Building a resilient oncology workforce in the Asia–Pacific: From outcomes to systems thinking in workforce well-being

Five years after the onset of the COVID-19 pandemic, health workers worldwide continue to endure significant, ongoing strain. The World Health Organization's (WHO) 2025 global assessment reported that 63% of country offices observed job-related impacts on health workers.¹ Initially an acute crisis characterized by equipment shortages, overcrowded facilities, and rapidly evolving protocols, the pandemic has evolved into a protracted systemic challenge. Complementary analyses from the Organization for Economic Co-operation and Development (OECD) indicate that nearly 40% of physicians under the age of 55 report burnout, with over 10% intending to leave clinical practice.² WHO further projects a global shortfall of 10–11 million health workers by 2030.¹ Together, these findings underscore the deep structural pressures confronting health systems worldwide. Although the immediate threat of infection has receded, psychological and organizational pressures remain substantial for healthcare providers. Across the Asia–Pacific (APAC) region, clinicians continue to report high levels of emotional exhaustion, anxiety, and disengagement. A systematic review and meta-analysis of over 159,000 Asian healthcare providers estimated pooled rates of depression (37.5%), anxiety (39.7%), stress (36.4%), and burnout (over 68%) - all substantially higher than pre-pandemic global averages (25% to 30%).³

Regional patterns and persistent strain

Country-specific findings mirror these patterns. In Singapore, 38% of healthcare professionals experienced clinically significant emotional exhaustion – the central component of burnout – while nearly one-third met criteria for high depersonalization and 44% for overall burnout.⁴ Depersonalization, defined in the Maslach Burnout Inventory (MBI) as detached or cynical attitudes toward work and colleagues, reflects a psychological adaptation to sustained emotional strain.⁵ When combined with emotional exhaustion and reduced personal accomplishment, depersonalization represents multifaceted burnout that undermines both individual well-being and team cohesion. In China, early pandemic surveys revealed that more than half of healthcare workers experienced moderate to severe psychological impact, with one-third reporting anxiety and nearly one-fifth depressive symptoms.⁶ Subsequent meta-analyses across East, Southeast, and South Asia confirmed similarly elevated prevalence rates, with depression approaching 35%, anxiety 40%, stress exceeding 30%, and burnout as high as 68%.^3,7 Importantly, these rates remain elevated beyond the acute crisis. A 2024 multi-institutional survey in Taiwan found that 35% of critical care staff met burnout criteria, with over 70% reporting emotional exhaustion.⁸ In Japan, nearly one-third of frontline workers – particularly nurses and early-career clinicians – reported comparable levels of distress.⁹

Unique vulnerability of APAC oncology workforce

Within the APAC healthcare workforce, oncology nurses constitute a particularly vulnerable group. A systematic review of oncology nurses across Asia documented pooled emotional exhaustion scores of 22.1 and depersonalization scores of 6.9, with 36.4% reporting high emotional exhaustion – significantly exceeding rates among general nursing populations.¹⁰ This vulnerability stems from unique occupational stressors: routine exposure to end-of-life care, challenging prognostic discussions, and the emotional burdens of supporting cancer patients and their families.8., 9., 10. However, research on oncology workforce well-being in the APAC region remains constrained by outcome-focused measurement, limited geographic scope, and underrepresentation of key workforce segments. These gaps restrict understanding of modifiable organizational and systemic factors that influence resilience and retention in oncology care.

Evidence gaps in APAC workforce well-being research

Overrepresentation of urban tertiary hospitals

Most APAC studies are based in large urban tertiary hospitals, with scant attention to rural, district, or primary care settings. Yet, these peripheral settings often face severe staff shortages, sustained workloads, and scarce resources¹¹ In many low- and middle-income countries, midwives, community health workers, and technicians deliver essential frontline care but are rarely included in workforce well-being studies.¹¹ Consequently, evidence disproportionately reflects well-resourced institutions, neglecting the most vulnerable contexts.¹¹ The absence of data is particularly concerning in countries facing workforce migration. For instance, the large-scale outmigration of nurses from the Philippines has exacerbated domestic shortages and intensified workloads for remaining staff.¹²

