Are SHA workers experiencing burnout?
The PH WINS 2017 added the Oldenburg Burnout Index, a validated measure of burnout, exhaustion, and disengagement (Figure 3). Because the OLBI is a relative measure, we examined which agencies were experiencing higher levels of burnout than the national average. Nationally, the OLBI shows a relatively normal distribution, with a slight skew toward lower burnout for SHA workers. Nine states have 55% or more of their staff rating above the national average on burnout. Four states have 45% or lower of their staff rating below the national average on burnout.
What are the top training needs and gaps of SHA workers?
The PH WINS 2017 training needs assessment was organized into tiers based on supervisory status, with skills aligned with 8 focus areas (Table 5). A training need or skill gap was identified if a respondent indicated 2 things: (1) that it was somewhat or very important in their day-to-day work; and (2) that they were unable to perform the skill or considered themselves a beginner in the skill. Gaps at the focus area level are identified when any 1 skill item in that focus area has a skill gap.
The largest overall gaps for the SHA workforce were observed in budget and financial management, systems and strategic thinking, and developing a vision for a healthy community. Statistically significant differences were observed across almost every domain, especially between nonsupervisors and others. Among nonsupervisors, who constitute the vast majority of the workforce 70%(69%-70%), the biggest gaps were also in the budget and financial management focus area 53%(51%-55%) and systems and strategic thinking (44%, 95% CI: 42%-45%). The focus area with the fewest self-reported gaps among executives was effective communication (5%, 95% CI: 3%-7%).
Are SHA workers aware of emerging public health concepts?
Respondents were asked to reflect on 6 emerging public health concepts, first identifying whether they had heard of the concept and then identifying how much the concept impacts their day-to-day work (Table 6). The concepts that the largest percentage of the workforce was aware of were fostering a culture of quality improvement (82%, 95% CI: 81%-83%) and evidence-based public health practice (77%, 95% CI: 76%-79%). The concepts that the smallest percentage of the workforce was aware of were health in all policies (55%, 95% CI: 54%-56%) and multisectoral collaboration (66% 95% CI: 65%-66%).
Like awareness, the concept that the largest percentage of staff thought impacted their work a fair amount/a great deal was fostering a culture of quality improvement (68%, 95% CI: 67%-69%), and the concept that the smallest percentage thought impacted their work a fair amount/a great deal was health in all policies (43%, 95% CI: 42%-44%). Interestingly, among those staff who were aware of the 6 concepts, a smaller proportion of the workforce thought that the concepts impacted their day-to-day work a fair amount or great deal compared to the percent of staff that had heard of the concept.
Respondents were also asked to identify how involved they felt their agency ought to be in effecting change in a set of specific social determinants of health. Reasonably substantial disagreement was observed in national aggregates. Eighty-three percent of respondents (95% CI: 82%-84%) thought that their agency should be somewhat/very involved in addressing health equity, compared with 46% (95% CI: 45%-47%) who thought their agency should be somewhat/very involved in affecting the quality of transportation in their jurisdiction.
PH WINS 2017 generated the second nationally representative dataset of SHA employees and built upon the first iteration of the survey to further grow the knowledge base about the SHA workforce. These data should directly inform workforce strategies to ensure that the workforce and SHAs in which they work can optimally function to address emerging health challenges and improve community health outcomes.
In the SHA workforce, over 3 times as many employees are older than 55 years than are younger than 31 years. Despite the small percentage of the workforce younger than 31 years, nearly one-third of the overall workforce reports having fewer than 5 years of experience in public health practice. This suggests that many come to work at governmental SHAs later in their professional careers. The mobility in the workforce is also worth noting when considering the aging workforce, with two-thirds of the workforce having been in their current position for 5 years or less. While the workforce is generally well educated, less than 20% of the workforce has a degree at any level in public health. This finding, coupled with the aging of the workforce and the large proportion of the workforce with 5 years or fewer in public health practice, points to potential challenges in the workforce pipeline for state governmental public health agencies. Greater engagement with the nation's schools and programs of public health is needed to recruit younger people into the SHA workforce to address the need for a more robust pipeline and increase the proportion of the workforce with public health training.
The pipeline is of critical importance, given the potential for turnover in state governmental public health agencies.4,17 Despite relatively high levels of job and organizational satisfaction in the workforce, more than one-third of the workforce is considering leaving their position in the next year, the majority of whom have already taken steps toward leaving. While pay is a considerable factor in deciding to leave, and pay satisfaction is relatively low compared with job and organizational satisfaction, other factors related to employee engagement clearly contribute to considering leaving. Potential employee departure should be of increased concern among the state governmental public health leadership. When employees leave state health agencies, there is no guarantee that the position will be refilled at the same position level with the same salary or experience level, if it is refilled at all. The SHA workforce never recovered the positions lost in 2008.18,19 Leaders in state health agencies should prioritize retention to maintain an effective workforce. While compensation is rarely within the control of individual managers in an SHA, other factors that could impact retention may be including opportunities to promote staff and grow within a position, assessing and satisfying training needs, improving communication between leadership and staff, and rewarding creativity and innovation in the workplace.
