Abstract
Objective:
The purpose of the current study was to examine governmental public health employee experiences during the COVID-19 pandemic.
Design and Setting:
A total of 5169 responses to a PH WINS 2021 open-ended question were qualitatively coded. The question asked employees to share their experiences during the COVID-19 response. The 15 most common themes are discussed.
Participants:
Responses from governmental public health employees in state health agencies (SHAs), big cities (Big City Health Coalition or BCHC agencies), and local health departments (LHDs) across all 50 states were included.
Results:
The most frequently identified theme was pride in public health work and/or the mission of public health (20.8%), followed by leadership (17.2%), burnout or feeling overwhelmed (14%), communication (11.7%), and overtime/extra work (9.7%). Among the top 15 themes identified, comments about pride in public health work and/or the mission of public health (95.9%), teamwork (81.5%), and telework (61%) were predominantly positive. Co-occurring themes for responses that expressed pride in public health work and/or the mission of public health were often countered with explanations of why respondents remain frustrated, including feeling burned out or overwhelmed, disappointment with the community's sense of responsibility or trust in science, and feeling unappreciated either by the community or their agency. All of these co-occurring themes were predominantly negative.
Conclusions:
Employees are proud to work in public health and value teamwork but often felt overworked and unappreciated during the COVID-19 pandemic. Reviewing existing emergency preparedness protocols in the context of lessons learned during the COVID-19 pandemic and listening to employees' experiences with teleworking and task sharing may better prepare agencies for future challenges. Creating channels for clear communication during a period of changing information and guidelines may help employees feel more prepared and valued during an emergency response.
Keywords: burnout, communication, COVID-19, PH WINS, public health workforce
The unprecedented global circumstances of the COVID-19 pandemic placed significant expectations and burden on US public health agencies and their employees in leading the response and supporting communities. Public health has been preparing for and responding to large-scale emergencies and pandemics since 9/11, with increased attention and resources dedicated to federal, state, and local agencies.1,2 However, despite the lessons of responding to Hurricane Katrina, the BP oil spill, numerous wildfires, H1N1, and Zika,3–5 as the longest protracted and broad-ranging event to date, the COVID-19 pandemic introduced new challenges for public health agencies. It also compounded existing challenges faced by the public health workforce, in particular the growing need for robust infrastructure.6,7 Despite the number of public health emergency response events in the last 2 decades, federal investments in public health had declined overall in the decade prior to the COVID-19 pandemic.8 These budget cuts along with ongoing public health workforce recruitment and retention issues translate to persistent challenges in public health emergency response efforts.9–12
More than 50 000 temporary public health workers were hired to support the response in the United States; yet, recent studies report ongoing public health staff shortages and widespread burnout among the workforce.13–15 Stone and colleagues15 surveyed 225 public health employees in 31 states, assessing the mental and physical risks experienced by public health employees. At the time of their survey (months 6-10 of the COVID-19 pandemic), almost a third of respondents reported a sense of burnout. Similarly, a qualitative study utilizing interviews with 24 public health employees in the second year of the COVID-19 pandemic (2021) identified burnout as a major theme among respondents.14 The National Association of County and City Health Officials (NACCHO) 2020 Forces of Change survey, which collected insights from leaders of 237 local health departments (LHDs), illustrated the prevalence of staffing shortages, staff and agency harassment, and high numbers of temporary hires.13 Although these findings offer key early insights into experiences of the public health workforce in responding to the COVID-19 pandemic, none of the recent studies represent the broader experiences of the US public health workforce. The 2021 Public Health Workforce Interests and Needs Survey (PH WINS) provides an opportunity to examine the perspectives of the larger governmental public health workforce.
The purpose of the current study was to examine governmental public health employee experiences during the COVID-19 pandemic. More specifically, this study utilized an open-ended question on PH WINS 2021 that asked employees to share their experiences. A total of 5169 qualitative responses were coded including perspectives of employees in state health agencies (SHAs), big cities (Big City Health Coalition or BCHC agencies), and LHDs across all 50 states. Findings provide context regarding workforce experiences and may inform planning for future emergency response efforts as well as day-to-day workforce needs and preferences.
Methods
Sample
This study utilizes cross-sectional data collected as an open-ended question on PH WINS 2021. Jointly administered by the Association of State and Territorial Health Officials (ASTHO) and the de Beaumont Foundation, fielded during September 2021 and January 2022, PH WINS 2021 provides nationally representative workforce insights from state and local governmental public health employees. PH WINS collects employee demographic characteristics as well as perspectives about leadership, the organizational environment, and individual competencies and training needs.
