This article describes challenges, issues, and strategies

Transcription

1 Studying an Ill-Defined Workforce: Public Health Workforce Research Jean Moore This article describes challenges, issues, and strategies associated with public health workforce research. The factors that contribute to workforce supply and demand imbalances are reviewed, and the unique difficulties encountered with studies of public health workers are identified. Two case studies of previous public health workforce research conducted by the New York Center for Health Workforce Studies are used to illustrate how different levels of analyses can be used to better understand recruitment and retention issues of public health workers and to inform programs and policies designed to ensure a well-sized and competent public health workforce. Case study 1, conducted in 2005, assessed supply and demand gaps in state and local health departments in six states and helped estimate the scope of recruitment and retention problems in these agencies. Case study 2, conducted in 2006, provided a detailed examination of the current public health workforce in local health departments in New York. Data drawn from this study were used to identify specific workforce challenges faced by these agencies. Findings from these case studies, conducted at different levels of analyses (multistate vs single state) and using different research methods (qualitative vs quantitative), are reviewed, highlighting differences based on scope and methods. Finally, suggested areas for future studies about the public health workforce are considered. KEY WORDS: public health workforce, recruitment, retention, supply of and demand for public health workers The objectives of this article are to briefly identify the challenges associated with studies of the public health workforce, describe the factors that contribute to supply and demand imbalances in the public health workforce, and use two case studies to illustrate different approaches to public health workforce research. J Public Health Management Practice, 2009, November(Suppl), S48 S53 Strengths and limitations of differences in study scope (multistate vs single state) and study methods (qualitative vs quantitative) are discussed. Finally, suggested areas for future studies about the public health workforce are considered. Health Workforce Issues: The Broader Context Well-prepared public health professionals are essential to an effective public health system in the United States, yet there is concern about the adequacy of both the supply of these workers and their skills and competencies. 1 The lack of clear definitions and good data make it difficult to fully assess the sufficiency of the supply of qualified public health workers in relation to the demand for them as well as the adequacy of their skills and competencies in relation to their roles and responsibilities. These issues make public health workforce research challenging for a variety of reasons. The public health workforce is not easily defined or measured. The public health workforce draws from a wide array of professions both within and outside of healthcare. Some The 2005 Six-State Case Study of the Public Health Workforce was supported by funding from the Bureau of Health Professions of the Health Resources and Services Administration (HRSA), US Department of Health and Human Services. To view the full report, go to the HRSA Web site reports/publichealth/default.htm. The 2006 Enumeration of the Local Public Health Workforce in New York was supported by funding from the New York State Department of Health. To view the full report, go to the Center for Health Workforce Studies Web site: Corresponding Author: Jean Moore, MSN, Center for Health Workforce Studies, School of Public Health, University at Albany, 1 University Pl, Rensselaer, NY (jmm04@health.state.ny.us). Jean Moore, MSN, has served as the Director of the New York Center for Health Workforce Studies since Her work focuses on research about the supply, demand, use, distribution, and education of the health workforce. Before joining the Center, she spent 15 years at the NYS Department of Health, where she was responsible for health workforce policy development and programs. She is currently enrolled in the Doctor of Public Health Program at University at Albany. S48

