Creating Customized Workforce Development Plans for Medium-to-Large Public Health Departments

Abstract

Objectives:

The objectives of our study were to (1) illustrate a public health workforce assessment process in a medium-sized city or county health department and (2) demonstrate the insights gained by moving from the use of aggregate department-level and competency domain-level training needs results to more granular division-level and skills-level results when creating a workforce development plan.

Methods:

We used a 130-question needs assessment to guide the creation of a workforce development plan for the Lincoln Lancaster County Health Department (LLCHD) in Nebraska and its 7 divisions. Using SurveyMonkey, we administered the survey to 128 (of the 129) LLCHD public health staff members in June 2015. Using a Likert scale, respondents indicated (1) the importance of the skill to their work and (2) their capacity to carry out 57 skills in 8 domains of the core competencies for public health professionals. We identified training needs as those for which the percentage of respondents who perceived moderate-to-high importance was at least 15 percentage points higher than the percentage of respondents who perceived moderate-to-high capacity.

Results:

LLCHD as a department had training needs in only 2 competency domains: financial planning and management (importance-capacity difference, 15 percentage points) and policy development and program planning (importance-capacity difference, 19 percentage points). The Health Promotion and Outreach division had training needs in all 8 domains (importance-capacity difference range, 15-45 percentage points). Of the 57 skills, 41 were identified by at least 1 of the LLCHD divisions as having training needs. In 24 instances, a division did not qualify as having training needs in the overall domain yet did have training needs for specific skills within a domain.

Conclusions:

When performing public health workforce assessments, medium-to-large public health departments can obtain detailed workforce training needs results that pertain to individual skills and that are tailored to each of their divisions. These results may help customize and improve workforce development plans, ensuring that the workforce has the necessary skills to do its job.

The public health field is changing rapidly, and new public health challenges require public health providers to continuously build their competence and capacity. For decades, the Institute of Medicine has called for the public health workforce to pursue the education and training necessary to perform its many roles.^1,2 The Institute of Medicine has also emphasized the importance of assessing gaps in public health workforce knowledge and skills, and it has indicated that public health agencies are responsible for both identifying workforce education and training needs and creating plans to address those needs.³

In line with this call, various organizations have initiated programs involving not only public health workforce training but also ongoing assessments of training needs and gaps in skills. In 1999, the Health Resources and Services Administration established 10 Regional Public Health Training Centers. One of the program’s legislative mandates was that each regional center continually assess the education and training needs of the public health workforce in the state or region that it serves. Through the years, Regional Public Health Training Centers have led numerous statewide education and training assessments, primarily by using the Council on Linkages Between Academia and Public Health Practice Core Competencies for Public Health Professionals (hereinafter, core competencies) as their standard for evaluating skills.⁴ These core competencies are organized into 8 domains, each of which has multiple skill areas or competencies.

However, these assessments have weaknesses. First, because they have typically been conducted for an entire state or region of the country, results of training needs have been reported in aggregate for all public health professionals in the state or region, although these professionals may represent various public health departments and disciplines. The results often have been presented as part of a state training plan, and they have used aggregate data. This means that these plans might identify the same education and training needs for professionals who work in widely different settings (eg, for a professional working as a health educator in a small rural health department),^5-8 even though the needs of these professionals likely differ. Second, Regional Public Health Training Centers lack the authority to require that public health agencies address gaps in training identified by the assessments. Third, few results from these assessments have been published.⁹

More recently, another organization has begun to provide comprehensive examinations of training needs for various health departments. In 2015, the de Beaumont Foundation, in partnership with the Association of State and Territorial Health Officials, published the results of its Public Health Workforce Interests and Needs Survey.¹⁰ The main goals of this project were to (1) identify trends in workforce attitudes, morale, and climate and (2) build an evidence base of training needs and gaps in skills for the entire US public health workforce. However, similar to the Regional Public Health Training Center Program assessments, the results have been reported in aggregate for entire health departments; as such, training needs in various departmental divisions have not been assessed.¹⁰

Since 2015, faculty and staff members of the University of Nebraska Medical Center (UNMC) College of Public Health have administered education and training assessments for 15 local and state health departments in Nebraska, primarily to help them achieve national accreditation. The Public Health Accreditation Board, the national accrediting body for state, tribal, and local health departments, was launched in 2017. Among the Board’s expectations for all public health departments that seek accreditation is that they ensure a competent workforce, complete assessments of staff competencies, offer individual training and professional development, and provide a supportive work environment.¹¹

The objectives of this study were to (1) illustrate our public health workforce training needs assessment process and (2) suggest ways that these results can be used to create a workforce development plan. For this study, we used a single medium-sized city/county health department with a structure similar to that of other medium-to-large local health departments in the United States. We also share insights gained by moving from the use of aggregate department-level and core competencies domain-level results of training needs to the use of more granular division-level and core competencies skills-level results when creating a workforce development plan.