PH WINS participants were identified by each participating health department. The initial frame included 47 SHAs, 29 BCHC agencies, and 260 LHDs, of which 137 446 individuals were invited to participate in the survey.16 PH WINS received 44 732 responses representing 35.0% of eligible participants. In the initial survey of SHA staff, 87 739 participants were invited to complete the survey, with 27 346 completed responses (34.0% of eligible participants). A total of 7922 responses were received from BCHC agencies (28.0% of eligible participants) and 3046 responses from LHDs (46.0% of eligible participants). LHDs in Health and Human Services (HHS) Regions 5 and 10 were oversampled for “PH WINS for All,” generating another 6418 LHD staff responses (56.0% of eligible participants) from 215 of the 221 LHDs in those combined regions. However, a total of 968 of the responses from 100 LHDs in PH WINS for All were not large enough to be included in the national sample as they did not have a minimum of 25 staff members and/or serve a minimum of 25 000 people. Notably, a change from previously administered PH WINS is the inclusion of nonpermanent employees in the nationally representative sample, as temporary employees comprised a sizable portion of the workforce, particularly during the COVID-19 pandemic response.
For this study, the authors qualitatively coded the following open-ended survey question: “Please share your thoughts and experiences about serving in your health department during the COVID-19 pandemic.” A total of 12 655 public health employees completed the survey and also responded to this question. A subset of 5169 (41.0%) responses from BCHC agencies, LHDs, and state health departments were randomly selected and coded for this study.
Analysis
Between February 2022 and April 2022, responses to the open-ended questions were coded using an inductive approach. Following the review of a subset of 200 responses, an initial coding protocol was developed. This included a list of codes, their explanations, and corresponding example quotes. Using this coding protocol, a team of 5 coders analyzed half of the same subset of 200 responses. Each response was assigned at least 1 code and as many as 4 codes. Each assigned code was also assigned a disposition of negative, neutral, or positive to denote the temperament of the participant's response. Following the coding of the first round of 100 responses by individual coders, codes were reviewed as a group and discussed. The coding protocol was revised as needed (see Supplemental Digital Content Appendix A, available at http://links.lww.com/JPHMP/B82), and the second half of the initial 200 codes was coded by each member of the team. Again, group review identified any discrepancies, which were then resolved through discussion. Given the high level of coding consistency (84.0%), coders were then given their own set of responses to code. During the coding period, the coding team met weekly to discuss any responses that were unclear and to discuss any concerns with codes or responses. If a response was deemed to be irrelevant or as not contributing an informative or clear response, it was coded as “irrelevant” and excluded from the final sample. The Figure displays the coding process as described. The top 15 most common codes are summarized with example quotes. The disposition (negative, positive, or neutral) of each code is summarized along with the top 5 co-occurring codes for each of the 15 most common codes. This study was deemed exempt by the institutional review board at the institution of the first author.
FIGURE.
Qualitative Coding Process
Results
A total of 798 (15.4%) of the 5169 coded responses were deemed irrelevant and removed from the sample. The remaining 4371 responses received codes and were assigned dispositions. The characteristics of the 4371 respondents whose open-ended comments were coded are summarized in Table 1. Respondents include public health workers employed across all participating states (data not shown) and all 10 HHS regions. Similar to the overall PH WINS 2021 sample, a majority of coded responses were from public health workers who self-identified as women (79.8%), were employed in a decentralized governance structure (62.2%), and were nonsupervisors (n = 2947/4367 or 67.5%). In addition, most of the respondents whose comments were coded were permanent staff employed by the health department (87.2%), although this sample also includes temporary employees (8.1%) and interns (0.3%).