2 Studying an Ill-Defined Workforce S49 hold profession-specific licenses. Some have had formal training in public health, but many have not. 2 Within the public sector, responsibility for public health services is shared among different levels of government and across multiple agencies. There are also major state-by-state variations in function and responsibility among state and local government and private groups, compounding the difficulty of counting and tracking the public health workforce. 3 In addition, functions and responsibilities can vary within a state between rural and urban locations. Currently available occupational classification systems, such as the one used by the US Bureau of Labor Statistics, do not effectively describe the existing public health workforce. Not surprisingly, national data on the size and composition of the public health workforce are limited. In-depth knowledge of forces that broadly influence health workforce supply and demand is crucial for understanding and effectively responding to public health workforce shortages. Fluctuations in health workforce labor markets can lead to widespread workforce imbalances, referred to as shortages or surpluses. These imbalances can take many forms: profession imbalances, such as shortages of registered nurses (RNs), or specialty imbalances within professions, such as shortages of primary care physicians; geographic imbalances, which include differences in the supply of health workers between rural and urban areas or between economically disadvantaged and affluent communities; institutional and service imbalances, which relate to differences in the supply of health workers in different healthcare settings, for example, acute care compared to public health; public and private imbalances, which are associated with differences in the supply of health workers between publicly and privately sponsored healthcare providers; and gender or racial and ethnic imbalances in healthcare professions, which refer to differences in the representation of women or various racial and ethnic groups in healthcare professions as compared to their presence in community. 4,5 Many factors contribute to these imbalances, and they vary by occupation. Short-term factors include competition for workers in a strong economy; growing demand for health services, which increases demand for health workers; increased intensity and complexity of health services, which result in growing demand for more highly skilled workers; and educational system response lags in the production of new health workers. 4 While workplace factors can discourage recruitment into healthcare professions, they typically exert a stronger effect on the retention of existing workers. Workplace factors that can lead to turnover and attrition from the field include physically and emotionally demanding jobs and noncompetitive wages and benefits. All contribute to worker dissatisfaction. 5 In addition, many supervisors and managers may be experienced and well trained, often in clinical areas, but not necessarily adept in managing subordinate workers effectively. This can result in high levels of job stress for them and conflict with those working under them. 5,6 Short-term and workplace factors explain the chronic nature of health workforce shortages, despite repeated efforts over many years to address them. In addition, a number of long-term factors point to a worsening of these shortages in the future. The changing demographics of the US population will result in an increasing number of retirements from an aging health workforce and, at the same time, growing demand for health services by an aging population. 7 Health policies designed to expand access, improve quality, or control costs must take into account the health workforce availability in order for these policies to succeed. However, lack of relevant and timely data on the health workforce is a barrier to identifying the factors underlying health worker shortages and to developing effective health workforce programs and policies that could ensure a sufficient supply of workers, avert health workforce shortages, and support improvements in the health and public health systems. 8 Studies of the Public Health Workforce The public health system is a network of public and private agencies across the country that provides population-based health services, health education, clinical services, and prevention programs. Despite variation in state and local responsibility for public health services, governmental public health agencies are viewed as the primary force in organizing and mobilizing public health practice in most communities. 9 Consequently, an important focus of public health workforce research is governmental public health. A better understanding of the governmental public health workforce and the recruitment and retention issues faced by state and local public health agencies is critical to informing programs and policies designed to address supply and demand gaps and strengthen the ability of this workforce to provide basic public health services. Given the challenges of public health workforce research cited previously, it may be appropriate to conduct public health workforce studies at different levels of analyses, using both qualitative and quantitative methods to fully understand and describe the public health workforce and identify the factors that

3 S50 Journal of Public Health Management and Practice contribute to supply and demand imbalances. Broad assessments of supply and demand gaps can be useful in helping estimate the scope of the problem. More detailed assessments of the current public health workforce in specific agencies, states, and regions can better profile the existing workforce, including demographics, educational background, roles and responsibilities, training needs, and future plans. Such studies can help inform the specific programs and policies needed to ensure a well-sized and competent public health workforce. The following are two case studies that illustrate public health workforce research one multistate study using qualitative methods and one single-state study using quantitative methods and the different data these studies yielded. Case Study 1: Public Health Workforce Study, 2005 The Center for Health Workforce Studies at the School of Public Health, State University of New York at Albany, with support from the Bureau of Health Professions of the Health Resources and Services Administration (HRSA), conducted a six-state case study of the governmental public health workforce. A major goal of the study was to identify supply and demand gaps for workers in state and local governmental public health agencies, particularly public health nurses (PHNs), physicians, and dentists, as well as workers with formal public health training. The study also examined the roles that schools of public health play in assisting these agencies to recruit, retain, and provide continuing education to their workforce. Interviews with state and local public health agencies were conducted in six states. The states were selected to ensure representation of the four organizational models described in Local Public Health Practice: Trends and Models, 9 which represent different relationships between the state and local public health agencies. The four models are centralized (New Mexico); decentralized (Montana); shared (Georgia); and mixed (California, Texas, and New York). Because of the significant diversity of local public health agencies within states, including population size and density, at least five local or district public health agencies in each state, including at least one urban, one rural, one suburban, and where appropriate, one agency on an international border, were selected to be in the case study. This allowed for an analysis of the staffing needs across the spectrum of operating environments under different models of sharing responsibility between state and local governments. The fieldwork included surveys of participating district and local public health agencies, with topics such as general workforce issues, staffing and functions, PHNs, public health physicians, oral health workforce, workers with formal public health training, training and continuing education needs, and collaborations. The fieldwork also included interviews of key stakeholders, including state, district, and local public health leaders and managers. The fieldwork aimed to identify the most pressing health workforce issues facing local, district, and state health departments today and whether these issues were driven by inadequate financial resources, lack of qualified candidates, or the need for continuing professional education. Key findings from this six-state study 10 are as follows: Public health agencies in all six states reported difficulty recruiting PHNs, especially in rural areas, but less difficulty retaining them. In addition to difficulty recruiting PHNs and, to a lesser extent, physicians and dentists, governmental public health agencies reported difficulty recruiting workers in a wide array of occupations, including health educators, nutritionists, social workers, clerical staff, and epidemiologists. The single biggest barrier to adequate staffing of governmental public health agencies was budget constraints. Beyond budget constraints, recruitment difficulties were attributed to general shortages of workers within an occupation (eg, RNs, nutritionists), noncompetitive salaries, and lengthy processing time for new hires. Public health workers with formal public health training, such as a master s of public health degree, usually worked in state health departments or as leaders of large public health agencies. They were needed in small public health agencies, but rarely available. Lack of access to advanced education, including baccalaureate nursing and graduate studies, was a significant barrier to upgrading existing staff, particularly in rural areas. There were only a few examples of successful collaborations (eg, recruitment of graduates into governmental public health, continuing and advanced education for the existing public health workforce) between schools of public health and local public health agencies, and schools of public health, in