While it may be challenging to create opportunities for advancement on a career ladder within an SHA, leaders can offer stretch assignments, mentoring opportunities, and other programs to help staff grow and practice their skills and develop their leadership abilities. Such programs can also contribute to succession planning, an area of needed investment given the aging workforce, as nonsupervisory staff learn and grow in their positions and demonstrate their leadership skills. Approximately 70% of the workforce agreed or strongly agreed with related statements of “I have had opportunities to learn and grow in my position over the past year,” “I am satisfied that I have the opportunities to apply my talents and expertise,” and “my supervisor provides me with opportunities to demonstrate my leadership skills.” However, there tend to be lower levels of agreement with these statements among nonsupervisory staff as compared to higher levels of supervisory status. Participating departments should assess their own results to consider possible employee development programs. In addition, with only slightly more than half of the workforce agreeing or strongly agreeing that their training needs were assessed, assessing and meeting training needs may be another opportunity to improve worker engagement, which in turn can benefit retention.
While more than 80% of the workforce agreed/strongly agreed that they have good working relationships with their supervisors and that their supervisors treat them with respect, the percentage that agree/strongly agree with the notion that communication between senior leaders and employees is good was much lower. Except for executives, fewer than half of all employees agreed/strongly agreed with this statement. The difference between executives who agreed/strongly agreed and all other staff was more than 20%, indicating that the most senior leaders in state health agencies may be unaware of this challenge and its potential impact on the workplace environment. This finding should serve as a call to all executives working in SHAs to consider strategies to improve their communications with staff throughout the agency.
PH WINS 2017 data also confirm that creativity and innovation are not flourishing in SHAs. This lack of creativity and innovation will make it difficult for SHAs to attract and retain highly educated and skilled individuals who seek to apply their talents to the nation's most pressing social challenges. Promoting creativity and innovation in the workplace and its effect on employee engagement are well described.20–25 However, the strategies to do this—for example, promoting experimentation and supporting failure, creating environments that allow all ideas to be expressed and explored, or creating space for teams to work without assuming that the identified organizational leader must lead discussions and assume responsibility—may run counter to what typically is expected in a governmental work environment and from staff's own degree of risk aversion in the public sector.26 Funding mechanisms may inadvertently reinforce this lack of creativity and innovation by focusing on delivery of a specific service rather than allowing for the proposal of solutions to specific communities' problems. The SHA leaders who want to attract and retain talent should work actively to create workplace engagement and support workforce development strategies that are supportive of creativity and innovation.
Interesting findings have also emerged from PH WINS 2017 data related to staff awareness of and perceived impact of emerging concepts in public health and perceptions of levels of agency involvement in sectors outside of public health. There was greater awareness of concepts that inform the operational practice of public health, such as quality improvement and evidence-based public health, but lower awareness of health in all policies and forming multisectoral partnerships, which are both part of a fundamental shift in the conceptualization of the role of public health and its practice.27 These are critical approaches through which state public health agencies can accomplish their goals of advancing population and community health. However, training and promotion strategies are needed to translate these concepts that appear to be relatively removed from practitioners on the ground into something where staff can understand and relate them to their functional practice.
State health agencies and their leaders are often held accountable for community-level health outcomes measures, and while agencies tackle complex challenges (eg, rising rates of sexually transmitted diseases, opioid use, and obesity rates), little focus is placed on the essential role of the workforce in successfully changing these rates. Healthy communities are dependent upon healthy state governmental public health agencies, with sufficiently trained and engaged staff. While many of the activities within SHAs require external funding, there are opportunities to improve retention and engagement of the workforce with internal initiatives that may not require additional funding.
Implications for Policy & Practice
- Almost half of governmental public health staff in SHA-COs say that they are considering leaving their job in the next year or are planning to retire by 2023. This represents a profound challenge to workforce development and means succession planning and the transfer of institutional knowledge ought to be critical components of any workforce plan.
- Several of the top reasons for leaving might be somewhat immutable within an organization—pay, opportunities for advancement—but many are ripe for intervention, including perceived lack of support, burnout, and lack of acknowledgment/recognition. These are important reasons staff say they are considering leaving that are suited to amelioration by leadership-led change.
- Job satisfaction remains high among public health staff—this appears to be tied to employee engagement, satisfaction with one's supervisor, and organizational support. Leaders can continue to bolster these positive feelings, even while other correlates of job satisfaction (eg, pay) may be less positive and harder to change.
- Skill gaps are prevalent and not merely among nonsupervisors but also for supervisors, managers, and executives. Agencies and support institutions, such as public health training centers, ought to tailor high-quality distance training to address these needs by the supervisory tier.
This study has several limitations. First, 47 of 50 states responded. While states that did not participate do not appear materially different from their peers who did, this form of bias—where staff in nonparticipating states versus participating states are different—remains possible. Moreover, if respondents are different from nonrespondents, nonresponse bias may be a problem. Balanced repeated replication weights were used to account for sample design and nonresponse. Another limitation is the self-reported nature of the data; this is especially worthy of consideration in analyzing training needs and skill gaps. Finally, these data should be viewed as generalizable only to SHA-CO staff; analyses of local health department staff are conducted elsewhere in this supplement.28,29
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
governmental public health workforce; Public Health Workforce Interests and Needs Survey; workforce development