TABLE 1. Descriptive Statistics for PH WINS 2021 Respondents and Those Whose Open-ended Responses Were Coded for This Studya.
| Characteristic | All PH WINS Respondents (N =44 732), n (%) | Sample Respondents (N = 4371), n (%) |
|---|---|---|
| Geographic region | ||
| HHS Region 1 | 1 995 (4.5) | 179 (4.1) |
| HHS Region 2 | 2 976 (6.7) | 267 (6.1) |
| HHS Region 3 | 4 183 (9.4) | 442 (10.1) |
| HHS Region 4 | 9 903 (22.1) | 818 (18.7) |
| HHS Region 5 | 8 579 (19.2) | 924 (21.2) |
| HHS Region 6 | 4 777 (10.7) | 476 (10.9) |
| HHS Region 7 | 1 629 (3.6) | 135 (3.1) |
| HHS Region 8 | 1 942 (4.3) | 217 (5.0) |
| HHS Region 9 | 5 712 (12.8) | 573 (13.1) |
| HHS Region 10 | 3 036 (6.8) | 336 (7.7) |
| Governance structure | ||
| Decentralized | 27 387 (61.2) | 2 718 (62.2) |
| Centralized | 7 579 (16.9) | 746 (17.1) |
| Shared | 8 082 (18.1) | 717 (16.4) |
| Mixed | 1 684 (3.8) | 186 (4.3) |
| Program area | ||
| Communicable disease | 11 067 (24.8) | 1 280 (29.3) |
| Organizational competencies | 7 769 (17.4) | 623 (14.3) |
| Other health care | 6 803 (15.2) | 606 (13.9) |
| Maternal and child health | 6492 (14.5) | 653 (15) |
| Environmental health | 3 853 (8.6) | 337 (7.7) |
| Assessment | 3742 (8.4) | 346 (7.9) |
| Chronic Disease & Injury | 2 029 (4.5) | 201 (4.6) |
| Other | 1697 (3.8) | 184 (4.2) |
| All Hazards | 637 (1.4) | 75 (1.7) |
| Communications | 613 (1.4) | 59 (1.4) |
| Leadership level | ||
| Nonsupervisor | 32 768 (73.3) | 2 947 (67.5) |
| Supervisor | 7 344 (16.4) | 794 (18.2) |
| Manager | 3 590 (8.0) | 480 (11.0) |
| Executive | 1 030 (2.3) | 146 (3.3) |
| Employment status | ||
| Permanent staff employed by health department | 38 221 (86.2) | 3 792 (87.2) |
| Temporary staff employed by health department | 3 664 (8.3) | 352 (8.1) |
| Contractor providing services to the health department | 1 947 (4.4) | 163 (3.7) |
| Federal employee detailed to the health department | 346 (0.8) | 29 (0.7) |
| Intern employed by the health department | 154 (0.3) | 14 (0.3) |
| Tenure in agency | ||
| 0-5 y | 21 233 (49.9) | 1 985 (46.6) |
| 6-10 y | 7 259 (17.0) | 761 (17.9) |
| 10-15 y | 4 806 (11.3) | 515 (12.1) |
| 16-20 y | 3 898 (9.2) | 434 (10.2) |
| ≥21 y | 5 380 (12.6) | 565 (13.3) |
| Age | ||
| 18-30 y | 5 488 (13.6) | 459 (11.4) |
| 31-40 y | 9 690 (24) | 969 (24.0) |
| 41-50 y | 9 941 (24.6) | 980 (24.3) |
| 51-60 y | 10 186 (25.2) | 1 050 (26.0) |
| 61+ y | 5 146 (12.7) | 578 (14.3) |
| Race | ||
| White | 30 828 (71.7) | 3 203 (75.6) |
| Black or African American | 6 485 (15.1) | 532 (12.6) |
| Two or more races | 3 172 (7.4) | 324 (7.6) |
| Asian | 2 978 (6.9) | 242 (5.7) |
| American Indian or Alaska Native | 754 (1.8) | 84 (2) |
| Native Hawaiian or other Pacific Islander | 266 (0.6) | 26 (0.6) |
| Ethnicity | ||
| Hispanic | 7 280 (16.6) | 674 (15.7) |
| Non-Hispanic | 36 511 (83.4) | 3 626 (84.3) |
| Gender | ||
| Female | 34 706 (78.6) | 3 446 (79.8) |
| Male | 8 656 (19.6) | 794 (18.4) |
| Some other way | 766 (1.7) | 81 (1.9) |
Abbreviation: HHS, Health and Human Services.
aVariable totals may not equal the total sample (n = 4371) depending on response completion. If a response was deemed to be irrelevant or as not contributing an informative or clear response, it was coded as “irrelevant” and excluded from the final sample. A total of 798 (15.4%) of the 5169 coded responses were deemed irrelevant and removed from the sample.