4 Studying an Ill-Defined Workforce S51 general, had done a poor job of partnering with these agencies. Public health agencies were concerned about losing senior staff to retirement in the next 5 years and reported a need for better succession planning. 10 The full report of this research study, which includes a more in-depth description of methods and findings, is posted to the HRSA Web site: healthworkforce/reports/publichealth/default.htm. This study makes a valuable contribution to understanding the workforce issues faced by the public health system. It was conducted at a time when concern about nursing shortages was receiving prominent media attention. However, much of the media coverage focused on the impact of these shortages on healthcare providers such as hospitals, nursing homes, and home health agencies. This study raised awareness about the workforce needs of governmental public health agencies and demonstrated that these agencies were competing for many of the same healthcare professionals, including RNs, as other healthcare providers. According to the findings of this research study, governmental public health was often viewed as a less attractive option for workers seeking jobs. The study also pointed out the limited roles played by schools of public health across all case study states in assisting these agencies to recruit, retain, and provide continuing education to their workforce. Case Study 2: Enumeration of the Local Public Health Workforce in New York, 2006 The Center for Health Workforce Studies, in collaboration with the New York State Department of Health (DOH) and the New York State Association of County Health Officials (NYSACHO), conducted an enumeration survey of New York s local governmental public health workforce. The goal of the study was to produce a profile of local public health workers and understand how health workers demographics, roles, educational backgrounds, training needs, and future plans affected the organizational capacity of local health departments (LHDs) in New York to perform essential public health services. 11 All LHDs in New York were invited to participate in the survey. The objective was to include all LHD employees other than those in home health agencies, including part-time, temporary, and per diem workers. Thirty-two of the 58 LHDs in the state participated in the survey, which was conducted from June 2006 to January A total of individuals from 32 LHDs completed surveys. Response rates for participating LHDs were variable, ranging from 21 to 100 percent; the overall response rate for all participating LHDs was 64 percent. 11 Key findings from this study 11 are described below. The local public health workforce in New York was older than average, with a median age of 49 years, compared to the median age of a US civilian worker of 40 years. The public health workforce was not as diverse as the population it served. Blacks/African Americans and Hispanics/Latinos were particularly underrepresented (only 4% and 3%, respectively) when compared to their overall representation in the population (each 8%). Nearly one-quarter (24%) of public health workers worked in nursing job titles. Almost one-quarter of public health workers reported beginning their public health careers within the last five years. The majority of public health workers (64%) reported a need for training in emergency preparedness, as well as training in communicable and infectious diseases and management/supervisory skills. Almost one in five LHD employees had an advanced degree, but only two percent had an advanced degree in public health. At the same time, 19 percent wanted to pursue a master s degree and more than one-third of these were interested in a master s degree in the field of public health. Nearly one in five local public health workers (18%) reported retirement plans. About half of public health workers aged between 55 and 64 years (47%) planned to retire within the next five years. Twenty percent of public health workers younger than 35 years reported plans to leave the field of public health within the next five years. Plans of employees of all ages to remain in current positions were lowest among those in epidemiology/disease control titles. 11 The full report of this research study, which includes a more in-depth description of methods and findings, is posted to the Center for Health Workforce Studies Web site id=11,0,0,1,0,0. This study highlighted many workforce challenges faced by LHDs in New York, and the issues raised serve to inform the development of programs and policies aimed at improving recruitment and retention. The study findings pointed to the importance of taking steps to (1) attract new recruits to local public health, (2) provide career development to the current local public Bureau of Labor Statistics, Current Population Survey, Basic Monthly Survey, June Master s degree or higher.