Measurement focused on outcomes, not systems

Although commonly used tools like MBI,⁵ DASS-21,¹³ and GAD-7¹⁴ quantify burnout, depression, and anxiety, few studies examine the underlying organizational determinants contributing to these outcomes. As a result, they describe symptoms but provide limited insight into systemic solutions. Moreover, these assessment tools are frequently administered without sufficient cultural or linguistic adaptation – for instance, deploying English-language scales in Malaysia and Vietnam, which may lead to misinterpretation.³ In Southeast Asia, distress is frequently expressed somatically through symptoms such as fatigue, headaches, or gastrointestinal complaints, that conventional instruments may overlook.⁷ This results in outcome-heavy, system-blind evidence that reduces both accuracy and practical applicability.

Hierarchical cultures and stigma

Hierarchical workplace cultures and stigma further discourage disclosure, particularly among junior clinicians and nurses, leading to systematic underreporting.^15,16 Concerns about confidentiality and career repercussions compound this reluctance, reducing both data accuracy and the likelihood of seeking support.^15,16

Exclusion of allied and support staff

Most studies focus narrowly on physicians and nurses, excluding allied health professionals, administrative personnel, and ancillary workers. Even within nursing, specialty groups such as oncology nurses receive limited attention despite facing distinctive stressors. In a multicenter study from Singapore, nurses accounted for nearly 60% of respondents, while other roles were minimally represented.¹⁶ Multi-country analyses reveal similar patterns. The omission of these groups underestimates the full burden of distress and obscures vulnerabilities across the broader healthcare workforce.¹⁷

From outcomes to systems thinking

Evidence-based, theory-driven frameworks for workforce well-being have gained traction globally. The National Academy of Medicine (NAM) Systems Approach to Clinician Burnout conceptualizes burnout as a systems-level issue shaped by conditions at the frontline, organizational, and policy levels.¹⁸ The framework emphasizes aligning job demands with resources, redesigning workflows, and embedding leadership accountability. Major U.S. health systems such as Mayo Clinic and Kaiser Permanente have applied this approach, demonstrating reductions in burnout and improved clinician engagement.^19,20 Similarly, the NIOSH Total Worker Health (TWH) model integrates occupational safety with health promotion through the Well-Being Questionnaire (WellBQ), which measures five domains: work evaluation and experience, workplace policies and culture, environment and safety climate, health status, and home/community factors.²¹ The TWH framework underscores that well-being depends as much on organizational context as on individual behavior, advocating preventive strategies such as equitable staffing and supportive supervision. Although piloted in U.S. public health surveillance, its use for organizational redesign remains limited.²²

In the APAC region, adoption of such frameworks is nascent. Malaysia offers the most concrete example, where the WellBQ was translated and validated among 366 healthcare workers at a tertiary hospital in Kelantan, demonstrating high reliability and validity.²³ However, broader policy integration and evidence of system-level impact remain absent. To date, no APAC-specific contextual inquiry framework has been developed for healthcare workforce well-being. The closest analogue is the Scaling-Up Noncommunicable Disease Interventions in South-East Asia (SUNI-SEA) guideline, implemented in Myanmar, Indonesia, and Vietnam.²⁴ While not designed for workforce well-being, SUNI-SEA applies an implementation science approach, using 34 contextual factors to tailor interventions, demonstrating the feasibility of APAC-led contextual adaptation.

A systems framework for oncology workforce well-being

Our team at the University of North Carolina (UNC) has applied the NAM and TWH frameworks across multiple healthcare settings – including emergency medicine, surgery, oncology, and primary care – engaging over 1000 clinicians and staff in both urban and rural facilities25., 26., 27., 28., 29., 30., 31., 32., 33.. Preliminary findings indicate that oncology teams experience distinct burnout patterns requiring tailored interventions addressing end-of-life care challenges and ethical complexity. These interventions yielded measurable improvements: a 15% reduction in burnout scores among surgical teams, a 12% increase in resilience scores within hospital medicine units, and a 20% decrease in workflow disruptions in radiation oncology. Although implemented in North Carolina, the proposed five-phase mixed methods framework is adaptable to international contexts, including APAC health systems, with appropriate cultural modification (Fig. 1).