Themes identified
The 15 most common themes ranged in occurrence in the sample responses from 20.8% to 5.7% (Table 2). When asked about experiences serving in the health department during the pandemic, the most frequently identified theme was pride in public health work and/or the mission of public health (20.8%). While many respondents offered a variety of insights, 1 out of 5 responses included this sense of pride in being involved in public health work. The second most common theme identified was leadership (17.2%). Leadership comments were coded into 2 nearly evenly divided but different subthemes including those that discussed leadership issues (56.3%) experienced during the response and those that shared experiences of leadership support (43.7% of leadership comments). The third most common theme, expressed in 14.0% of responses, was about a sense of burnout or feeling overwhelmed (14.0%). Communication (11.7%) was the fourth most common theme. Communication comments were also coded into 2 subthemes: comments about either internal communication within the health department (61.5%) or external communication with partners or others involved in the response (38.5%). Having to work overtime or do extra work (9.7%) was the fifth most common response theme, occurring among approximately 10.0% of responses.
TABLE 2. Explanation, Example Quotes, and Frequencies of the 15 Most Frequent Themes Identified in Qualitative Coding of Open-Ended Responses to PH WINS 2021 (N = 4371).
| Theme | Explanation/Uses of Theme | Example Quote(s) | n (%) |
|---|---|---|---|
| Pride in public health Work/Mission | Sense of pride in the work and/or pride in having helped the public health mission | “We have tried diligently to respond appropriately to COVID in our clinic, even with tireless hours and tears shed. I cannot speak for the entire health department, but our clinic spearheaded the response and continues to do so with our heads held high.” | 909 (20.8) |
| Leadership |
Subtheme— Leadership Issues Lack of faith in leaders, perception of no leadership, opinions about how leadership should be, opinions about leadership not supporting the staff, etc (n = 426 or 9.7%) |
“I have never worked under administrations that treat staff as terribly as this one. I have had many successes and won multiple awards ... during my career for my work and have worked for many other administrations in 2 states that valued my work, but these people I am working for now care about no one but themselves and how to make their own lives easier.” | 756 (17.2) |
| “Our leadership seems to be undermining our efforts to keep the community safe. I feel that our main leadership is angling for re-election rather than community support” | |||
|
Subtheme—Leadership Support Opinions about leadership supporting the staff, examples of ways leaders are doing a good job (n = 330 or 7.5%) |
“Our agency was very well-organized and clear in its communication and training strategies! I felt very well-supported and confident in my assignment throughout this response. Also, once additional contract personnel were brought on, roles were more well-organized and more easily executed. I feel our health department delivered a strong response during such a difficult and at stressful time!” | ||
| Burnout/Overwhelmed | Sense of too much work to the point of discontent with the job, extreme stress, etc | “Stressful—very difficult to manage, especially when you have a family at home. There came a time when I felt resentful for all the hours I was working and the lack of opportunity for rest.” | 613 (14.0) |
| Communication |
Subtheme—Internal communication Discussion of internal organizational communication; sharing internal response/updates (n = 315 or 7.2%) |
“Communication has been horrible. Everything I learn about COVID comes from Facebook and the news before I hear it from my own organization.” | 512 (11.7) |
|
Subtheme—External communication Comments about communication with the community, external partners, media, etc (n = 197 or 4.5%) |
“The challenge in aligning messaging with current facts and political structures, along with finding a way to speak that made sense to the public, was a huge challenge. Silos and limitations made it much harder.” | ||
| Overtime/Extra work | Indications of being busy, having extra work, working overtime, etc | “Doing all that I was doing alone was challenging. I needed more help and better pay.” | 424 (9.7) |
| Compensation | Wanting to be paid for extra work, wanting raises, salary complaints in the context of the response | “Although I have not participated in the COVID-19 response, I do know that DHEC has compensated employees who have for both additional work and additional duties. I am thankful that my coworkers who are doing extra work are being compensated for it.” (Record #74) | 365 (8.4) |
