Abstract
In 2013, the Nebraska Department of Health & Human Services, Division of Public Health (Nebraska’s State Health Department); and the University of Nebraska Medical Center, College of Public Health developed a comprehensive approach to assess workforce training needs. This article outlines the method used to assess the education and training needs of Division staff, and develop comprehensive workforce development plans to address those needs. The EDIC method (Engage, Develop, Identify, and Create) includes the following four phases: (1) Engage Stakeholders, (2) Develop Assessment, (3) Identify Training Needs, and (4) Create Development Plans. The EDIC method provided a process grounded in science and practice, allowed input, and produced buy-in from staff at all levels throughout the Division of Public Health. This type of process provides greater assurance that the most important gaps in skills and competencies will be identified. Although it is a comprehensive approach, it can be replicated at the state or local level across the country.
Keywords
Introduction
The changing public health landscape creates several new challenges and opportunities for local and state health departments. To take advantage of some of these new opportunities, many departments are placing a greater emphasis on community and strategic planning, analyzing new data sets related to electronic medical records and other large databases, focusing more on quality improvement and performance management, and forming collaborative partnerships with patient-centered medical homes to improve population health outcomes. However, these changes have forced local and state health agencies to reassess the skills and competencies of their public health workforce.
Another part of this changing landscape is the opportunity to receive accreditation from the Public Health Accreditation Board (PHAB). Although the accreditation standards are voluntary, a total of 79 local and state health departments have already been accredited and 259 more are actively seeking accreditation (PHAB, 2015). To become accredited, local, state, and tribal health departments must be able to document that they have met the 32 standards in 12 different domains that address the core public health functions and essential services (PHAB, 2013). As a result, these local and state health departments are greatly expanding their activities in areas such as preparing needs assessments, developing community and state health improvement plans, formulating more effective policies, working more closely with primary care and mental health practitioners to assure appropriate care, conducting quality improvement studies, and implementing evidence-based public health strategies (Brownson, Fielding, & Maylahn, 2009).
One of the PHAB domains recognizes that a highly trained and capable public health workforce is critical to the overall success of the field. Domain Eight’s Standard 8.2 states, “Ensure a competent workforce through the assessment of staff competencies, the provision of individual training and professional development, and the provision of a supportive work environment” (PHAB, 2013, p. 194).
Within Standard 8.2, a key measure is to develop
“a health department-specific workforce development plan. The plan must include: An assessment of current staff competencies against [Council on Linkages] core competencies. Training schedules and a description of the material or topics to be addressed in the training curricula to address gaps in staff competencies. A description of barriers/inhibitors to the achievement of closing the gaps or addressing future needs in capacity and capabilities and strategies to address those barriers/inhibitors.” (PHAB, 2013, pp. 194-195)
It is now more important than ever to build capacity at all levels within our governmental public health system. To do this successfully, the development of workforce assessments and subsequent development plans must use a mixed-methods approach, be based on an accepted set of competencies, and include tailoring for different departments/units of a health department.
In 2013, the Nebraska Department of Health & Human Services, Division of Public Health (Division; Nebraska’s State Health Department) and the University of Nebraska Medical Center, College of Public Health (UNMC COPH) developed a comprehensive approach to meet PHAB Standard 8.2. This article is a research-to-practice link outlining the methods used to (a) assess the education and training needs of Division staff and to (b) develop comprehensive workforce development plans to address those needs.
Background
For decades, the Institute of Medicine (IOM; 1988, 2007) has voiced a strong recommendation that the public health workforce possess the appropriate education and training necessary to perform its roles. Additionally, the IOM stressed the importance of assessing the gaps in the knowledge and skills of the public health workforce. The report specified that public health agencies are responsible for identifying the education and training needs of the agency and are accountable for creating plans to address the needs (IOM, 2003). These recommendations are still relevant today as Healthy People 2020 established the newest related national goal: Ensure that Federal, State, Tribal, territorial, and local health agencies have the necessary infrastructure to effectively provide essential public health services. Specifically, Healthy People 2020 (2015) states that this infrastructure requires (1) a capable and qualified workforce, (2) up-to-date data and information systems, and (3) public health agencies capable of assessing and responding to public health needs.
