Burnout in health care isn't an 80/20 problem: why a more balanced view is needed and what it means for you and your workplace

A psychologist with a PhD specialising in doctors’ health challenges the 80/20 burnout narrative, sets out four key risk factors and charts possible solutions.

You probably don’t need convincing that burnout is widespread within health care. But if you did, there is plenty of data to support the claim. Estimates within health care vary based on how ‘burnout’ is defined, although estimates of at least 50% seem to be the norm.¹ Nearly 70% of Australian GPs report experiencing burnout.² Measurement issues aside, the fact this syndrome resonates with so many healthcare professionals highlights a major problem in the sector.

Burnout and the 80/20 narrative

If the scale was not enough to raise alarms, then consider the consequences of healthcare professional burnout. Healthcare professionals experiencing burnout are more likely to report making errors, with links also evident for objectively measured medical errors.^{3, 4, 5} Healthcare professionals report experiencing less empathy for their patients.^{6, 7} Patients are more likely to change doctors when their preferred doctor is experiencing burnout.⁸

The productivity and turnover costs in the United States of America among doctors alone were conservatively estimated at $4.6 billion each year back in 2019.⁹ Further, burnout is linked to intention of leaving the profession;⁶ with the widespread workforce shortages facing Australian healthcare professionals,¹⁰ this threatens to exacerbate workload and thereby create a vicious cycle of deterioration. Burnout in healthcare professionals urgently requires solutions.

Solutions must come from individuals, organisations and healthcare systems, appropriately weighted to those with the most control — often this will be workplaces. Increasingly, though, I have been hearing the phrase that burnout follows the 80/20 rule — that 80% of burnout is caused by organisations and systems, and only 20% of causes are individual factors. I understand the sentiment — that we cannot blame individuals for experiencing burnout.

However, this is a polarising and misleadingly precise claim. No research exists that quantifies this balance. Rather, it originated from an interview where a burnout researcher made an informal approximation rather than a quantifiable, evidence-based finding. Although research does somewhat suggest there may be more impact from organisational and systemic interventions,¹¹ applying the 80/20 rule, in my opinion, does more harm than good.

Christina Maslach, burnout research pioneer, strongly argues that burnout is fundamentally a psychosocial process — a psychological reaction within a context.^{12, 13} Research identifies individual, organisational and systemic risk factors for healthcare professional burnout, but does not suggest we can say any one of these is more important than the others.^{14, 15}

We also cannot overlook the potential damage of this 80/20 characterisation for individuals. Those experiencing burnout already experience helplessness.¹⁶ This framing may reinforce their helplessness by implying they can only influence a small fraction of their experiences.

I propose that we replace the 80/20 narrative given it is polarising and potentially self-defeating. Instead, we need to empower individuals and organisations with evidence so they can both focus on what is in their control and advocate for the bigger changes required.¹⁷

This is not a radical idea, with a clear basis in the widely accepted Job Demands-Resources model.^{18, 19} To make this more practical, let’s consider how this plays out across four key risk factors for burnout, and what actions are feasible and required at individual, organisational and system levels.

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4 key risk factors for burnout

1. Individual psychological experiences

A person’s individual psychological experiences are one risk factor for burnout. There are well-documented links between healthcare professionals having historical or current psychological distress and being more likely to experience burnout,¹⁴ acknowledging that working conditions often contribute to this. Underlying psychological factors such as perfectionistic strivings — often exacerbated by professional cultures — may be associated with greater risk of burnout. Targeted responses to these risk factors require effective psychological supports for individuals. Simply offering an employee assistance program, however, is not sufficient.

Workplace and professional cultures play a major role in shaping and reinforcing these psychological characteristics.²⁰ Further, stigma and fear of consequences can discourage help-seeking, allowing problems to fester.^{21, 22, 23} Accessibility is a key concern as well for many healthcare providers.²⁴ We therefore simultaneously need cultural reform and increased opportunities to facilitate help-seeking among individuals. Psychological characteristics may often be relegated to the responsibility of the individual, but meaningful organisational and systemic intervention is vital for success.