| “I was unable to earn comp or extra pay for the extra hours worked because of my role as a supervisor.” | |||
| Emergency response protocols | Discussion/issues with emergency response protocols such as not knowing what to do in the emergency response or how to do it; comments about the success of emergency response protocols | “I wish the organization provided better guidance in the form of a plan/protocol for handling an emergency on a large scale that is specific to laboratory services. For example, personnel allocation, set scheduling, handling the large influx of supplies, scaling up non-pandemic processes to adequately respond to pandemics.” | 340 (7.8) |
| Staff shortages | Comments about not having enough workers or being shorthanded | “We desperately need staff. I am the sole Emergency Preparedness Coordinator and I have been at the helm of the response work since March 2020. Not having additional backup or staff that are planning oriented severely hinders our agency's ability to lean forward and get ahead of issues. We were always reactionary.” | 325 (7.4) |
| Teamwork | Expressing a sense of strong peer support, sense of community in workforce | “I have enormous respect for the employees and leadership at the Department of Health. I feel that the public does not value them enough. Too many people see their role in this pandemic as self-serving when it is the opposite.” | 314 (7.2) |
| Employee wellness | Comments about employee health not being prioritized or about employee health/wellness/ill health | “We all got COVID at the same time in our office in June of 2020 and the agency really did nothing to protect us prior to that barely after.” | 308 (7.0) |
| Disappointment with community's sense of responsibility/Trust in science | Expressions of discontent/disappointment with how the community reacted to guidance, disregarded recommendations, etc | “It was fine when there was a goal to achieve (waiting for the vaccine) but with all the misinformation and denial from the public and the unwillingness of leadership in the Health Department and government to actively combat and denounce it, it makes it feel like it was all a waste of time.” | 300 (6.9) |
| Strain on core responsibilities of public health | Strain on routine or core public health activities and work (Women Infants and Children [WIC], lead, inspections, etc) | “It was at times very long hours and most of my regular work was put on hold to assist with the clinics.” | 259 (5.9) |
| “We have struggled to find a balance between our main lines of business—First Steps, WIC, Dental, Family Planning and Primary Care clinical services—and pandemic response.” | |||
| Telework | Comments about remote work or telework | “COVID didn't affect me professionally, except that it gave me the wonderful opportunity to work remotely for a year. Then my agency insisted that we all come back to the office, even though we were not vaccinated.” | 256 (5.9) |
| “Some roles within our office can have the capability to work from home and there were some staff in management who were working from home. It was not fair that the entire team was not given the option.” | |||
| Politicization | Comments about politics; influence of politics on community or agency; politics in the context of community discontent with public health guidance, etc | “It has been difficult to navigate when politics are leading the effort and not science. Information changes so rapidly and is inconsistent. Employees are scared to voice their concerns.” | 256 (5.9) |
| Unappreciated | Not feeling appreciated by leadership/the agency or by the community | “...we were never thanked, acknowledged, or supported (seemingly) from anyone else besides our direct division including leadership/management, our board, our department at large, and definitely not community entities and the public” | 250 (5.7) |
Additional common themes included compensation (8.4%), comments about emergency response protocols (7.8%), staff shortages (7.4%), teamwork (7.2%), employee wellness (7.0%), disappointment with the community's sense of responsibilities or trust in science (6.9%), strain on the core responsibilities of public health (5.9%), telework (5.9%), feeling unappreciated (5.7%), and the politicization of COVID-19 and public health response efforts (5.9%).
Theme dispositions and co-occurring themes
Among the top 15 themes identified, comments about pride in public health work and/or the mission of public health (95.9%), teamwork (81.5%), and telework (61.0%) were predominantly positive (Table 3). Regarding teamwork, one respondent said,
TABLE 3. Theme Dispositions and Top 5 Co-occurring Themes.