Fig. 1.

Five-phase mixed-methods framework for healthcare workforce stressor assessment and prioritization.

Fig. 1 summarizes this integrated mixed-methods framework, which generates actionable, context-sensitive recommendations incorporating frontline perspectives and enabling system-level interventions. Supplementary File 1–3 provide extended methods and phase-specific outputs that accompany the framework. Building on Phase 4 outputs (Fig. 1), organizational leaders collaborated to design and implement targeted interventions. Regular monitoring, review sessions, and data-driven adaptation ensured that interventions remained responsive to evolving workforce needs, reinforcing long-term well-being.

Empirical evidence from APAC workplaces supports these mechanisms. Studies in India and Singapore demonstrate that team-based recognition, transparent communication, and structured follow-up on staff feedback are foundational for psychological safety and sustained engagement.^34,35 Our adapted framework integrates these locally validated practices through culturally anchored recognition systems, standardized communication protocols, and closed-loop feedback mechanisms, as further detailed in Supplementary File 4.

Policy alignment and future directions

Recent regional policies underscore the potential for structured, systems-based approaches to support workforce well-being. WHO SEARO's Decade of Strengthening Human Resources for Health emphasizes continuous workforce assessment and capacity building across professions.³⁶ The ASEAN Health Cluster 3 Work Programme prioritizes mental health resilience and participatory engagement of health workers.³⁷ In parallel, the Philippines' Universal Health Care reforms exemplify stakeholder-driven workforce planning, workflow redesign, and systematic well-being evaluation.³⁸ These initiatives align closely with each phase of our proposed framework. Evidence consistently shows that burnout and emotional exhaustion remain disproportionately high among APAC health workers compared with high-income benchmarks.^39,40 Hierarchical cultures and stigma further constrain disclosure, underscoring the need for participatory, contextually grounded interventions. System-level interventions, rather than individual-focused resilience training, have demonstrated greater effectiveness and highlight the importance of culturally adapted, evidence-based frameworks within the region.^15,16

By embedding this five-phase framework into routine workforce assessments, APAC health systems can transition from reactive coping mechanisms to proactive system redesign, strengthening resilience and retention in oncology and broader clinical settings. Future research should emphasize longitudinal evaluation, iterative refinement of culturally contextualized interventions, and integration of well-being indicators into national health system performance frameworks. Specialty-specific adaptations, particularly for oncology nurses, remain critical given their compounded exposure to emotional and organizational demands.

Conclusions

The post-pandemic era demands a shift from outcome measurement to systems thinking in workforce well-being. By integrating global evidence-based frameworks with the specific contexts of the Asia Pacific region, APAC health systems have a unique opportunity to strengthen the resilience of their oncology workforce – ensuring the delivery of compassionate, high-quality care amid ongoing healthcare challenges.

CRediT authorship contribution statement

Karthik Adapa: Conceptualization, reviewing, and editing. Anjali Yellapuntula Venketa: Writing and reviewing. Mahima Reji: Writing and reviewing Lukasz Mazur: Reviewing, editing and supervision Lisa Vizer: Reviewing and editing. Jennifer Bissram: Reviewing and editing. Emily Kertcher: Reviewing. Nadia Charguia: Reviewing. All authors have read and approved the final manuscript.

Ethics statement

Not required.

Data availability statement

Data availability does not apply to this article as no new data were created or analyzed in this study.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the author(s) used ChatGPT and Google Gemini to proofread and quality check for language/grammar. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Funding

This study received no external funding.

Declaration of competing interest

The authors declare no conflicts of interest. The views expressed in this article are solely those of the authors. In particular, the views of the corresponding author, Dr. Karthik Adapa, are his own and do not reflect the official positions of the World Health Organization (WHO), the Carolina Health Informatics Program, or the Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine at UNC Chapel Hill. Dr. Adapa serves as an editorial board member of the Asia–Pacific Journal of Oncology Nursing. The article has undergone the journal's standard publication procedures.

Appendix A. Supplementary data

The following is the Supplementary data to this article: