Advancing Governmental Public Health Workforce Well-being: Lessons From a Maryland Pilot Test

ABSTRACT

Prioritizing employee well-being is critical to retaining and sustaining a strong, prepared, and effective public health workforce. The Putting Our People First: Discussion Guide for Public Health Agencies to Advance Worker Well-being, a customizable tool to address worker needs and promote a culture of well-being, was pilot tested with 3 Maryland local health departments. Although employees across the 3 pilot agencies shared a strong public health mission orientation and commitment to their work and the communities they serve, key priority areas identified to advance a culture of well-being included internal communications, leadership, and organizational infrastructure and policies. This report shares lessons from Maryland's pilot sites and highlights how the guide can be adapted to local context, with insights that can be scaled across public health agencies to foster a culture of well-being and better support and sustain a strong, effective workforce to deliver essential services and respond to community needs.

Introduction

Public health workers operate in a shifting landscape under constant budget constraints, polarization, and uncertainty.¹ These challenges undermine workforce capacity and place additional strain and morale injury on an already overburdened workforce.^2,3 In the 2024 Public Health Workforce Interest and Needs Survey, >70% of state and local governmental public health workers reported experiencing at least 1 symptom of burnout in the past year, with 1 in 5 reporting near-constant burnout symptoms.⁴ Within Maryland, turnover intentions among state health employees exceed the national average, with overwhelming workloads and workplace stress among the primary drivers.⁵ Prolonged hiring timelines, sometimes exceeding 7 months for Maryland's local health departments (LHDs),⁶ intensify pressure on current staff to absorb additional responsibilities while vacancies persist, perpetuating a cycle of burnout and departures. This is especially concerning given workforce needs: in behavioral health alone, Maryland requires >30 000 new workers by 2028.⁷ Alleviating burnout is essential to cultivating a work culture that attracts and retains staff.

Public health agencies have started addressing longstanding workforce recruitment challenges^8,9; however, more focus is needed on retention. In Maryland, shared governance reinforces systemic barriers that compound workforce stress and turnover, including limited advancement and pay competitiveness because of restrictive job classifications.⁷ Systems-level changes prioritizing staff well-being and workforce development are critical to reducing turnover and creating a culture for staff to thrive and effectively serve their communities.¹⁰

Putting our people first: A discussion guide for public health agencies to advance worker well-being

Although resources addressing recruitment and retention are plentiful, few emphasize a structured approach to advancing workforce well-being, and those that do are often narrowly focused (eg, Joy in Work Toolkit for staff morale¹¹). Having a structured guide to facilitate collective staff and leadership dialogue on workforce well-being needs can inform institutional changes to prioritize well-being, alleviate burnout, and improve work culture and retention. Researchers from the Johns Hopkins University Bloomberg School of Public Health (JHU) partnered with the Public Health Accreditation Board with input from state and local public health practitioners to develop the Putting Our People First discussion guide as a tool to facilitate conversations that position workforce well-being as an organizational priority. The guide offers a structured process to surface and translate well-being concerns into documented priorities with actionable steps.

The discussion guide is customizable for use in any public health department, division, unit, or team and includes critical readiness questions along with a roadmap to identify priorities and desired outcomes and create and execute an implementation and evaluation plan. Given variations in department size, staffing, geography, structure, and resources, the guide intentionally provides broad guidance that users can customize to their specific context. Recognizing that implementation will vary across settings, a framework is provided to facilitate discussion and interpretation rather than prescribe specific actions, enabling users to guide meaningful change within their unique contexts. The guide's design allows users to engage with components most aligned to their needs and readiness; departments with established workforce well-being priorities might advance directly to implementation, whereas those just beginning to explore well-being might start with a baseline assessment or establish a workgroup to lead these efforts.