| Theme | n (%) | Disposition | Top 5 Co-occurring Themes | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Negative | Positive | Neutral | Co-Theme 1 | Co-Theme 2 | Co-Theme 3 | Co-Theme 4 | Co-Theme 5 | ||
| Pride in public health work/Mission | 909 (20.8) | 3.2% | 95.9% | 0.9% | Teamwork | Burnout/Overwhelmed | On-the-job learning | Disappointment with community's sense of responsibility/Trust in science | Unappreciated |
| Leadership | 756 (17.2) | 79.0% | 20.5% | 0.5% | Communication | Pride in public health work/Mission | Emergency response protocols | Employee wellness | Compensation |
| Burnout/Overwhelmed | 613 (14.0) | 98.0% | 0.5% | 1.5% | Overtime/Extra work | Staff shortages | Leadership | Pride in public health work/Mission | Compensation |
| Communication | 512 (11.7) | 88.7% | 9.0% | 2.3% | Leadership | Emergency response protocols | Changing policies/Guidance/Science | Politicization | Pride in public health work/Mission |
| Overtime/Extra work | 424 (9.7) | 92.7% | 0.9% | 6.4% | Compensation | Staff shortages | Leadership | Burnout/Overwhelmed | Employee wellness |
| Compensation | 365 (8.4) | 95.0% | 2.5% | 2.5% | Overtime/Extra work | Inequity in response roles/Obligations | Unappreciated | Leadership | Burnout/Overwhelmed |
| Emergency response protocols | 340 (7.8) | 82.3% | 16.5% | 1.2% | Leadership | Communication | Lack of appropriate education/Training | Pride in public health work/Mission | Overtime/Extra work |
| Staff shortages | 325 (7.4) | 95.0% | 1.3% | 3.7% | Overtime/Extra work | Strain on core responsibilities of public health | Leadership | Burnout/Overwhelmed | Emergency response protocols |
| Teamwork | 314 (7.2) | 16.6% | 81.5% | 1.9% | Pride in Public health work/Mission | Leadership | On-the-job learning | Communication | Burnout/Overwhelmed |
| Employee wellness | 308 (7.2) | 84.7% | 13.1% | 2.2% | Leadership | Overtime/Extra work | Compensation | Intent to leave/Turnover | Telework |
| Disappointment with community's sense of responsibility/Trust in science | 300 (6.9) | 93.3% | 5.3% | 1.4% | Leadership | Politicization | Pride in public health work/Mission | Jaded | Communication |
| Strain on core responsibilities of public health | 259 (5.9) | 95.4% | 1.2% | 3.4% | Staff shortages | Overtime/Extra work | Leadership | Pride in public health work/Mission | Burnout/Overwhelmed |
| Telework | 256 (5.9) | 24.2% | 61.0% | 14.8% | Employee wellness | Discontent with having to work in person | Leadership | Pride in public health work/Mission | Communication |
| Politicization | 256 (5.9) | 96.5% | 1.2% | 2.3% | Communication | Pride in public health work/Mission | Leadership | Political involvement in public health activities | Distrust/Negative view of public health |
| Unappreciated | 250 (5.7) | 91.6% | 8.0% | 0.4% | Compensation | Leadership | Pride in public health work/Mission | Inequity in response roles/Obligations | Overtime/Extra work |
Our people are perpetual problem solvers in every facet of this outbreak and all involved have worked tirelessly to keep things moving forward in as organized manner as possible and with good support and good attitudes that made all the difference in how we get through our days.
However, co-occurring themes for responses that expressed pride in public health work and/or the mission of public health were often countered with explanations of why respondents remain frustrated. These included feeling burned out or overwhelmed, their disappointment with the community's sense of responsibility or trust in science, and feeling unappreciated either by the community or by their agency. All of these co-occurring themes were predominantly negative. One respondent said,
It has been an honor to work on the response and contribute to state, national, and global fight. The earlier months were chaotic and we had little additional staffing resources. Many staff, myself included, worked months without a full day off, let alone a weekend and were working 10-12 hours a day (sometimes more). Later on this improved with staff resources, but also brought other challenges (eg, administrative burdens of hiring, onboarding) and changes to activities, and navigating influx of federal funds within inflexible state systems. Now that balance is better since there is a rhythm to the work and because the hours of operation have changed. However, staff are still feeling burn out. In addition, the lack of political, community, and high agency support, make it challenging. Also, as PH workers, we are constantly bombarded by COVID misinformation and frustration from the public—which is also disheartening and exhausting after so many long hours, dedication, and immense effort.
Comments about leadership support, one of the 2 subthemes of the main leadership theme, were also commonly positive comments. For example, one respondent said,
I have never been more proud to work for public health as during the pandemic. Our agency's leadership has been courageous, transparent, ambitious and evidence-based throughout this challenging time.
However, overall, comments about leadership as a whole (both subthemes of leadership issues and leadership support) were generally negative (79.0%), highlighting perceived lack of compensation and communication, working overtime, inequity in assigned response roles or who could telework, and not feeling appreciated by leadership. One respondent noted,
Just a complete lack of support from our leadership. We rarely hear from those in charge and when we do it's to criticize us for not working hard enough. There is no communication. Information is never relayed back to us.... We are kept in the dark on purpose because they feel it's beneath them to have to explain themselves to us. We are worked into the ground with no pay or rewards for it. We are forced to work weekends and holidays and they refuse to pay us overtime for it.
Comments about both internal and external communications were predominantly negative (88.7%). Responses discussed changing policies, guidance, and science caused by the evolving pandemic as well as leadership not communicating effectively to employees and a lack of emergency response protocols. For example, one respondent said,
There were numerous breakdowns in communication between leadership, both intra-agency and inter-agency. Much of the time, it seemed that no one was on the same page. Staff often expressed that they felt their safety was not prioritized. There was a general lack of organization and procedures were constantly changing, which is confusing for staff and for the public.
Comments about politicization were also largely negative (96.5%). Responses suggested that politicization led to a lack of clarity of public health messages and to distrust and/or a negative view of public health. To this end, one respondent said,
The politicization of such a major public health event has been an extreme challenge. Working on responding to a public health need with the pitfalls that also come with a political spotlight made a very challenging response almost impossible in some scenarios. The spotlight also made it very difficult to respond appropriately to public health needs when the political agenda of leadership did not align with public health needs.
The majority of responses about employee wellness were also negative (84.7%), with many respondents expressing that employee wellness was not prioritized. Co-occurring themes for responses relating to employee wellness included not receiving sufficient compensation, working overtime and/or having extra work, intending to leave their job in public health/turnover, and leadership issues. One respondent noted,
It was great to be a part of something that was different from the usual and important, but it did wear on me. I did not take much time off and I still don't feel back to normal, but I have a light at the end of the tunnel that many don't (in that I can retire next year). I believe that the senior leadership should have focused more on staff getting time to refresh. But many of them don't like to take time off and be at home or with their family. But many of us do want that, and that puts pressure on us to keep going as well. I know it was not easy (short staffed and all) but I expect more, or at least an attempt at more.
Responses about compensation and feeling unappreciated were nearly all negative (95.0% and 91.6%, respectively). Respondents expressed feeling unappreciated by their agency/department and/or their community. Respondents explained that there was inequity in response roles and/or obligations for public health employees such as having to work overtime and/or who continued health department activities (often through telework) while their colleagues were pulled into face-to-face COVID-19 response roles. One individual said,
The response was and continues to be a heavy burden on a small, select group of staff. Many staff were not engaged in the initial response and it took over a year for some staff to take part in response activities.
Some expressed the sentiment that the response obligations could have been more evenly shared across staff to address staff shortages due to their department's COVID-19 response and that telework options were inequitable. Others felt that staff working on activities other than COVID-19 response were not treated fairly and rarely received recognition from leadership. One respondent said,
Staff that remained in the office for the duration of the national/state COVID-19 response were burned out carrying the workload which resulted from some staff [being] pulled away into COVID-19 roles and shortages resulting from quarantined/ill staff. Several staff covered programs by working beyond normal hours for over 12-14 months without compensation or recognition from senior leadership. If you didn't have a direct role specific to COVID-19, you were not supported. Not once did senior leadership check on my division during the pandemic.
Discussion
The rapidly evolving COVID-19 pandemic has significantly burdened the public health workforce and has compounded many of their existing challenges in their effort to support and protect communities nationwide. Currently, no literature provides a comprehensive representation of public health employees' experiences responding to the pandemic. PH WINS 2021 data provide an opportunity to examine the experiences of governmental public health employees working in state, local, and BCHC departments during the COVID-19 response.
