The Impact of Hospital Pharmacists' Psychological Contracts on Medication Adherence Management: The Mediating Role of Job Burnout

1. Introduction

Medication adherence remains a critical issue in healthcare, with non-adherence persisting as a widespread and enduring challenge(Osterberg, et al., 2005). The World Health Organization (WHO) estimates that 25% to 50% of patients worldwide fail to follow prescribed medication regimens. In the United States, inadequate adherence is responsible for around 125,000 deaths annually—equivalent to the combined mortality from colorectal, breast, and prostate cancers(Baryakova, et al., 2023). Poor adherence undermines treatment efficacy, leading to incomplete therapy, disease progression, and, in some cases, death. A study on patients with chronic obstructive pulmonary disease (COPD) found that poor adherence worsened symptoms, increased hospitalization and mortality, and raised healthcare costs(Ammous, et al., 2024). As healthcare models evolve and patient needs grow more complex, the role of pharmacists in enhancing medication adherence and ensuring patient safety has become increasingly important(Chisholm-Burns, et al., 2010; Glover, et al., 2024; Wu, et al., 2023).

The concept of the psychological contract refers to an employee's perception of mutual obligations between themselves and their organization, first introduced by Argyris in the 1960s(Rousseau, 1990). This implicit agreement significantly influences employee engagement(Rodwell, et al., 2022), and research highlights that fulfilling the psychological contract enhances motivation(Yu, 2022). Previous studies have shown that pharmacists’ psychological contracts positively impact their attitudes and behaviors in providing pharmaceutical services(Zhang, 2019). However, unmet organizational commitments can breach the psychological contract, leading to reduced job satisfaction, diminished motivation, and increased turnover intentions. Research on physicians shows that such breaches elicit strong negative emotions, resulting in undesirable behaviors(Hu, et al., 2023; Collins, et al., 2020). To enhance employee motivation and loyalty, organizations must prioritize psychological contracts alongside economic agreements, thereby improving healthcare quality(Yu, et al., 2020). Understanding pharmacists' psychological contracts is essential to fostering engagement, improving medication adherence, and ultimately enhancing patient care quality.

In our previous research, we developed and validated a psychological contract scale for hospital pharmacists based on data from 77 public medical institutions in Zunyi, China(Zhang, et al., 2020). This scale was proven reliable and valid, providing a robust tool for future studies. The current study aims to explore the relationship between hospital pharmacists' psychological contracts and their attitudes and behaviors toward patient medication adherence. By identifying the psychological contract factors influencing pharmacists' involvement in adherence management, this research aims to offer insights for improving their participation and ultimately enhancing patient adherence and health outcomes.

2. Materials and Methods

2.1. Scale Development

A comprehensive literature search was conducted using the keywords "Medication Adherence," "Pharmacist," "Research Progress," "Psychological Contract," and "Management" in both Chinese and English. Several databases were queried, including CNKI, Wanfang, VIP, PubMed, and Web of Science. The retrieved literature was systematically reviewed and synthesized. Based on expert consultations, a preliminary draft of the "Pharmacist's Attitudes and Behaviors Toward Patient Medication Adherence Management" scale was developed. This scale comprises two subscales: "Pharmacist's Attitudes Toward Patient Medication Adherence Management" (8 items) and "Pharmacist's Behaviors Toward Patient Medication Adherence Management" (25 items).

2.2. Delphi Expert Consultation

A Delphi consultation questionnaire was designed based on the initial scale, consisting of three sections: (1) Introduction (study background, purpose, and significance), (2) Main questionnaire (item content details), and (3) Expert demographic survey (expert information, item familiarity, and judgment criteria).

Sixteen experts were selected for the Delphi process, with inclusion criteria: (1) pharmacists in healthcare institutions, (2) associate senior title or higher, (3) bachelor's degree or above, (4) at least 5 years of experience, and (5) informed consent to participate. Exclusion criteria included external trainers.

