Work satisfaction, stress and burnout in New Zealand ophthalmologists: a comparison of public hospital and private practice

Burnout is a psychological syndrome that results from chronic workplace stress, characterised by emotional exhaustion, depersonalisation and a reduced sense of personal accomplishment.¹ Ophthalmologists, like other healthcare professionals, are susceptible to burnout due to high workloads, long hours and the emotional toll of patient care. Despite being viewed as a highly desirable specialty,^2–4 several studies have shown that at least 25% of ophthalmologists report experiencing burnout, which negatively impacts both their mental health and the quality of care they provide to patients.^4–8

Ophthalmology services in New Zealand are delivered across both the public and private sectors, with government-funded public hospitals and privately run practices providing patient care. The public health system, Health New Zealand – Te Whatu Ora, provides essential healthcare services to all New Zealanders, ensuring equitable access regardless of financial status. However, the public sector is often constrained by annual budget allocations, resulting in long waitlists and resource limitations.^9–11 Public ophthalmologists manage a wide range of cases, including complex trauma, acute eye conditions and emergency treatments, in addition to subspecialty and multidisciplinary work. They also play a key role in registrar training, providing hands-on supervision and contributing to clinical education. Additionally, their responsibilities extend to participation in the on-call acute roster, further increasing their workload. Despite these demands, the public healthcare system provides valuable opportunities for professional growth, including access to continuing medical education funding and dedicated leave, supporting ongoing career development and advancement.

In contrast, private practices offer more timely access to care, funded either directly out of pocket, through private health insurance—held by approximately 37% of New Zealanders as of 2022¹²—or by Accident Compensation Corporation (ACC) claims. Private practitioners maintain greater autonomy over their workload and patient intake, with a focus on elective procedures, routine follow-ups and non-urgent care.^9,11 This distinction in practice environments has a direct impact on job satisfaction, with public sector clinicians often facing higher stress and burnout risks due to workplace pressures, while private practitioners benefit from greater flexibility in managing their clinical responsibilities.^9–11,13

As of 2023, there were 175 Medical Council of New Zealand (MCNZ) vocationally registered ophthalmologists serving a population of about 5.1 million people.¹⁴ This equates to roughly 34 ophthalmologists per 1,000,000 people.^14,15 Compared with other high-income countries such as Japan, Switzerland, Australia and the United States, where the ophthalmologist-to-population ratios range from 40 to 114 per million population, New Zealand’s ratio of 34 per million is one of the lowest.¹⁶ Of the 175 ophthalmologists, 47.4% primarily worked within the public sector, 48.9% primarily in the private sector and the small remainder were within academic or government departments.¹⁴

Method

A cross-sectional quantitative study design was utilised to address the study objectives. At the start of the study, 171 MCNZ-registered ophthalmologists were identified as eligible participants.

The primary outcome was assessed using a modified version of the Mini Z 2.0 Burnout Survey, a validated tool developed by the American Medical Association to measure workplace satisfaction, stress, burnout and their associated risk factors. This survey has been validated against the Maslach Burnout Inventory.^17,18 The original Mini Z survey consists of 10 items scored on a five-point Likert scale and evaluates key workplace factors, including job satisfaction, stress levels, burnout symptoms, workload control, alignment of professional values with organisational leadership, teamwork efficiency, administrative time pressure and workplace disorder. For this study, minor modifications were made to the survey by combining documentation, electronic medical record (EMR) use and EMR proficiency into a single category labelled “administrative time”. This adjustment was necessary as EMR use is not uniformly implemented across all New Zealand regions, rendering it less applicable to the study population. A total Mini Z score of ≥30 (out of 40) was used to define a joyful work environment.

Responses from the five-point Likert scale were transformed into binary variables. Positive responses (e.g., strongly agree and agree) were grouped together, while neutral and negative responses (e.g., neither agree nor disagree, disagree and strongly disagree) were similarly categorised.

In addition to the Mini Z survey, demographic data were collected, including gender, age, subspecialties and years of experience within the specialty. Further practice-related demographics were also captured, such as full-time equivalence, work location, specialty and certification status and presence of registrars.

Data were collected using an anonymous SurveyMonkey survey. (Symphony Technology Group, 2017, trademark SURVEYMONKEY^®). Email addresses were collected only for survey distribution, and responses were de-identified.

A reminder email was sent 2 weeks prior to the survey’s closure, with the survey remaining open for a total of 6 weeks, from 11 November 2024 to 25 December 2024.

Statistical analyses were conducted using Mann–Whitney U test to compare the Mini Z survey responses between ophthalmologists working in the public and private sectors. Single logistic regression was used to estimate odds ratio (OR). A p-value <0.05 was considered statistically significant.