The most common theme identified in employee responses about experiences during the COVID-19 pandemic was the expression of pride in public health work and/or the mission of public health. One out of 5 respondents included this sentiment in their responses. This sense of pride in the work, however, was offset by a pervasive sense of burnout and feeling overwhelmed. Insights about burnout within the workforce are not surprising, given studies conducted earlier in the COVID-19 pandemic response and additional PH WINS 2021 findings presented in this supplement, but it seems that the innate value of public health work remains a prominent component of the workforce's perspective.13–15,17,18 In fact, comments about pride in public health work or the mission of public health were among the top 5 co-occurring themes for 11 of the 15 most common themes. Expressions of pride in the work accompanied complaints about leadership, staff shortages, strain on the core responsibilities of public health, feeling unappreciated, and disappointment with the community's sense of responsibility/trust in science. However, since intentions to leave/turnover were discussed infrequently in the open-ended responses, perhaps pride in public health work serves as a mitigating factor balancing the many frustrations expressed by the workforce. Additional findings from PH WINS 2021 show that despite the challenges of the COVID-19 pandemic, 93.0% of the governmental public health workforce say that they are determined to give their best effort at work every day.18
Leadership was the second most common theme, highlighting the value of leaders and their impact on health department employees. Of note, only 20.0% of the leadership comments were positive or expressed a sense of leadership support. Instead, the majority were critical commentary about leadership issues including a lack of communication, employee wellness not being prioritized, complaints about compensation, feeling unappreciated, staff shortages, working overtime, and inequity in response roles/obligations and/or who could telework. Agency leaders are unfortunately limited in their agency resources and their fiscal and legal authorities, which were challenged during the pandemic and in many cases reduced.19–22 Indeed, some of the leadership issues expressed were about financial resources and limitations to when they are provided and for what,23–25 but other leadership issues raised related to skills that can be enhanced among leaders and decision makers within agencies (eg, communication, leading under pressure).26–30
Although many negative comments about leadership were identified, positive comments about teamwork are a reminder of how important the collective sense of working together can be. Insights about teamwork in this study align with prior findings from the Scales and colleagues14 interviews of public health employees. It is imperative for leadership to work to strengthen the workplace culture to ensure that team-oriented competencies are incorporated into general practice and to foster a mindset of shared responsibilities among employees, particularly in the case of an emergency event.31,32 Given the insights of respondents, agencies should work to enhance teamwork, especially as day-to-day routine work resumes; review and revise existing emergency preparedness protocols in the context of lessons learned during the response, particularly around communication and employee well-being; and develop telework guidelines that are equitable across roles and employees.
Respondents discussed how the evolving nature of the COVID-19 pandemic meant that the science and the guidance available to public health workers were constantly changing, which complicated both internal and external communications. Respondents reported issues with timeliness and adequacy of internal information and challenges in communicating changing information to the public. Issues with the lack of emergency response protocols or a lack of consistency in how they were followed often accompanied comments about internal communication. Comments about the complicating factor of politicization highlighted challenges in communicating with the public. Ensuring improved consistency in communication from the federal government to states, territories, and locals is an issue discussed in the recent recommendations from the Commission on a National Public Health System and something that needs to be addressed in the near term as we continue to address COVID-19 and prepare for future large-scale outbreaks.6,7
Implications for Policy & Practice
Employees are proud to work in public health and value teamwork but often felt overworked and unappreciated during the COVID-19 pandemic.
Reviewing existing emergency preparedness protocols in the context of lessons learned during the COVID-19 pandemic and listening to employees' experiences with teleworking and task sharing may better prepare agencies for future challenges.
Creating channels for clear communication during a period of changing information and guidelines may help employees feel more prepared and valued during an emergency response.
Issues raised in these findings that relate to staff shortages, overtime/extra work, employee wellness, and compensation are ongoing challenges resulting from the persistent underfunding of public health and the cyclical nature of emergency response funds that are time and activity (eg, funding that cannot be spent on infrastructure or hiring new staff) restricted.6,10,12,23,24,33 While politicization was included in the top 15 themes of the current study, contrary to recent studies that highlighted workforce attention to politicization,14 it was surprisingly not frequently mentioned, perhaps demonstrating the lesser importance and attention given to the matter by public health employees as the pandemic continues. Alternatively, the topic of telework, which has been raised in recent studies and was a top 10 theme in the current findings, highlights the workforce's desire for work flexibility.14 Facilitating equity in telework options should be considered.
Strengths and limitations
This study has a number of strengths and limitations. First, among recent studies of experiences of the public health workforce during the pandemic, this study has the largest and most generalizable sample to date, with data reflecting the experiences of governmental public health workers across state and local health agencies. The PH WINS data analyzed provide the most recent insight into the governmental public health workforce experiences over a year and a half into the COVID-19 pandemic. Furthermore, the data provide more explicative insight due to the open-ended qualitative nature of the survey question used. The study is limited by the qualitative nature of the data, which involves some degree of interpretation in the coding process. However, to ensure consistency, the authors implemented routine discussions of unusual responses.
Supplementary Material
Footnotes
The authors thank members of the coding and analytical team including Elizabeth Quinn, Jack Thomas Jones, Margaret Unruh, and Dr Olena Mazurenko for their support.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (http://www.JPHMP.com).
Contributor Information
Valerie A. Yeager, Email: vyeager@iu.edu.
Emilie R. Madsen, Email: ermadsen@iu.edu.
Kay Schaffer, Email: schaffer@debeaumont.org.
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