Lunch breaks and burnout: A profession at a crossroads

Dr Catriona Bradley provides food for thought on the need to protect our patients and ourselves

A cup of cold tea and a half-eaten sandwich; the remnants of a day when I worked as a locum in community pharmacy. Working as a solo pharmacist in busy dispensaries, I often didn’t get the chance to eat lunch fully. I didn’t think much of it at the time. As the shutters came down each evening, I’d sometimes wonder: Is it too late to finish that sandwich?

Back then, I was young, energetic, and felt invincible. I was undertaking research in Trinity, with the intention of pursuing a PhD, and felt grateful to be able to supplement my rather meagre income (which didn’t even cover my rent) by doing locums. In 1999, only Irish-trained or, rather bizarrely, Australia/New Zealand- trained pharmacists working in Ireland under reciprocal agreement provisions, could work as pharmacists in newly-opened pharmacies (within three years of establishment). With just 50 graduates from Trinity each year, Irish pharmacists were in high demand. Locum work was a win-win: pharmacists got a break, and I could afford my rent.

That was a long time ago… last century, in fact, when I was practicing under laws that had been written the century before. The Pharmacy Act of 1875 has since been replaced with that of 2007, and practice has changed considerably. Yet many pharmacists still work without lunch breaks, and this isn’t just an Irish issue.

Conference last July, I facilitated a workshop on pharmacist burnout. The audience included practitioners, academics, regulators, and internationally recognised leaders. After sharing Irish research, which indicated that over 62 per cent of pharmacists experience burnout (with psychological safety, hope, and optimism acting as predictors of burnout), I opened the floor for discussion.

Unprompted, the focus quickly turned to rest breaks, specifically lunch breaks. An English pharmacist initially raised the issue, and colleagues from America, Canada, Europe, Asia, Australia, and Ireland all confirmed that it was a shared concern.

Why are lunch breaks still a problem?

The group identified several contributing factors:

• Ownership structures: In some countries, non-pharmacist owners or corporate bodies do not have statutory responsibilities for patient care and may prioritise profit over safety. When I described Ireland’s pharmacy regulations, where owners, superintendents, and supervising pharmacists all have regulatory responsibilities, the group expressed envy. That envy turned to surprise when they realised that lunch breaks are still a problem in Ireland.

• Cultural norms: Some pharmacists choose to work through lunch or have fallen out of the habit of taking breaks, unaware of the patient safety risks. I recalled a younger version of myself and was grateful for supportive employers who kept me within safe limits for most of my career.

• Retail versus healthcare priorities: Whilst pharmacy’s retail setting is invaluable in providing patient access to healthcare services, retail values are not always aligned with those of healthcare. Pharmacists often operate at the intersection of two conflicting cultures, viewed as a cost in retail terms, rather than a valuable healthcare asset.

• Workforce shortages: Without available cover, breaks become impossible without closing the pharmacy.

Regulation vs responsibility

When exploring solutions, there was lively debate. Here’s a flavour of some of the sometimes-contradictory views that were expressed:

• Pharmacy regulation should enforce lunch breaks as a patient safety issue.
  It should be no different to how working hours for airline pilots are managed.

• Professional regulation of lunch breaks is micro-management. Pharmacists need to be trusted to make a professional call on how they manage lunch breaks.

• If pharmacy regulations are needed for lunch breaks, are they also needed for toilet breaks, study leave or maximum weekly hours? Once we start, where do we stop?

• A values-based, professional culture needs to be cultivated in community pharmacy, rather than digging ourselves deeper into a compliance culture. Other healthcare professionals manage without specific regulation of this issue. Why can’t we?

• Regulation already exists in most countries for rest breaks under employment law. If employers
  or pharmacists don’t adhere to employment law, what makes us think they’ll adhere to pharmacy law?

• Any regulation without compliance is ineffective. Increased inspection and enforcement are the only solution.

• If dissatisfied with their working conditions, pharmacists can raise the issue with their employer. If issues remain unresolved, most countries
  have a process for reporting employers who breach employment law. If issues persist, pharmacists can resign and find a job elsewhere.

Some of the statements evoked strong reactions and rich discussion. Various perspectives were considered: Locums who don’t want lunch breaks, preferring payment; owners who want lunch breaks but can’t find pharmacists; newly-qualified pharmacists who may not have the confidence to confront employers; pharmacists from different generations with different workplace expectations; pharmacists who fear losing patients to competitors if they close for lunch; patients who have different expectations of pharmacists compared to other healthcare professionals, such as general practitioners.

Many topics bubbled through the discussion. Some related to professional concepts within pharmacy: Identity; isolation; leadership; intra-and inter- professional dynamics; evolving scope of practice; and differences between practice settings. Other topics were tangential, but still highly relevant, to the professional agenda: Management structures; rota management; manpower planning; retail culture; inter- generational differences; administration burdens; medicine shortages; achieving collective impact; and increasing levels of intolerance in society. It was a veritable smorgasbord of concepts, any one of which, by itself, could be the subject of an entire workshop, or indeed a future Irish Pharmacist column.

