Moral injury and workforce burnout constrain public health agencies' operational capacity. The COVID-19 pandemic has increased the urgency and scope of public health professionals' work, while decreasing individual capacity and effectiveness. Nearly half of all public health workers left their positions between 2017 and 2021.1 In 2021, 55% of public health employees polled reported 1 or more posttraumatic stress disorder symptom.2 These alarming rates highlight the importance of making the public health workforce's long-term well-being an organizational priority to prevent adverse downstream effects on population health outcomes.
Governmental public health agencies, as compared with private industry,3,4 face unique restrictions when it comes to recruitment, retention, and employee experience. These limitations include formal policies around human resources, civil service classifications and procedures, and political processes and pressure that can complicate efforts to address the public health workforce's needs.
In addition, while workforce burnout was an issue even prior to the COVID-19 pandemic,1 the scale and importance of public health worker responsibilities ballooned during the pandemic response. The need for contact tracing, data collection and reporting, vaccine planning and distribution, and effective public communication remained priorities, while public and political criticism contributed to an atmosphere of hostility toward the public health workforce.5 This workforce therefore remains dedicated to the public health mission but continues to feels the strain brought about by a traumatic few years.2
Government agencies are now at risk of pivoting from an emergency public health response to more routine operations without the technical expertise or capacity to address serious workforce issues. Survey data show these issues may lead to continued turnover and loss of expertise across all ranks of public health agencies. Since 2014, ASTHO has collaborated with the de Beaumont Foundation to conduct the Public Health Workforce Interests and Needs Survey (PH WINS), which is disseminated to public health agencies nationwide and contains specific questions related to workforce demographics, job characteristics, training needs, intent to stay or leave, professional engagement and satisfaction, and other areas.2 The concept of “workforce well-being” is a measure of the overall functional health of the public health workforce, ensuring its ability to perform at a high level of engagement and operational readiness over an extended period. Monitoring trends in agency-level responses to employee mental and emotional well-being can provide direction and justification for building workforce well-being efforts into agency priorities and plans, such as by developing healthy supervisory relationships, mitigating sources of work-related stress, ensuring manageable workloads, and improving infrastructure and staffing levels.
More than ever, it is imperative for leaders and policy makers to prioritize workforce well-being and retention strategies to ensure continuity of public health operations.
A Technical Package of Practical Recommendations
In this column, ASTHO recommends this technical package of strategies to support state, territorial, and local health department efforts to address burnout and moral injury among governmental public health workers and improve retention.
ASTHO technical packages are based on our subject matter experts' assessment of evidence-based strategies, expert recommendations, overviews of current activities, and a review of the Centers for Disease Control and Prevention and other federal funding guidance. They are not intended to be comprehensive. They provide a more focused and proactive approach to our technical assistance roles. There is a relative dearth of research on the issue of government agency workforce sustainability, and future recommendations should incorporate the growing body of research. At present, ASTHO has prioritized specific areas of work—outlined in Supplemental Digital Content Table (available at https://links.lww.com/JPHMP/B188).
Developing effective and skilled managers
Supervisors play a significant role in employee well-being and satisfaction.6 Developing supervisory skills in leadership and management, as well as an understanding of trauma-informed principles and practices, is critical to improving employee well-being and reducing burnout. Typically used in clinical settings, public health agencies can apply a trauma-informed approach to strengthen population health strategies with communities,7 as well as integrating these principles into agency policies, communications, and initiatives with the desired goal of reducing stress caused by structural and organizational factors.8 Public health agencies should support supervisors through management training and coaching to develop leadership skills at all levels of a public health agency, and the ongoing modeling and application of these skills by agency leaders.
Creating positive workplace culture and connection
A positive workplace culture is based on employees' feelings about their team and agency and how they perceive the organization values them. Employees' experience—beginning with attracting and recruiting qualified staff and spanning the entire time an employee spends with an agency—is critical to an employee's decision to stay or leave an organization. Survey data show that poor organizational culture is a known driver of public health agency disengagement and turnover, in turn presenting a threat to public health agencies' operational readiness.2 Yet, policies to support employees from the time they begin onboarding for a position are underdeveloped and deprioritized, either due to lack of resources or due to urgency of the agency's public health mission. In addition, an agency's commitment to internal diversity, equity, inclusion, accessibility, and belonging can affect employee satisfaction with agency culture as well as engagement and psychological safety.