2.3. Expert Evaluation and Data Analysis

Expert characteristics were summarized using frequencies and percentages. Expert engagement and authority were assessed through the response rate and expert authority coefficient (Cr), calculated as follows:

$$Cr={\displaystyle \frac{Cs+Ca}{2}}$$

A Cr value ≥ 0.7 indicates good reliability. Here, Cs represents the expert's familiarity with the questionnaire (ranging from "very familiar" (0.9) to "very unfamiliar" (0.1))(Dai, et al., 2019), and Ca refers to the expert's judgment basis, which is classified into practical experience, theoretical analysis, relevant literature, and personal intuition, with corresponding values assigned as shown in Table 1 (Hu, et al., 2019).

The concentration of expert opinions was assessed using the importance score and the percentage of maximum scores. Importance was rated on a 5-point Likert scale (1 = very unimportant to 5 = very important). Consistency among expert opinions was evaluated through the coefficient of variation (CV) and Kendall’s coefficient of concordance (W). Specifically: CV < 0.3 indicates high coordination; W with P < 0.05 indicates significant agreement(de Goumoëns, et al., 2025).

Items were retained if the average importance score was ≥ 3.5 and the CV was < 0.3(Robinson, et al., 2014; Wells, et al., 2014). Expert opinions were also used to determine whether each item should be retained in the final version.

2.4. Participant Recruitment

A stratified random cluster sampling method was used to select participants from tertiary, secondary, and primary healthcare institutions in Zunyi and Bijie cities, China. Pharmacists were invited to anonymously complete a survey, which included demographic information and measures related to the "Hospital Pharmacist Psychological Contract," "Pharmacist Involvement in Patient Medication Adherence Management Attitudes and Behaviors," and "Job Burnout." Inclusion criteria included: (1) a background in pharmacy, (2) current employment as a pharmacist, and (3) voluntary participation. Trainee pharmacists were excluded from the study.

2.5. Reliability and Validity Testing

Reliability was assessed using Cronbach's α coefficient, where values between 0.5 and 0.7 indicate acceptable reliability, values above 0.7 indicate high reliability, and values above 0.9 indicate excellent reliability(Teo, et al., 2025).

Validity was assessed using exploratory factor analysis (EFA). The Kaiser-Meyer-Olkin (KMO) test and Bartlett's test of sphericity were conducted. A KMO value > 0.7 indicates suitability for factor analysis, while a significant P-value (P < 0.05) from Bartlett’s test confirms data appropriateness for analysis(Wu, 2014).

2.6. Statistical Analysis

Data were entered into Excel and analyzed using SPSS 29.0. A P-value < 0.05 was considered statistically significant, with all tests being two-tailed. Demographic data were presented as frequencies and percentages, and scale scores as mean ± standard deviation. For binary and multi-category data, independent sample t-tests, one-way ANOVA, and Kruskal-Wallis H tests were used, with LSD and Games-Howell post hoc tests for multiple comparisons. Spearman’s correlation analysis was used to assess relationships between pharmacists’ psychological contract, job burnout, and their attitudes and behaviors toward medication adherence management. Multiple linear regression was used to identify factors influencing pharmacists' participation in medication adherence management.

3. Results

3.1. Expert Panel

3.1.1. Expert Demographics

All 16 experts in the Delphi consultation held at least a bachelor's degree, with 25% holding doctoral degrees. All experts held professional titles of associate senior or higher, and 44% had over 20 years of work experience (Table 2).

3.1.2. Expert Correlation Coefficients

As shown in Table 3, all 16 consultation questionnaires were returned, resulting in a 100% response rate. The expert authority coefficient was 0.83, indicating high expertise and reliable consultation results. The coefficient of variation for each item ranged from 0.08 to 0.60, and Kendall's coefficient of concordance was 0.198, which was statistically significant (P < 0.01).

3.2. Delphi Results

After the Delphi consultation, one item was removed from the attitude scale, and two items were modified. For the behavior scale, two items were removed, and 14 items were revised, with three new items added. The highest mean score was 4.81, and the lowest was 2.75. The highest frequency of full scores was 81.25%, and the lowest was 12.50%. The coefficient of variation ranged from 0.08 to 0.60. Detailed modifications are shown in Table 4.

A total of 196 questionnaires were distributed, with 183 returned, 180 of which were valid, yielding an effective response rate of 98.36%. The demographic information of the pharmacists is shown in Table 5.

