prevention of suicide among our pharmacy colleagues.
Workplace Change Collaborative Framework
The Workplace Change Collaborative has created a
national framework to address burnout and moral injury
in the health and public safety workforce (Figure 1).33 It
outlines numerous and intersecting factors that contribute
to burnout and moral injury and includes environmental
factors that contribute to breakdowns in operations and
relationships.
Operational breakdowns include lack of safety (i.e.,
abusive behaviors by employers, peers, or patients),
chronic understaffing, excessive clinical and nonclinical
practice demands, and administrative burdens. Distrust
of employers and supervisors, insufficiently trained
pharmacy personnel, and lack of professional autonomy
are reflective of relationship breakdowns. A review of
moral distress and moral injury in the health professions
outlines distinctions and psychological consequences, and
commonalities among the professions, including guilt,
anguish, blaming, and powerlessness.27
Application of the Workplace Change Collaborative
framework for pharmacists has the potential to advance
the recognition and organization of factors contributing
to moral injury. Developing operational and relational
strategies can lead to implementing solutions across the
spectrum of stakeholders in our profession and all of
healthcare.
37
Patient Safety and Other Concerns
In addition to burnout, stressful pharmacy job demands
have been linked to patient safety concerns, especially
medication errors that are worrisome for pharmacists and
other pharmacy personnel.34,35 A core cause of this stress
is the fear that pharmacists face—fear of committing a
medication error because of exhaustion and distraction,
fear of retribution when helping patients with women’s
health issues that are not currently clear from a legal
standpoint, or fear of speaking up about unsafe working
conditions. Pharmacists and other healthcare workers
are also fearful of reprisal in today’s corporate healthcare
world; most of the published articles in mainstream media
are laden with interviewee requests not to be identified for
fear of retaliation by employers.2,3
Based on the definition of moral distress, many pharmacy
situations could be contributing factors for those
practicing pharmacy. However, whether any of them
result in moral injury and for whom is not currently
known. This unanswered question warrants further
investigation. Among these situations are these examples:
• Does working toward health equity over time for myriad
people with diverse characteristics and health challenges
(e.g., age, gender, gender identity, disease condition,
veterans’ status) contribute to moral injury?
• What has been the impact on pharmacists and
pharmacy technicians who supported the walkouts in fall
2023 and on those who decided not to participate because
of their strong desire to fulfill their responsibilities to
patients’ well-being and health?36
• To what degree have job problems and related moral
distress or mental health conditions (e.g., anxiety and/
or depression) led to moral injury, suicidal ideation, and
completed suicides?
• What impact have state and national laws and
regulations had regarding the employment situations of
pharmacists, increasing the fines on corporations that
put profits ahead of patient safety, and dictating what
pharmacists are allowed to do in difficult situations?
• Are pharmacists and pharmacy technicians in different
practice settings experiencing varying degrees of moral
distress and injury based on their roles, responsibilities,
and limitations?
Conclusion: Call for Focused Research Into Moral
Distress and Injury in Pharmacy
Burnout has been well-characterized for healthcare
professionals, and continued attention to this matter for
pharmacists and pharmacy personnel is warranted. What
is critical to deal with now is further consideration of
moral distress and moral injury and their impact on the
pharmacy profession, as burnout does not adequately
characterize all of what is being experienced by
pharmacists and pharmacy personnel.
Learning from other sectors and applying definitions,
understanding contributing factors, identifying
differences across work settings, and characterizing
outcomes will advance strategies to address moral distress
and moral injury on the individual and system levels so
38 www.CPhA.com/CaliforniaPharmacist | vol. 71, no. 1 | California Pharmacist
that work settings can be improved to ensure the health
of the pharmacists and pharmacy technicians who care
for patients and communities. Additionally, positive
media campaigns are needed to illustrate the vital role
that pharmacists have in rural and urban communities,
combat pharmacist invisibility, and support consumer
confidence that might otherwise be eroded by negative
attention to untenable workplace conditions.37,38
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