The study has been evaluated by the New Zealand Health and Disability Ethics Committee and deemed not to require ethics approval.

Results

A total of 171 questionnaires were distributed; 10 were undeliverable due to invalid email addresses, resulting in 161 successfully delivered surveys. Of these, 84 responses were received, an overall response rate of 52.0%.

Among the 84 respondents, 53 (63.1%) worked across both public and private sectors, while 18 (21.4%) were exclusively in the public sector and 13 (15.5%) exclusively in the private sector. Given that most respondents had experience in both sectors, the analysis focussed on comparing their experiences rather than categorising them into exclusive groups.

The demographic characteristics of ophthalmologists working in the public and private sectors, along with the number and percentage achieving a Mini Z score of ≥30, indicative of a joyful workplace, are summarised in Table 1.

Overall, a total of 71 (84.5%) respondents had roles within the public sector, of whom 15 (21.1%) achieved a Mini Z score of ≥30, reflecting a joyful workplace. In contrast, a total of 68 (81.0%) worked in the private sector, of whom 51 (75.0%) achieved a Mini Z score of ≥30.

Ophthalmologists reported distinct experiences when working in public versus private settings, with higher scores across all Mini Z items seen in the private sector: job satisfaction, stress levels, burnout symptoms, workload control, alignment of professional values with organisational leadership, teamwork efficiency, administrative time pressure and workplace disorder (Figure 1). Logistic regression analysis, using public sector work experience as the reference group (Table 2), identified statistically significant differences across all Mini Z survey items (P<.05).

While 62.0% of ophthalmologists reported job satisfaction when working in the public sector, only 21.1% characterised their workplace as joyful. In contrast, 94.1% of ophthalmologists working in the private sector reported job satisfaction, with a significantly higher 75.0% describing their workplace as joyful.

Burnout symptoms were noted in 19.7% of ophthalmologists working in the public sector, significantly higher than the 4.4% observed in private practice. Similarly, 25.4% of ophthalmologists working in the public sector reported experiencing a great deal of stress, compared with 17.6% in the private sector.

Although 77.5% of ophthalmologists working in the public sector reported efficient teamwork, 50.7% described their work environment as chaotic or trending towards chaos. By contrast, 97.1% of those working in the private sector noted efficient teamwork, with only 8.8% characterising their workplace as chaotic. Ophthalmologists working in the public sector also reported significantly poorer alignment of personal values with leadership (OR 0.04), worse control over workload (OR 4.3) and less time for administrative tasks (OR 3.7) compared with working in the private sector.

View Table 1–2, Figure 1.

Discussion

New Zealand ophthalmologists report notable differences in their working environment between the public and private sectors, with working in the public sector being perceived as significantly less joyful. This aligns with existing literature indicating that other New Zealand healthcare specialists, including radiologists, oncologists and psychologists, within the public system face challenges that increase their susceptibility to work dissatisfaction and burnout.^9–11 Key contributors include excessive workloads, bureaucratic inefficiencies and the added pressures of political and administrative constraints.^13,19,20

Public hospitals are essential in providing equitable access to ophthalmic care, regardless of financial status. However, resource limitations and growing patient demand place considerable strain on the public sector workforce. Ophthalmologists must manage heavy caseloads, on-call responsibilities and the additional duty of training junior staff, contributing to significant occupational stress. These cumulative pressures heighten the risk of burnout, reduce job satisfaction and diminish workplace enjoyment. This aligns with existing evidence identifying excessive workload as a major contributor to burnout among ophthalmologists.^5–7

In addition to workload pressures, ophthalmologists working in the public sector frequently face inequities in resource allocation.^13,15,19 Performance targets set by hospital organisational leaders, such as increasing clinic capacity to decrease patient backlog, often fail to account for the severity of patients’ conditions.^21,22 As a result, similar time and resources are allocated to both low- and high-severity cases, creating inefficiencies in care delivery. Clinicians often need to dedicate additional time and attention to complex cases, which limits their ability to address the needs of other patients—a challenge that is frequently overlooked by hospital leaders.²⁰ This imbalance forces ophthalmologists in the public sector to work longer hours to meet demand, often without adequate remuneration. The resulting misalignment of values between clinicians and hospital leadership further exacerbates the strain on public sector ophthalmologists, impacting both their job satisfaction and wellbeing.^13,20,23

Unlike public hospitals, private practices provide ophthalmologists the opportunity to serve as their own organisational leaders. This autonomy allows for greater control over workload and patient volumes, facilitating a more manageable balance between clinical responsibilities and personal wellbeing.^{5,6,9–11,20}