Reliability and validity analysis indicated that the Cronbach's α coefficients for the scales on pharmacists' attitudes and behaviors toward medication adherence management, as well as for the overall questionnaire, were all greater than 0.7. The KMO values were above 0.8 (P < 0.01), as shown in Table 6 and Table 7.

3.4. Statistical Analysis Results

3.4.1. Analysis of Pharmacists' Demographic Data on Psychological Contract, Job Burnout, and Attitudes and Behaviors Toward Patient Medication Adherence Management

Significant differences in behavior scores were observed between male and female pharmacists (P < 0.05). While no overall differences were found in job burnout scores across age groups, post-hoc analysis revealed that pharmacists aged 40-49 had higher job burnout levels compared to those aged 50-59 (P < 0.05). Income level differences were noted in both psychological contract and behavior scores (P < 0.05). Detailed results are presented in Table 8.

3.4.2. Correlation Between Pharmacists' Psychological Contract, Job Burnout, and Attitudes and Behaviors Toward Patient Medication Adherence Management

Spearman’s correlation analysis was conducted to examine the relationships between pharmacists' psychological contract, job burnout, and their attitudes and behaviors toward medication adherence management. Results are displayed in Table 9.

3.4.3. Regression Analysis of Pharmacists' Attitudes and Behaviors Toward Patient Medication Adherence Management

Multiple linear regression analysis, using psychological contract and job burnout as independent variables, and attitudes and behaviors as dependent variables, revealed that both psychological contract and job burnout significantly predicted pharmacists' attitudes toward medication adherence management. Specifically, the regression coefficient for psychological contract was 0.147 (P < 0.05), and for job burnout, it was -0.140 (P < 0.01). For behaviors, psychological contract significantly predicted pharmacist involvement, with a regression coefficient of 0.489 (P < 0.01). See Table 10.

3.4.4. Mediating Effect of Job Burnout

A mediation model using psychological contract as the independent variable, job burnout as the mediator, and attitudes/behaviors as the dependent variables was tested with SPSS Process 4.1, as shown in Table 11. Results showed that psychological contract negatively affected job burnout (β = -0.2554, P < 0.01) and positively affected attitudes (β = 0.1824, P < 0.05). Job burnout negatively influenced attitudes (β = -0.2181, P < 0.01), and psychological contract positively impacted behaviors (β = 0.2955, P < 0.01).

Further testing of the mediating effect using the non-parametric percentile Bootstrap method (Table 13) indicated that in the attitude model, the indirect effect’s 95% CI did not include 0, suggesting job burnout partially mediated the relationship between pharmacists' psychological contract and attitudes toward medication adherence management (effect size = 0.0448). However, in the behavior model, the CI included 0, indicating job burnout did not mediate the relationship between psychological contract and behavior. The specific pathways are illustrated in Figure 1 and Figure 2.

Table 12. Table of Decomposition of Total Effect, Direct Effect, and Mediated Effect.

Model	Type of effect	Effect	standard error	t/Z	P	Boot CI Upper Limit	Boot CI lower limit	Proportion of effect
Attitudes	Total	0.1914	0.0585	3.2713	0.0013	0.0759	0.3068	100.00%
	Direct	0.1466	0.0592	2.4753	0.0143	0.0297	0.2635	76.59%
	Professional burnout	0.0448	0.0203			0.0113	0.0899	23.51%
Behaviors	Total	0.4858	0.1185	4.0992	0.0001	0.2519	0.7197	100.00%
	Direct	0.4888	0.1229	3.9769	0.0001	0.2463	0.7314	100.62%
	Professional burnout	-0.0003	0.0381			-0.0823	0.0724	-0.62%

Table 12. Table of Decomposition of Total Effect, Direct Effect, and Mediated Effect.