Methods

For this study, we used a cross-sectional survey design and followed the principles of practice-based systems research. These principles involve systematic inquiry into the systems, methods, policies, and programmatic applications of public health practice, with the goal of improving the quality, performance, efficiency, and effectiveness of public health systems that affect community health outcomes.¹² The UNMC Institutional Review Board considered this study to be a quality improvement project and declared that it was non-human subjects research.

We worked with the Lincoln Lancaster County Health Department (LLCHD) in Lincoln, Nebraska, for this study. LLCHD is a medium-sized city/county health department that serves a population >314 000. Of 155 staff members working at LLCHD in 2015, 26 were administrative and 129 were professional. The 129 professional staff members worked in the following divisions: (1) Animal Control, (2) Community Health Services, (3) Dental Health and Nutrition, (4) Environmental Public Health, (5) Health Data and Evaluation, (6) Health Promotion and Outreach, and (7) Information and Fiscal Management, as well as in the Director’s Office.

In this study, we used a training needs assessment tool to guide the creation of a workforce development plan for LLCHD. The tool allowed us to (1) assess the capacity and capability of the professional public health workforce, (2) determine gaps in capacity and capability that might warrant additional training and education, and (3) help establish workforce training and education priorities for LLCHD. The tool was initially developed by Grimm et al⁹ to assess the training and education needs of local and state health department staff members.

We administered the tool, a survey that contained 130 questions in 3 sections, by using SurveyMonkey. An email explained the purpose of the survey, outlined the potential benefits and risks of taking it, and emphasized that respondents would remain anonymous. The health department director sent the email with the survey link to all 129 LLCHD professional staff members. The survey was available for 4 weeks during June, and 2 reminder emails were sent to all staff members.

Section 1 of the survey inquired about 57 skills in 8 core competency domains¹³: (1) analytical and assessment, (2) basic public health sciences, (3) cultural competency, (4) communication, (5) community dimensions of practice, (6) financial planning and management, (7) leadership and systems thinking, and (8) policy development and program planning. For the 57 skills, respondents indicated the level of importance of the skill to their work by using a 5-point Likert scale (0 = not applicable or I don’t know, 1 = not at all important, 2 = slightly important, 3 = moderately important, and 4 = highly important). Respondents also assessed their capacity to carry out the skills by using a 5-point Likert scale (0 = not applicable or I don’t know, 1 = I am unaware or have very little knowledge of the item, 2 = I have heard of it but have limited knowledge and/or ability to apply the skill, 3 = I am comfortable with knowledge or ability to apply the skill, and 4 = I am very comfortable, an expert, and could teach this skill to others). For both importance and perceived capacity, we combined responses of 1 or 2 into a “low” category and responses of 3 or 4 into a “moderate-to-high” category. We excluded responses of 0 from analysis and reported them as missing data. Next, for each of the 57 skills, we calculated the percentages of all respondents who perceived the skill to be of low importance, low capacity, moderate-to-high importance, and moderate-to-high capacity.

We defined the skills (and domains) for which training and education were needed as those for which the percentage of respondents perceiving moderate-to-high importance was at least 15 percentage points higher than the percentage of respondents perceiving moderate-to-high capacity. We selected 15 percentage points because we wanted a cutoff that would ensure having enough skills from which to choose when developing the workforce development plan, but not so many that the number would be overwhelming. We also used this cutoff in a previous study.⁹ We combined these percentage results for each skill by domain and applied the same definition.

Subsequently, we provided a workforce development (education and training) report for the health department as a whole and for each division. These reports identified training needs and included graphs of the results for each of the 8 core competency domains. To ensure confidentiality, we did not give these reports to divisions with ≤5 professional staff members.

Section 2 of the survey included questions about preferred modes and settings for delivery of educational programs, and Section 3 included questions about demographic characteristics.

Results

One hundred twenty-eight of 129 (99.2%) professional LLCHD staff members responded to the survey (Table 1). Of 125 respondents who indicated their years of experience at LLCHD, 64 (51.2%) had worked at the department for more than 10 years, of whom 33 (51.6%) had worked there for more than 20 years. Of 127 staff members who responded to a question about retirement, 22 (17.3%) planned to retire within 5 years and 38 (29.9%) planned to retire within 10 years.

Table 1.

Work-related and educational characteristics of 128 professional public health staff members responding to a needs assessment tool^a at the Lincoln Lancaster County Health Department (LLCHD), Lincoln, Nebraska, June 2015

Characteristics	Respondents, No. (%)
Division of employment at LLCHD (n = 128)
Animal Control	9 (7.0)
Community Health Services	35 (27.3)
Dental Health and Nutrition	18 (14.1)
Environmental Public Health	34 (26.6)
Health Data and Informatics	9 (7.0)
Health Promotion and Outreach	14 (10.9)
Information and Fiscal Management	7 (5.5)
Director’s Office	2 (1.6)
Education (n = 126)
High school/GED	11 (8.7)
Associate’s degree	13 (10.3)
Bachelor’s degree	67 (53.2)
Graduate certificate	4 (3.2)
Master’s degree	27 (21.4)
Doctoral degree (MD, JD, PharmD)	4 (3.2)
Time working at LLCHD (n = 125), y
0-2	27 (21.6)
3-5	18 (14.4)
6-10	16 (12.8)
11-20	31 (24.8)
>20	33 (26.4)
Estimated time until retirement (n = 127), y
0-2	8 (6.3)
3-5	14 (11.0)
6-10	16 (12.6)
>10	56 (44.1)
Not sure	33 (26.0)

Abbreviations: GED, general educational development; JD, juris doctor; MD, doctor of medicine; PharmD, doctor of pharmacy.

^aNeeds assessment tool initially developed by Grimm et al to assess education and training needs of local and state health department staff members.⁹ The tool was a survey that contained 130 questions and was administered by using SurveyMonkey.

We applied our criteria for determining training needs (moderate-to-high importance at least 15 percentage points higher than moderate-to-high capacity) to all 57 skills in the 8 core competencies domains. As an entire department, LLCHD had training needs in only the financial planning and management (importance-capacity difference, 15 percentage points) and the policy development and program planning (19 percentage points) domains (Table 2). When we analyzed these data by division, domain-level training needs ranged from all 8 domains for the Health Promotion and Outreach division to no domain-level training needs for the Animal Control division.

Table 2.

Perceptions of public health professional core competency domains,^a by domain and division, based on a needs assessment tool^b administered to 128 public health professionals at the Lincoln Lancaster County Health Department, Lincoln, Nebraska, June 2015

Core Competencies Domainsa	Percentage-Point Differences Between Respondents Perceiving Moderate-to-High Domain Importance and Capacityc
	LLCHD	LLCHD Division
		Animal Control	Community Health Services	Dental Health and Nutrition	Environmental Public Health	Health Data and Informatics	Health Promotion and Outreach	Information and Fiscal Management
Analytical and assessment	10	0	6	14	15	0	23	0
Basic public health sciences	14	0	13	27	15	15	19	21
Cultural competency	12	0	13	9	16	6	37	3
Communication	9	9	0	0	13	14	25	14
Community dimensions of practice	12	0	15	22	9	8	15	26
Financial planning and management	15	0	25	25	14	0	29	29
Leadership and systems thinking	9	0	7	12	7	13	21	4
Policy development and program planning	19	5	11	37	20	10	45	4

^aCore competencies for public health professionals include 57 skills organized into 8 domains.¹³

^bThe needs assessment tool (a survey) was initially developed by Grimm et al⁹ to assess education and training needs of local and state health department staff members.⁹ The survey contained 130 questions and was administered by using SurveyMonkey.

^cFor each of 57 skills, respondents indicated the level of importance to their work and the degree to which they were capable of carrying out the skill (perceived capacity). The need for training and education in a domain was defined as the percentage of respondents who perceived the domain to be of moderate-to-high importance (level of importance to their work) being at least 15 percentage points higher than the percentage of respondents who perceived the domain to be of moderate-to-high capacity (degree to which they were capable of carrying out the skill).

Of the 57 skills, 41 were identified by at least 1 division as having training needs (Table 3). The skill identified as having training needs by the most divisions (n = 6) was “identify the 10 essential services of public health” (from the basic public health sciences domain). Of 124 respondents, 69 (56%) indicated that the 6 skills in the financial planning and management domain were not applicable to their work, invalidating the identification of training needs in this domain. Finally, we found 24 of 32 possible occurrences in which divisions that did not qualify as having training needs in certain domains still had training needs for skills in those domains.