Administrative tasks present a challenge for ophthalmologists, particularly in public hospitals, where bureaucratic inefficiencies are frequently encountered. These tasks, including extensive documentation, triaging referrals, conducting audits and frequent departmental meetings, consume significant clinical time and are a reported source of frustration.^5,6,24 Although intended to enhance workplace performance and team cohesion, many senior clinicians perceive them as excessive or unnecessary, thereby increasing job stress and contributing to burnout.^13,19 In contrast, ophthalmologists in private practice benefit from more efficient systems and a higher level of administrative support, allowing the delegation of non-clinical responsibilities. This redistribution significantly alleviates the administrative burden,¹³ highlighting the importance of streamlined processes in mitigating stress and enhancing job satisfaction in private practice settings.

Implications

Our study indicates that nearly one in five ophthalmologists in the public sector report symptoms of burnout, reflecting a substantial workforce burden. With an ageing population and increasing demand for eye care services, this prevalence is expected to rise in the absence of targeted interventions. Adding to this concern is the perception that public healthcare sectors are less desirable workplaces, prompting many ophthalmologists to transition to private practice. A 2022 survey by the Association of Salaried Medical Specialists revealed that 15.5% of health professionals were reducing their public workloads to increase private practice hours.²⁵ This shift was largely driven by dissatisfaction with remuneration, the desire for greater control over workload and scheduling and higher clinical satisfaction—all of which, as this study demonstrates, are more favourable in private practice.

As the demand for eye care continues to grow, ensuring that the ophthalmology workforce is adequately prepared to meet these challenges is critical. While ophthalmology remains a desirable specialty among medical students and junior doctors,^2–4 workforce projections indicate a concerning decline. Despite a retention rate of 71%, with approximately two-thirds of New Zealand-trained ophthalmologists remaining in the country (26), the ophthalmologist-to-population ratio is projected to decrease from 34 to 30.6 per million by 2050, marking a 9.8% reduction.¹⁴ These workforce challenges underscore the urgency of addressing workplace factors that influence job satisfaction and burnout in the public sector.

The findings of this study highlight key strategies that could improve the public sector’s appeal and retain ophthalmologists. Public hospitals could adopt best practices from private practice, such as delegation of administrative processes, minimising unnecessary bureaucratic burdens (e.g., excessive reports, audits or mandatory meetings that do not directly impact patient care) and granting ophthalmologists greater autonomy over their work.

Public–private partnerships (PPPs) offer another potential strategy for enhancing ophthalmic care delivery by integrating private sector capacity with government-funded healthcare systems. These collaborative agreements aim to improve service efficiency, optimise resource utilisation and support workforce distribution.^27–29 By enabling clinicians to work across both sectors and facilitating publicly funded procedures in private settings, PPPs can help alleviate pressure on public hospitals and improve job satisfaction and retention within the public system. However, without proper oversight, PPPs may exacerbate health inequities by prioritising insured patients and fostering a profit-driven model that increases healthcare costs and strains public resources.^27–29 To maximise benefits while minimising risks, PPPs must be structured with transparency, equitable access and a patient-centred approach.

Limitations and suggestions for future research

Like all voluntary self-report surveys, our research is subject to non-response biases that can influence both the data collected and their interpretation.³⁰ Non-response bias could result in the underestimation of stress or burnout if affected ophthalmologists were less likely to participate. Nevertheless, the response rate of 52% aligns with similar studies,^6–8 supporting the representativeness of the findings. Additionally, self-reported data are inherently prone to reporting bias, as participants may exaggerate or downplay their experiences due to factors such as social desirability or recall limitations.

Future research could include longitudinal studies to evaluate the long-term effects of workplace interventions on job satisfaction and burnout among ophthalmologists. Additionally, further studies may offer deeper insights into the unique challenges across different workplace sectors, providing a clearer understanding of the factors influencing satisfaction, stress and burnout. An upcoming study is currently assessing the impact of various workplace factors on burnout, specifically addressing these raised questions.

Conclusion

This study identifies significant disparities in job satisfaction, stress and burnout of ophthalmologists working in New Zealand’s public and private sectors. Those working in the public sector face notable challenges, including heavier workloads and bureaucratic inefficiencies, whereas those working in private benefit from greater autonomy, administrative support and better organisational structures. Integrating key strategies from the private sector, including competitive remuneration, enhanced workload management, flexible scheduling and strategic implementation of PPPs, may help improve job satisfaction and retention within the public sector. These findings have broader implications for workforce planning, recruitment and retention of ophthalmologists and other health professionals, both in New Zealand and in public health systems worldwide.