Methods

The Putting Our People First discussion guide was developed to address a practitioner-identified need for actionable tools to elevate workforce well-being as an organizational priority. To assess its utility in practice, the JHU team piloted the guide between June 2024 and February 2025 with 3 Maryland LHDs. The pilot included departments of varying sizes, representing both urban and rural jurisdictions. Pilot participation was voluntary and uncompensated; recruitment was conducted in collaboration with the Maryland Association of County Health Officers (MACHO).

JHU partnered with each pilot site to codesign implementation approaches tailored to their specific context, capacity, and needs. Two of the 3 sites opted for a department-wide approach, whereas the third focused on a single division (Clinical Services). For the first pilot, JHU analyzed multi-year employee satisfaction surveys (close-ended questions only) from all department staff. For the remaining 2 pilots, JHU facilitated in-person focus groups with leadership and staff to assess employee needs and concerns; 1 site's participants were department-wide, whereas the other limited participants to its Clinical Services division. Focus group transcripts were coded, and qualitative thematic analysis was conducted. Full details on agency-specific guide implementation are described in Table 1.

TABLE 1.

Pilot Site Characteristics and Implementation Comparison of 3 Maryland Local Health Department Pilot Sites

Characteristic	Site 1 (Large, Urban County)	Site 2 (Medium, Rural County)	Site 3 (Medium, Rural County)
Agency size (total employees)	700–750 employees	200–250 employees	150–200 employees
Implementation scope	Division-level, Bureau of Clinical Services	Agency-wide, all divisions	Agency-wide, all divisions
Pilot participants	n = 135, 8 focus groups with staff and supervisors from 7 clinical service teams	n = 30, 3 focus groups with staff, supervisors, and members of the agency's workforce development committee	N/A, agency requested analysis of responses from 7 employee satisfaction surveys from 2014 to 2022
Participant selection	Selected by division leadership	Voluntary sign-up	N/A (all employees receive the survey to complete; completion rate typically averages ∼50%-60%)
Leadership engagement	Division director (newly hired) + interim health officer + ∼12 invited leaders from various division teams Role: planning/coordination, priority setting, and focus group recruitment, findings shared back to inform any follow-up actions	Health officer + workforce development committee (∼12 staff representing different programs/teams) Role: planning/coordination, priority setting, and focus group recruitment, findings shared back to inform any follow-up actions	Leadership from division of community health and evaluation (which fields the employee satisfaction survey) Role: priority setting and sharing survey data, survey finding analysis shared back to inform any follow-up actions
Pilot implementation process	Planning meetings with JHU and selected division leadership; facilitated focus groups; conducted qualitative analyses; presented findings to division leadership and interim health officer	Planning meetings with JHU, health officer, and workforce development committee (HO/WDC); facilitated focus groups; conducted qualitative analyses; presented findings to HO/WDC	Initial planning meeting with JHU and leadership from division of community health and evaluation; survey data provided; conducted survey analysis, synthesized findings, and shared summary report with division leadership for broader dissemination to agency-wide worksite wellness team
Pilot duration	5 months (inclusive of planning and analysis/reporting)	8 months (inclusive of planning and analysis/reporting)	4 months (inclusive of planning and analysis/reporting)
Guide customization	Baseline assessment to determine staff needs and concerns to guide whether division is ready to undertake a well-being effort/initiative. Division leadership requested assessment via focus groups.	Existing agency-wide workforce development committee; health officer is fully supportive and engaged. Baseline assessment already completed with 2 preidentified priority areas (staff recognition and inclusive workplace culture) aligned to agency reaccreditation criteria and workforce development plan. Requested focus groups to assess specific needs/concerns within these priority areas and identify other priority areas that staff/leadership deem as important to address.	Existing agency-wide worksite wellness team (includes health officer). Survey trend analysis requested to inform agency's strategic planning process and inform identification of priority areas.
Analytic approach	Qualitative thematic coding and analysis (inductive)	Qualitative thematic coding and analysis (deductive, in alignment with agency's preidentified priority areas)	Trend analysis of close-ended survey responses; provide recommendations to improve survey questions and flow.