Model	Type of effect	Effect	standard error	t/Z	P	Boot CI Upper Limit	Boot CI lower limit	Proportion of effect
Attitudes	Total	0.1914	0.0585	3.2713	0.0013	0.0759	0.3068	100.00%
	Direct	0.1466	0.0592	2.4753	0.0143	0.0297	0.2635	76.59%
	Professional burnout	0.0448	0.0203			0.0113	0.0899	23.51%
Behaviors	Total	0.4858	0.1185	4.0992	0.0001	0.2519	0.7197	100.00%
	Direct	0.4888	0.1229	3.9769	0.0001	0.2463	0.7314	100.62%
	Professional burnout	-0.0003	0.0381			-0.0823	0.0724	-0.62%

4. Discussion

Patient medication adherence is a critical factor in the effectiveness of clinical drug therapy. However, adherence is influenced by a complex interplay of multiple factors, including the patient's age, cognitive ability, psychological state, and economic status(Dawson, 2019). In addition to patient-related factors, pharmacists play a pivotal role in the medication process. Their professional guidance and communication skills are key to improving medication adherence(Ahn, et al., 2024). Pharmacists' work attitudes and behaviors are significantly influenced by their perceptions of the psychological contract with their healthcare institutions.

This study highlights the relationship between pharmacists' psychological contracts and their attitudes and behaviors in medication adherence management. These findings align with our previous research on the connection between pharmacists' psychological contracts and their attitudes and behaviors in pharmacy services(Zhang, 2019). Specifically, when pharmacists perceive a higher level of psychological contract fulfillment, they demonstrate more positive and proactive attitudes and behaviors toward managing patient medication adherence. In turn, this commitment enhances their relationship with the hospital, fosters patient trust, and promotes better treatment outcomes, all of which contribute to a stronger doctor-patient relationship(Listed N A., 2005). Research has shown that pharmacists who improve their service attitudes can strengthen patient trust, which subsequently boosts medication adherence(de Oliveira, et al., 2006). Pharmacists with a strong psychological contract perceive medication adherence management as an essential component of their professional role, leading to increased engagement in this task(Feng, et al., 2023).

Pharmacists with a robust sense of psychological contract recognize the importance of adherence management in improving treatment outcomes, reducing healthcare costs, and enhancing patients' quality of life. As a result, they are actively involved in this area. However, when the psychological contract is breached, pharmacists may feel disillusioned, leading to a decline in their motivation to manage medication adherence. This lack of motivation can result in diminished work quality, causing patients to question the efficacy and safety of their treatment regimens, which may, in turn, reduce medication adherence. Thus, fulfilling the psychological contract between healthcare institutions and pharmacists is crucial for encouraging their active participation in medication adherence management. Healthcare organizations should prioritize fulfilling these contracts by improving communication, ensuring fair workload distribution, and offering career development support to enhance pharmacists' perception of their psychological contract. This approach will foster pharmacists' enthusiasm and initiative in managing medication adherence, ultimately improving patient adherence and strengthening the doctor-patient relationship.

Additionally, this study incorporated burnout as a mediating variable in the relationship between the psychological contract and participation in medication adherence management. Pharmacist burnout significantly mediated this relationship and was negatively associated with both the psychological contract and attitudes toward adherence management. The psychological contract represents an implicit agreement between pharmacists and healthcare organizations. When pharmacists feel their psychological contract is fulfilled, they experience a sense of value and significance in their work, which leads to higher job satisfaction and reduced burnout(Sui, et al., 2023). Conversely, a low perception of the psychological contract—characterized by feelings of neglect, unappreciation, or an imbalance between effort and reward—can lead to burnout. This, in turn, negatively affects their attitude toward participating in medication adherence management, compromising work performance and the quality of medication adherence support provided to patients(Mu, et al., 2020).

High levels of burnout can cause pharmacists to lose enthusiasm and motivation, diminishing their attention to medication adherence management. They may become less proactive in communicating with patients or providing necessary medication guidance and follow-up. For example, they may adopt a perfunctory attitude, offering brief and impatient responses to patients' inquiries. Emotional distress may also impair their communication with patients, reducing trust and, consequently, medication adherence(Gu, et al., 2023). Therefore, hospitals and policymakers must prioritize addressing pharmacist burnout. This can be achieved by enhancing pharmacists' perceptions of their psychological contract through respect, support, and professional development opportunities, as well as optimizing the work environment to reduce negative factors contributing to burnout. This will prevent a decline in work quality and improve medication adherence management.