By the end of the workshop, there was a pretty even split in the group between two proposed solutions:
The regulation of working hours by pharmacy regulators (somewhat similar to aviation regulation); or cultural reform in community pharmacy. Some sat on the fence, advocating for simultaneous application of both solutions. Attendees lingered in the room long after the workshop had finished, some continuing to make an energetic case for their perspective, some looking a bit deflated that we hadn’t sorted the problem by the end of the 45-minute session!

Power dynamics in practice

The following day, one of the keynote speakers, in their conference address, remarked that the workshop had provided a rare, safe space for professional debate and stimulation of thought, and highlighted the importance of creating such spaces to support continuing professional development.

They also shared their concern for early-career pharmacists, especially those experiencing burnout, and contested that it was unrealistic for this group to challenge employers, as had been suggested during the workshop discussions. The power imbalance is just too great.

As for the proposal that employees could resign over lunch breaks, this was a privilege that most people simply could not afford. The speaker made their case for the regulation approach, and as their keynote closed, I found myself agreeing: How can we expect individual pharmacists to tackle a systemic issue that directly impacts patient safety? Regulation by pharmacy regulators, as part of their duty to protect patients, seemed the only viable solution.

A change of heart

In the weeks that followed, I thought about that workshop a lot and discussed and debated the issue with people who act as sounding-boards for me, from within and outside of the profession (thanks for indulging me… you know who you are!). These conversations led me to reconsider my position on the lunch break issue.

Regulation may seem like the obvious fix in countries where pharmacists
lack executive power but, in Ireland, we already have a range of regulatory mechanisms that have been leveraged to address this issue:

• Employment laws and PSI guidance.

• Regulatory responsibilities for owners, superintendents, and supervising pharmacists, as outlined in professional regulations.

• Accreditation of new schools of pharmacy to increase workforce supply.

• Pharmacy delineation provisions allowing temporary closure of pharmacies.

If regulation is the answer, why does the problem persist? Perhaps the issue runs deeper and points to a cultural challenge that regulation alone cannot solve.

We may be approaching a metaphorical fork in the road, not just on lunch breaks, but on the future direction of our profession. One path leads to a compliance-driven model, reliant on

regulation, inspection, complaints, and perhaps a precedent-setting case in the Workplace Relations Commission (WRC). The other path embraces a professional philosophy, where we proactively uphold our professional values in service of patients, colleagues, ourselves and our profession. We might try to hedge our bets and walk a middle path, but that risks delaying the inevitable. I believe we need to choose.

Pharmacists are not just workers who deliver pharmacy services. We are custodians of patient safety. If the lunch break issue is any indication, we have work to do in aligning our behaviours and attitudes (ie, our professional culture) with that identity. Shaping a professional culture is no small task. It requires sustained, co- ordinated effort from all stakeholders. However, we can take the first step on that journey by addressing the issue of lunch breaks.

A call to action

To those who are not providing/taking protected lunch breaks, whether employer or employee, consider this: The business of pharmacy is patient safety (credit to an IIOP mentor for that succinct truth). Would any independent advisor endorse your current approach, given the legal, reputational and professional risks?

If we accept that lunch breaks are essential to safe practice, then we must act accordingly:

• Employers: Review your staffing models and opening hours. Ensure your pharmacists have protected time for lunch breaks, where they are free to leave the workplace. If you’re already doing this, share your approach, help set a new standard, and recognise the valuable role you are playing in protecting patients and colleagues. You might also consider acting as a mentor with IIOP, to help guide others on this issue.

• Employees: Advocate for safe working conditions, not just for your own wellbeing, but for the safety of your patients. If you’re unsure how to raise concerns, seek support from trusted colleagues, mentor or networks. If you are a self-employed locum, review your own working practices and ensure you include sufficient protected rest during your working day and week.

• All pharmacists: Start the conversation, in team meetings, on social media, at conferences, with friends and colleagues. Raise awareness of the issue. Culture shifts begin with collective awareness and shared commitment.

It is at times like this that I lament the absence of a professional body for pharmacy in Ireland, whilst also wondering what such a body could achieve if we still struggle with something as fundamental as lunch breaks. Let’s not allow this issue to persist any further in our profession. Instead, let’s address it authentically and achieve collective impact through cohesive alignment of our individual efforts. In doing so, we protect our patients, our profession and ourselves. The time to act is now.

Dr Catriona Bradley is a pharmacist and psychologist and currently works as the Executive Director of the Irish Institute of Pharmacy. She’s particularly interested in exploring psychology in pharmacy and always welcomes pharmacists’ views & comments in this area at catriona1.bradley@gmail.com.