Dissemination of findings	Findings shared back via summary report and presentation to division leadership. Division leadership planned to determine next steps, but a concurrent change in health officer shifted departmental priorities; further outcomes remain pending. Unclear if findings were shared back with focus group participants.	Findings shared back via summary report and presentation to health officer and workforce development committee (HO/WDC). HO/WDC shared the summary of findings with agency staff, including focus group participants; now working on implementing changes and improvements to address identified needs/concerns.	Findings shared back via summary report. Division leadership shared the report with agency-wide worksite wellness team to inform the agency's strategic planning approach as part of a larger longer-term effort toward initial health department accreditation.
Implementation challenges	Inconsistent communication with participants about the pilot and purpose of the focus groups, along with shifting departmental priorities because of county policy changes and interim leadership (a new health officer was appointed after the pilot concluded)	Preidentified priority areas were driven by reaccreditation priorities rather than an employee assessment	Minimal postanalysis follow-up and engagement after survey analysis was completed; survey data from earlier time periods may not reflect current workforce well-being needs and priorities
Thematic illustrative examples from the 3 pilot sites
Theme: communications consistency and transparency	Focus group participant: “I think the number one thing we're missing since COVID is consistency [in communications]… there's a whole lot of flying by the seat of your pants… When you have people depending on you… I should be able to give them consistent answers…”	Focus group participant: “We all are here because we do care. We do want to see things get better. We do want to close gaps… But we can't really do that if we're in our little baby silos… if we were all together on it and being able to talk and have that transparency, then I think our mission would be further.”	Survey finding: “… during [2018–2022] the % of employees who do not believe that incidents and/or accidents that impact workplace health and safety are investigated quickly has continually increased.”
Theme: worker recognition	Focus group participant: “…before COVID, you know… We were recognized. There was Employee of the Month. There was all sorts of recognition for what you do. Now…customers and clients are literally where you get your recognition…”	Focus group participant: “…We've done employee enrichment committees. We've done kudos… We do the Employee of the Year… There have been some employees that do enjoy them, but then there's other employees that ask, well, what does it really matter? It's a mixed bag… regardless of what method we try.”	Survey finding: “From 2017 to 2022, there was an increase in % of respondents indicating that they are not at all likely to be praised by their supervisor or employer when they've done their job well.”
Theme: worker valuation and inclusiveness	Focus group participant: “I feel like the concerns are heard and I'm heard… and it's even taken, like, up the chain, but the feedback that we're getting is that, oh, well, this is the way we've always done it.”	Focus group participants: “Policies are made, things are discussed, and the parties that actually are on the ground doing the things are never really included in a lot of those decisions. And then we're just told, well, here's what you're going to do now.” “…inclusiveness to me… means being able to voice an opinion and be included in decision making that would affect that agency as a whole… being respected for the opinion that you have. I don't think that everyone is allowed to do that…”	Survey finding: “…among employees who indicated that they had a concern or suggestion about workplace health and safety, the % who felt comfortable voicing their concerns and suggestions has increased since 2018…”

Feasibility and utility guided the assessment of pilot success, focusing on each agency's capacity to integrate the guide into existing workflows and generate meaningful conversations and actionable insights. Site-specific themes, priorities, and considerations were summarized and shared with leadership teams to inform follow-up actions within the context of their capacity and existing initiatives, reinforcing that sustainable workforce well-being efforts must be internally driven and structurally embedded. Findings were synthesized across the pilots to identify shared themes and needs. This study received expedited review and approval from the JHU Institutional Review Board.

Results

The 3 Maryland LHDs began the pilot at different stages of workforce well-being advancement and with varying levels of leadership involvement. Two sites had established well-being committees with engaged leadership and sought to integrate well-being into department-wide strategic planning and reaccreditation, respectively. The third site focused efforts within a single division, spearheaded by new division leadership wanting to change work culture. See Table 1 for site-specific details, challenges, and illustrative examples.