Multiple national public health organizations—the National Association of County and City Health Officials, the Association of State and Territorial Health Officials (ASTHO), the American Public Health Association, and the Association of Schools and Programs of Public Health (ASPPH)—have documented concerns about the size, composition, distribution, skills, and performance of the public health workforce (Gebbie & Turnock, 2006). In 2006, common concerns identified included the following: insufficient number of workers, increased number of workers approaching retirement without adequate replacements in the pipeline, inadequately prepared workers being hired, and a lack of workplace incentives that reward individual development (Gebbie & Turnock, 2006). These same concerns persist today as evidenced by the recent workforce surveys conducted by ASTHO. The average age of a state public health worker was 47 years, and the average age of a new hire in state government is 40 years, and in 2012, over 50% of some state health agency workforces were eligible to retire (ASTHO, 2014). With the aging of the public health workforce, experts fear the number of trained workers available will be insufficient to replace the number retiring in the next decade. Approximately 110,000 workers, or nearly 25% of the current workforce, were eligible to retire by this year. By 2020, ASPPH reports, the United States will face a shortage of 250,000 public health workers. Given this challenge, it is critical to provide lifelong learning opportunities by offering more formal training such as short courses, certificate programs, and distance learning, as well as encouraging governmental health agencies at all levels to develop succession plans that will sustain their leadership (Rosenstock et al., 2008).
While these problems and recommendations are repeatedly acknowledged, public health agencies have not been held accountable for taking action. In the past, the assessment of education and training needs was completed through Health Resources and Services Administration Public Health Training Centers. While Public Health Training Centers did determine training priorities for the states’ public health workforce, they infrequently developed workforce development plans to address gaps and, furthermore, had no authority to require that public health agencies take action to decrease those gaps. In 2007, a shift began to occur with the incorporation of the PHAB. As the national public health accrediting body, PHAB does have the authority to hold health departments (at least those wishing to become accredited) accountable for maintaining a competent workforce.
Method
The needs assessment and workforce plan development process was a collaborative project between the Division and the UNMC COPH. The collaborative process used the principles of practice-based systems research. The goal of practice-based systems research is to improve quality, performance, efficiency, and effectiveness of public health systems that affect community health outcomes (ASPPH, 2006). Additionally, the researchers used a mixed-methods approach to obtain the information. Mixed-methods research gathers and integrates both quantitative and qualitative data, and the researchers draw interpretations based on the data (Creswell, 2015). The purpose of the project was to (1) assess the capacity and capability of the Division’s workforce, (2) determine the gaps in capacity and capability, and (3) establish education and training priorities for the workforce.
Engaging Multiple Stakeholders
Once the UNMC COPH was brought on board to serve as neutral convener for this process, conversations were held with the Division’s leaders of the accreditation effort to determine who the key stakeholders were and how to best engage them in the process. The final group at the planning table included the administrators from each of the Division’s eight units, along with the accreditation leads and the UNMC COPH facilitators. At the first meeting, norms were established for how decisions would be made throughout the process. For example, all input was welcome, and consensus would be used to create the final assessment survey.
Additionally, feedback loops were created to incorporate ideas and voices from staff at all levels of the Division. For example, when the survey was piloted, the group intentionally chose staff representing each Division and each level (managerial, front line, administrative, etc.). The focus groups held after analyzing the data were also populated with representatives of different Divisions and levels. Finally, it was recognized that for staff to buy-in to the final results, they needed to feel ownership over the training plans. To do this, forums were held to share their data back with them and to allow staff dedicated time to discuss potential action plans.