Balancing the mission-critical demands of daily public health work with the sustainability needs of the workforce can be a challenging task, but building on the development of supervisory skills across the agency provides a foundation for the ongoing work to improve workplace culture and prioritize connection. ASTHO's PH-HERO Workforce Resource Center provides a source for vetted resources intended to support these efforts.
Building infrastructure for a supported and fairly compensated workforce
If workplace culture is how employees feel about their job, workforce infrastructure is the policies and resources available to employees to compensate and support them in their jobs. Pay was cited as the top reason individuals considered leaving public health agencies in 2021.2 Governmental public health agencies have salary range and other state personnel rule limitations but can review pay scales and to ensure pay equity across the organization. Looking beyond pay, public health agencies can look to offer other benefits to their total compensation packages, such as tuition reimbursement, student loan assistance, or enhanced benefits such as employee assistance programs.
In addition to supplying compensation, agencies can support their workforce through tools and processes that make employees' jobs less stressful and more rewarding. Through thoughtful design and leveraging of technology, implementation of employee-centered policies such as standardized onboarding programs, retention interviews, flexible work arrangements, and employee councils, public health agencies can build an infrastructure for workplace satisfaction and retention.
Staffing to advance workforce priorities and manage workloads
Regardless of the improvements in organizational culture and management skill, if an agency is unable to fill positions for required workloads, stress and burnout will accumulate across the workforce and counteract any culture and process improvements. Likewise, if agency leadership commits to organizational change to improve workforce culture but fails to staff and empower individuals to prioritize this work, it faces long odds for success against the many competing needs facing a public health agency. Prioritizing recruitment and timely hiring to fill vacancies will minimize stress caused by increased workloads.
Advancing agency commitments to improve workforce culture and retention is necessarily a long process. It requires dedicated workforce staff who have technical expertise and the authority to engage senior staff within the public agency to influence and champion changes and new concepts, and support from staff throughout the agency to ensure follow-through across many initiatives. Understaffing the team tasked with this work, or reducing the access or influence of this team, risks rendering their work ineffective, exacerbating workforce burnout, and potentially wasting resources through a lack of organizational commitment to these priorities.
This package of strategies can be used to revitalize the public health workforce and create an infrastructure that supports the engagement, well-being, and retention of public health professionals for the future. ASTHO intends to support jurisdictions in their efforts to implement these evidence-based strategies to strengthen the sustainability of the public health workforce. Public health agencies will increasingly have opportunities to tailor these recommendations to develop specific strategies for their workforce needs based on their agency's employee survey and assessment data. Evaluation of the effectiveness of these strategies will inform future efforts for agencies to contribute to an evidence base for others to build upon and refine.
1. Leider JP, Castrucci BC, Robins M, et al. The exodus of state and local public health employees: separations started before and continued throughout COVID-19. Health Aff (Millwood). 2023;42(3):338–348. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.01251
. Accessed April 25, 2023.
2. de Beaumont Foundation and Association of State and Territorial Health Officials. Public Health Workforce Interests and Needs Survey: 2021 Dashboard. www.phwins.org/national
. Published August 3, 2022. Accessed April 25, 2023.
4. Fuhrmans V. After testing four-day week, companies say they don't want to stop. The Wall Street Journal. https://www.wsj.com/articles/after-testing-four-day-week-companies-say-they-dont-want-to-stop-a06089cc
. Accessed April 25, 2023.
5. Bryant-Genevier J, Rao CY, Lopes-Cardozo B, et al. Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic—United States, March-April 2021. MMWR Morb Mortal Wkly Rep. 2021;70(48):1680–1685.
6. Hämmig O. Health and well-being at work: the key role of supervisor support. SSM Popul Health. https://www.sciencedirect.com/science/article/pii/S2352827316301793
. Accessed April 25, 2023.
7. Parker S, Johnson-Lawrence V. Addressing trauma-informed principles in public health through training and practice. Int J Environ Res Public Health. 2022;19(14):8437. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9319668
. Accessed April 25, 2023.
8. Jackson Preston P. We must practice what we preach: a framework to promote well-being and sustainable performance in the public health workforce in the United States. J Public Health Policy. 2022;43(1):140–148.