Shared successes: what's working

Employees across all pilots demonstrated strong commitment to public health and community service. Staff valued meaningful coworker relationships and client interactions for the job satisfaction and sense of purpose they provided. Despite structural and resource constraints, employees demonstrated resilience and dedication to advancing public health.

Shared needs and challenges: what needs improvement

Shared priority areas across all 3 pilots included communications, leadership, infrastructure, and policies. Pilot participants underscored the need for consistent, transparent, and accountable communication within LHDs and statewide. There was also a desire for leaders at all levels to model a supportive, people-first culture that values workers and prioritizes work-life balance. Systemic changes to organizational infrastructure and policies were emphasized, including expanded leadership and workforce development, career advancement opportunities, improved worker safety and facility maintenance, and more efficient hiring processes.

Discussion

The Putting Our People First discussion guide was piloted with 3 Maryland LHDs to advance workforce well-being. Shared priority areas included consistent and transparent communications, supportive leadership that values employees, and stronger infrastructure and workforce policies.

Although some identified needs were site-specific or reflective of Maryland's shared governance structure, many mirror national workplace trends of declining well-being and rising stress. In the 2023 Work in America Survey, 77% reported work-related stress within the past month,¹² whereas in 2024, 71% of governmental public health workers reported burnout symptoms in the past year.⁴ These findings indicate a workforce in crisis that needs attention.

To better address these challenges and reflect pilot site feedback, the discussion guide is being restructured into modular components, providing a practical tool that complements existing priorities such as accreditation and strategic planning. This streamlined approach is especially critical for agencies experiencing persistent staff burnout and turnover. Modules will include resources and case studies illustrating specific integration points, eg, incorporating staff input mechanisms into accreditation documentation or aligning well-being goals with strategic priorities.

Although modular design supports individual agency action, pilot findings also revealed structural challenges requiring collective action through cross-jurisdictional collaboration or state-level initiatives. For example, 1 pilot site is prioritizing facility and worker safety issues with state and local decision makers, and MACHO, with state support, plans to offer leadership and communications training for all Maryland LHDs. These actions aim to deepen collaboration across Maryland's state and local agencies to improve communication and share workforce culture resources. Additional collaboration opportunities include standardizing hiring practices (eg, shared job classifications, coordinated onboarding) and improving recruitment and retention via shared mentoring programs and cross-jurisdictional fellowships.¹³

When undertaking workforce well-being efforts, agencies should align their approaches with their specific context, needs, and mission. The pilots highlighted that establishing structured processes for acting on concerns is as critical to morale as identifying the concerns. Two elements are critical: (1) visible leadership buy-in and support and (2) translation of employee input into tangible changes. Leadership engagement shapes agency progress from identifying needs to action, enabling greater measurable change and trust-building. Sustaining this progress over time requires embedding this work into organizational structures to withstand leadership turnover and evolving priorities.

Limitations

Findings should be interpreted within several limitations, including the small number of participating agencies, single-state setting, voluntary nature of pilot participation, and absence of quantifiable outcome measures related to burnout, job satisfaction, or retention. Although these limitations may affect generalizability, the findings from this early implementation effort position the discussion guide as a tool to drive critical conversations to advance workforce well-being as a core organizational priority.

Conclusion

Insights from Maryland's pilot of the Putting Our People First discussion guide and subsequent revisions can be adapted for use in public health agencies nationwide, accounting for local context. Prioritizing and investing in workforce well-being and retention is vital to support the workforce, improve job satisfaction, and enable agencies to effectively serve communities amid today's complex and evolving challenges.

Implications for Policy & Practice

• ■ Promote workforce well-being and retention by creating a supportive work environment with clear communication and visible leadership commitment where staff feel valued and employee input drives observable organizational change.

• ■ Set and align workforce well-being priorities and collaborate with other LHDs and the state health department to create shared, sustainable solutions.

• ■ Advance workforce well-being through people-focused workplace policies and practices to maintain a prepared and stable public health system.