5 S52 Journal of Public Health Management and Practice health workforce, (3) create stronger ties between public health education and practice, and (4) routinely collect data about the local public health workforce. Strengths and Limitations The six-state case study went beyond anecdotal concerns about worker shortages in public health and systematically described recruitment and retention problems in the public health workforce across states and across different state and local public health relationship models. The study also identified factors that contributed to supply and demand gaps, including those that impact all health sectors (eg, general shortages) and those factors unique to public health (eg, budget constraints). While the broad assessment of supply and demand gaps obtained through the six-state case study helped gauge the scope of the recruitment and retention problems in the public health workforce, results could not be quantified. For example, the study did not identify the number of PHNs needed to address the unmet demand for them. The enumeration study of New York s LHD workforce profiled, in quantitative terms, the public health workforce in the state s local health agencies, including roles, educational backgrounds, demographics, training needs, and future plans. While it provided a detailed description of the current stock of workers, the study did not consider supply and demand gaps. Together, these two studies begin to contribute to the base of knowledge needed to inform strategies designed to address public health workforce supply and demand imbalances. Clearly, this work should be considered a starting point, paving the way for future research in this area. Planning for the Future A well-trained and sufficiently sized public health workforce is critical to the success of public health programs across the country. However, there continues to be a need for systematic information about this workforce and the issues that contribute to recruitment and retention issues facing governmental public health. 12 The biggest barriers confronting researchers are the limited availability of data on the public health workforce and lack of policy commitment and resources to support health workforce research. Without a strong federal presence on health workforce research and policy, states face increased pressure to support such research and use the results to help shape state health workforce policies. 4 Looking ahead, public health workforce research should start with the basics, such as monitoring the size and composition of the public health workforce on a regular basis how many there are, what they do, what they look like, and what their future plans are. Furthermore, such monitoring should be ongoing, and if conducted by individual states, there should be general agreement on the use of a minimum data set that would allow cross-state comparisons. Gaps between public health worker supply and demand should also be monitored to learn more about which workers are in short supply and where these problems are most severe. These data, collected routinely, could inform programs and policies aimed at public health workforce development and retention. The United States expects a public health system that protects its citizens from a wide array of health threats and dangers by preventing and fighting epidemics and the spread of disease, protecting against environmental hazards, responding to disasters, and ensuring population health. Continued efforts to study the public health workforce will be essential to create and maintain a public health system that can protect the health of the country s citizens. REFERENCES 1. Gebbie K, Rosenstock L, Hernandez L, eds. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press; Tilson H, Gebbie K. The public health workforce. Ann Rev Public Health. 2004;25: Gebbie K, Turnock B. The public health workforce, 2006: new challenges. Health Aff. 2006;25(4): Moore J. Health workforce research: what are the issues? In: Holmes D, ed. From Education to Regulation: Dynamic Challenges for the Health Workforce. Washington, DC: Association of Academic Health Centers (preprint); Moore J, Karnaukhova J, McGinnis S, et al. Human Resources for Health: Options for Analysis and Monitoring. Paper presented at: the World Health Organization Meeting; March 2006; Geneva, Switzerland. 6. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, IL: American Hospital Association; Moore J, McGinnis S, Continelli T. Aging and the public health workforce. In: Miles T, Furino A, eds. Annual Review of Gerontology and Geriatrics: Aging Healthcare and Workforce Issues. Vol 25. New York, NY: Springer; 2006: Salsberg E. Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Care. New York, NY: Milbank Memorial Fund and the Reforming States Group; American Public Health Association. Local Public Health Practice: Trends and Models. Washington, DC: American Public Health Association; 2000.

6 Studying an Ill-Defined Workforce S US Department of Health and Human Services, Health Resources and Services Administration. Public Health Workforce Study. Washington, DC: US Department of Health and Human Services, Health Resources and Services Administration; publichealth/default.htm 11. McGinnis S, Robertson D, Moore J. Enumeration of the Local Public Health Workforce in New York: Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, University at Albany, SUNY; Cioffi J, Lichtveld M, Tilson H. A research agenda for public health workforce development. J Public Health Manag Pract. 2004;10(3):