This study aims to explore the psychological factors influencing pharmacists' participation in medication adherence management and examine the mediating role of burnout. It provides empirical insights into the psychological mechanisms underlying pharmacists' involvement in medication adherence management, offering theoretical support and practical guidance for healthcare organizations to develop more targeted management strategies. Based on these findings, the following recommendations are made to optimize pharmacists' motivation in medication adherence management and improve patient adherence: (1) Enhance the fulfillment of pharmacists' psychological contracts, such as strengthening trust between pharmacists and healthcare institutions, and improving communication between hospital management and pharmacists. Enhance the Fulfillment of Pharmacists' Psychological Contracts: Strengthen trust between pharmacists and healthcare institutions, improve communication between hospital management and pharmacists, and ensure psychological contract fulfillment. (2) Reduce burnout by improving working conditions, providing career development opportunities, and prioritizing pharmacists' psychological well-being. Reduce Burnout: Improve working conditions, offer career development opportunities, and prioritize pharmacists' psychological well-being to reduce burnout and enhance job satisfaction. (3) Boost pharmacists' motivation to participate in medication adherence management, e.g., fostering a sense of responsibility through training, establishing incentive mechanisms (e.g., incorporating participation in medication adherence management into performance evaluations and offering appropriate rewards), and promoting teamwork (e.g., enhancing collaboration between pharmacists and other healthcare professionals to provide comprehensive medication management services and improve adherence management outcomes). Boost Pharmacists' Motivation: Foster a sense of responsibility through training, establish incentive mechanisms (e.g., incorporating medication adherence management into performance evaluations and offering appropriate rewards), and promote teamwork (e.g., enhancing collaboration between pharmacists and other healthcare professionals to provide comprehensive medication management and improve adherence outcomes).

5. Limitations

This study has several limitations that warrant further investigation. First, only one round of the Delphi survey was conducted with a limited number of experts, which may impact the depth and comprehensiveness of the findings. Future research should involve multiple rounds of the Delphi survey and expand the expert panel to incorporate a broader range of perspectives, thereby enhancing the diversity and representativeness of the results. Second, the study focused exclusively on pharmacists in hospitals in Zunyi and Bijie, Guizhou Province, China, limiting the geographic scope of the research. Expanding the study to include regions with varying levels of economic and healthcare resources would improve the generalizability of the findings. Third, while this study explored burnout as a mediating variable in the relationship between pharmacists' psychological contracts and their involvement in medication adherence management, it may not fully capture the underlying mechanisms of pharmacists' behaviors. Future research should incorporate additional variables, such as professional responsibility and identity, to develop a more comprehensive theoretical model and enhance the explanatory power of the relationship between pharmacists' psychological contracts and engagement in medication adherence management. Lastly, this study primarily relied on quantitative surveys, which may not fully capture the complex experiences and psychological factors influencing pharmacists in real-world settings. Future research should integrate qualitative methods, such as in-depth interviews and case studies, with quantitative data to provide a more comprehensive analysis of the challenges faced by hospital pharmacists, offering deeper insights to inform decision-making.

6. Conclusions

The fulfillment of pharmacists' psychological contracts significantly influences their engagement in medication adherence management, with job burnout acting as a mediating factor. Furthermore, the psychological contract is a key determinant of pharmacist burnout. Effective management of pharmacists' psychological contracts is thus crucial for enhancing motivation, reducing burnout, improving patient adherence, and optimizing medication safety and treatment outcomes. The findings of this study offer an empirical foundation for understanding the factors that shape pharmacists' attitudes and behaviors in medication adherence management. They also provide theoretical support and practical guidance for healthcare organizations in developing strategies to manage pharmacists' psychological contracts. However, future studies should broaden the scope by exploring additional mediating variables, such as professional responsibility and identity, and investigating different types of pharmacists (e.g., community pharmacists, clinical pharmacists) and patient populations (e.g., chronically ill or elderly patients) to examine potential variations in the psychological contract's role across diverse groups. Moreover, integrating qualitative research alongside quantitative methods could offer a more nuanced understanding of the psychological factors that influence pharmacists' workplace behaviors, thus enriching our understanding of the dynamic relationship between psychological contracts and medication adherence management.