2. Isolation

A related risk factor is isolation. Connection is a basic human need²⁵ and essential to healthcare professional wellbeing.^{26, 27} Healthcare professionals themselves have raised connection as an important protective strategy against burnout.^{27, 28, 29} This factor again does not sit squarely with individuals or organisations. Building personal and professional support networks is an important personal task that individuals navigate.

However, organisations and professional cultures are responsible for enabling this to occur.³⁰ This could include using group-based rather than individual or asynchronous interventions to foster community,²⁷ which can be effective.³¹ Again, organisations can look to instigate cultural reform to dismantle stigma of experiencing wellbeing issues.^{21, 32} Workplaces hold a responsibility to meaningfully enable opportunities for individuals to seek genuine and safe connection.

3. Autonomy

Autonomy is another factor often discussed — healthcare professionals’ ability to direct their time between different tasks and spheres of life. Insufficient autonomy has been linked with burnout,^{14, 33} while higher autonomy builds engagement and satisfaction with work independent of workload.³⁴ Autonomy is traditionally something viewed as being in the hands of organisations and systems that must be granted to individuals. There is some truth in this.

Workplaces hold much power over this through rosters, task allocation and administrative burdens. As such, there will likely be benefits to empowering healthcare professionals. Even here, individuals’ use of autonomy can have different impacts on the benefits for their wellbeing.³⁵ An example of this is doctors who diversify their work — simply taking on other roles does not protect against burnout. However, using autonomy to engage in meaningful activities is key.^{36, 37} Autonomy is yet another case where partnership is needed.

4. Workload

The risk factor perhaps most commonly attributed to organisations and systems is workload. Yet, one of the key determinants of burnout^{14, 33, 37} is something that often lies beyond even organisations, relying on the volume of care needed to meet population-wide patient demand. What organisations do have responsibility for is ensuring adequate staffing to meet these demands at a sustainable level. This represents organisations’ duty to provide physical and psychosocial safety for those who deliver this care.

Just as organisations must establish and articulate boundaries in workload for their own viability, professional codes recognise how healthcare professionals must practise in a safe manner, requiring individuals to monitor themselves. This is a very complicated area, because power dynamics and professional cultures operate through employment security, training requirements, patient needs and funding models, among other factors.

However, to effectively navigate workloads in a sustainable way, we need coordination between individuals and organisations. Even in this case where the onus lies with organisations, input from individuals — within their remit — is critical to effect change.

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A shared — but not equal — responsibility

Traditional views create a false dichotomy between individual and organisational responsibilities. Instead, there is so much nuance to navigate the wicked problem of healthcare professional burnout. We must be careful of how catchy phrases may impede the cause of addressing burnout even if the sentiment is fair. Such phrases risk creating division and polarisation when we need the opposite: collaboration. Viable solutions to burnout will not lie exclusively with individual- or organisational-level solutions by themselves.

Burnout is multifactorial, with each risk factor lying on a spectrum of responsibility spanning individuals to healthcare systems. Only through pooling our resources across this spectrum — from individuals to large healthcare systems and institutions — will we begin to see meaningful progress. This means shared — but not equal — responsibility.

What does this look like? For healthcare professionals, this means practising safely and prioritising yourself. A foundational part is building awareness of yourself — recognising what your needs are, what meaningfulness looks like to you and how warning signs may show up. This knowledge can help you when striving to build supportive networks, seeking support for early warning signs, knowing your limits and deciding on career directions.

It also means recognising that burnout is not a personal failing, but the manifestation of a complex interplay of factors. Speaking out — where safe to do so — against practices and behaviours that perpetuate unhealthy cultures is something else to work towards. For workplaces, recognising that meaningful participation from your staff in wellbeing initiatives is key to bringing about change.

Rather than having dedicated wellbeing resources — although important — the aim should be focusing instead on more foundational changes that will enable connection, that support safety for not only patients but also healthcare professionals, and meeting commitments to leverage the power available to them.

This means fostering community through opportunities for social connection, providing personal leave that staff feel allowed to use, and being open to accepting and acting on feedback from healthcare professionals.

Let’s replace the mantra that 80% of burnout comes from organisations with a commitment by individuals, organisations and systems to cooperatively work within their spheres of influence to reach solutions to this common problem.

*Dr Shaun Prentice is a psychologist based in Adelaide with a professional focus on doctors’ burnout, wellbeing and sustainable medical practice.

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