Developing the Needs Assessment
The design of the assessment required the Division to decide which skills were necessary and needed to be acquired by all staff. The 91 skills in Tier 2 of the Council on Linkages (COL) competencies were used as a starting point for determining the skills necessary for all staff. This competency set was used because it is the recommendation of PHAB. The skills were determined using the Nominal Group Technique (Centers for Disease Control and Prevention, 2006). The group involved in the process included the eight unit administrators, the Division Deputy Director, and the Division Quality Improvement Manager. Faculty and Staff from the UNMC COPH facilitated two 2-hour focused conversations proceeding through the four steps of the Nominal Group Technique (Generating Ideas, Recording Ideas, Discussing Ideas, and Voting on Ideas). The group determined the skills they believed were needed for all professional staff in the Division within each of the eight domains of the COL competencies: (1) Analytical/Assessment Skills, (2) Policy Development/Program Planning Skills, (3) Communication Skills, (4) Cultural Competency Skills, (5) Community Dimensions of Practice Skills, (6) Public Health Sciences Skills, (7) Financial Planning and Management Skills, and (8) Leadership and Systems Thinking Skills. At the conclusion of these conversations, a total of 57 skills were identified as necessary for all professional staff (i.e., all individuals who were not identified as administrative support staff). Once the skills were determined, the unit administrators considered additional questions that would be important to include in the assessment. The final assessment tool included 130 questions in three sections.
Section 1 asked two questions about each of the skills in the eight domains. For each item, respondents were asked to indicate the level of importance to their work and the degree to which they are capable of carrying out the item. Five-point Likert-type scales were used. Importance: 1 (I don’t know/not applicable) through 5 (highly important) Degree of capacity: 1 (not applicable) through 5 (I am comfortable, an expert, could teach others).
Section 2 assessed topical areas of training needs and priorities (e.g., community planning, quality improvement, grant writing, informatics), and preferred modes of delivery for educational activities.
Section 3 included demographic questions related to education, job title, years in public health, and more.
Face validity was established by having experts in the field (n = 4; i.e., workforce development, assessment of competencies, and survey design) and public health practitioners (n = 11) review the tool. The experts and practitioners provided feedback and suggestions to make the assessment as useable as possible. The survey was piloted by two or three representatives of each unit (n = 21); changes were made based on feedback. The final survey was deployed using Survey Monkey, an online survey and data management software.
A second assessment of skills and competencies was developed for administrative support staff. This decision was made to account for the fact that those serving in this role/function needed an understanding of public health basics (cultural competency, working with the community, and basic public health sciences) but did not need to be competent in all core functions and essential services. For example, the planning group concluded that administrative support staff did not need to have knowledge of financial planning and management. The same process that was described above was also used for the development of this tool.
Identifying Training Needs
Overall, perceived importance and capacity were analyzed at the domain level and for each of the 57 skills. The domain results and individuals’ skills within each domain were categorized into overall perceived importance and capacity. “Not applicable” or “don’t know” responses were excluded from the analysis and reported as missing data. Each was presented as the percentage of respondents indicating moderate to high importance and moderate to high capacity. Figures 1 and 2 provide examples of how each item of the data was presented. Figure 1 is an example of the overall domain results, and Figure 2 is an example of skill-level results. Training needs were determined by those skills that had the largest variance between importance and capacity. For example, in Figure 2, the “develop budget priorities” skill had a variance of 16%.
Example of Overall Domain Results
Example of Individual Skill Results
The next step in the process was to disaggregate the findings for each unit in the Division. This resulted in education and training priorities for the entire Division and for each of the eight units and the administrative support staff. Once unit-specific results were available, the next step in the prioritization process was to hold focus groups using the Technology of Participation (ToP) facilitation method (The Institute of Cultural Affairs in the U.S.A., n.d.) with selected representatives from each unit. These focus groups were formed to gain a consensus on the priorities that were established from the survey results and discuss if other skills or topics should be added to the plan. The guide for the focus groups used the ToP Consensus Workshop Method (The Institute of Cultural Affairs in the U.S.A., 2000). A total of nine (one for each unit and administrative staff) 90-minute focus group sessions were held to explore the training priorities. Each focus group had between 12 and 17 participants from their respective unit. The participants were diverse in terms of their role and experience with the Unit (i.e., number of years working for the Division). ToP facilitation methods were used because the literature illustrates that these methods work well with a diverse group of individuals, provide a process to allow participants to focus on a topic to determine a consensus on direction, and apply structure to prevent conversations from getting off track (Stanfield, 2015). In addition, the Consensus Workshop Method used by facilitators leads to group consensus of the priorities omitting the need for traditional analysis of the data.
Creating Workforce Development Plans
The qualitative data from the focus groups were incorporated with the needs assessment results (quantitative data) and used to provide overall training recommendations (Table 1) and workforce development plans for the entire Division and for each individual unit. The results were presented by faculty from the UNMC COPH to staff from the entire Division. After the presentation, reports were provided to the unit administrators, and they were required to create training plans. The training plans covered the period from 2014 to 2016 and included the following areas:
Topic
Description of the proposed training
Priority audience
Competencies addressed
Completion data
Resources that already exist for the training
Recommendation Summary
In addition, recommendations were made for evaluation measures and tracking. At a minimum, it is expected that for any organized educational opportunity such as a presentation or webinar, an employee satisfaction survey will be completed. Those coordinating the opportunity would also decide to complete a pre-/posttest to evaluate the extent to which participants acquired the intended knowledge or skills and will apply what they learned on the job. For existing online courses, staff are required to keep any certificate or notice of completion for their records as evidence of completion.
Figure 3 illustrates the full (Engage, Develop, Identify, and Create) EDIC method, the process undertaken to prepare a comprehensive workforce development plan for the Division.
The EDIC Method
Discussion
There were several factors that make this a model others should now consider. First, forming a collaborative partnership between academe and practice is critical to assure that the process is grounded in science and practice. For example, faculty and staff from the UNMC COPH were familiar with the most current skills and competencies from the COL. Faculty and staff also objectively collected and analyzed the data and served as a neutral convener to present the data and information back to staff from the Division. They also facilitated the focus group discussions, which allowed for more open dialogue.
A second factor that made the process successful was the high level of engagement of Division staff. For example, several times during the process, input and feedback from the Unit managers in the Division were requested and acted up. Because of the openness of the discussions and the subsequent changes that were made based on staff recommendations, there continues to be strong buy-in from Division staff and a willingness to participate in and support the overall accreditation process. It also allowed for a customized assessment that fit the needs of the Division.
A third factor was that results were provided not only at the Division level but also at the Unit level. We found that one size does not fit all, and there were a number of differences between the different units in both perceived importance and perceived capacity. For example, only 48% of staff in the environmental health unit indicated that “Financial Planning and Management” was a moderate to highly important competency domain, whereas 92% of staff within the health promotion unit found that competency set to be of moderate to high importance. Likewise, current capacities differed. Within the epidemiology and informatics unit, for example, 94% of staff considered their capacity in the “Analytic/Assessment” domain to be moderate to high capacity, whereas only 57% of staff in the investigations unit perceived themselves to have moderate to high capacity in this competency domain. Having unit-specific results assists the Division in identifying tailored trainings to meet the highest needs.
Finally, once the training needs were documented, we found it was important to identify local expertise to meet these needs whenever possible. Local experts may be available internally within the Division, the community, or the COPH. By using local experts, expenses can be lowered and more people may be able to receive the training.
Conclusion
Although the overall skills and competencies of the public health workforce have been a concern for several years, the changing focus of public health practice and the interest of many local and state public health departments in public health accreditation have provided a strong impetus to build workforce capacity. To build this capacity, it is essential to conduct a comprehensive assessment process that involves comparing the skills and competencies of the current workforce against known standards. Once the gaps are determined, appropriate education and training programs can be identified or developed and implemented.
This study documented the role of the UNMC COPH in assisting the Nebraska Division of Public Health as it successfully completed a comprehensive workforce development plan. This type of process provides greater assurance that the most important gaps in skills and competencies will be identified. Although it is a comprehensive approach, it can be replicated at the state or local level across the country.