Table 3.

Public health professional core competency skills^a for which training and education are needed, by domain and division, based on a needs assessment tool^b administered to 128 public health professionals at the Lincoln Lancaster County Health Department, Lincoln, Nebraska, June 2015

Core Competency Skillsc and Domainsd	LLCHD	LLCHD Divisions
		Animal Control	Community Health Services	Dental Health and Nutrition	Environmental Public Health	Health Data and Informatics	Health Promotion and Outreach	Information and Fiscal Management
Analytical and assessment domain (n = 5 of 6 possible skills)
Identify factors to measure public health conditions	X			X	Xe		Xe
Use public health data and information in daily work				X	e		e
Distill results from data relevant to the community or population served				X	e		Xe	X
Use information technology (ie, databases) to collect, store, and retrieve data					Xe		Xe
Use ethical principles in the collection, maintenance, use, and dissemination of data and information					Xe		e
Basic public health sciences domain (n = 4 of 5 possible skills)
Identify the 10 essential services of public health	X		X	Xe	Xe	Xe	Xe	X
Know whom to contact or where to find laws, regulations, and procedures for research, surveillance, and evaluation	X		X	Xe	e	e	e	X
Locate and use scientific evidence to address a public health issue, concern, or intervention	X	X	X	Xe	e	e	Xe	X
Describe the core public health functions (ie, assessment, assurance, and policy development)				e	Xe	Xe	Xe
Cultural competency domain (n = 6 of 6 possible skills)
Assess public health programs for their cultural competence	X		X	X	Xe		Xe	X
Respond to diverse needs that are the result of cultural differences	X			X	Xe		Xe
Explain the dynamic forces that contribute to cultural diversity			X		e		Xe
Consider the role of cultural, social, and behavioral factors in the accessibility, availability, acceptability, and delivery of public health services				X	e		e
Describe the needs for a diverse public health workforce					Xe		e
Incorporate strategies for interacting with persons from diverse backgrounds					e	X	e
Communication domain (n = 6 of 8 possible skills)
Assess the health literacy of populations served (Can the population understand the information provided?)	X	X			X	X	Xe	X
Use a variety of social media approaches to disseminate public health information	X	X				X	e
Develop health information at appropriate literacy levels		X			X	X	e
Apply appropriate group facilitation techniques					X		e	X
Use a variety of print approaches to disseminate public health information						X	Xe
Present scientific information for use by professional and lay audiences							Xe	X
Community dimensions of practice domain (n = 7 of 7 possible skills)
Use appropriate facilitation techniques to encourage community involvement	X		e	Xe	X	X	Xe	e
Develop and maintain productive partnerships with key stakeholders		X	e	Xe			e	e
Ensure participation of key stakeholders			Xe	Xe			Xe	e
Use community input when developing public health policies and programs			Xe	e	X		e	Xe
Promote the health department’s policies, programs, and resources to communities or populations served			e	e		X	e	Xe
Distinguish the role of governmental and nongovernmental organizations in the public health system			Xe	e			Xe	Xe
Inquire about and use available community assets and resources			e	e			e	Xe
Leadership and systems thinking domain (n = 5 of 8 possible skills)
Be aware of internal and external influences that may affect the delivery of public health services	X			X			Xe	X
Modify individual practices with changing social, political, and/or economic situations	X		X		X		Xe
Participate with stakeholders to identify key values and a shared vision for the benefit of communities or populations served				X			e	X
Describe how my individual program or division fits into the overall mission of the health department				X		X	e
Be able to participate in and resolve conflict productively							Xe
Policy development and program planning domain (n = 8 of 11 possible skills)
Implement strategies for continuous quality improvement	Xe		X		Xe		Xe	X
Develop strategies for continuous quality improvement	Xe				Xe		Xe	X
Develop evaluation plans to monitor programs for their effectiveness and quality	Xe		X	e	X		e
Develop work plans to implement policies	e		X	Xe	e		e
Locate and apply information relevant to public health policy issues (eg, procedures, regulations, and laws)	e			Xe	e		e
Use evaluation results (internal or external) to improve programs	e	X		e	e	X	e
Conduct program evaluations	e	X		e	e		Xe
Develop work plans to implement programs	e	X		Xe	e		e

Abbreviation: X, identifies a training need for the skill.

^aThe core competencies for public health professionals include 57 skills organized into 8 domains.¹³

^bThe needs assessment tool (a survey) was initially developed by Grimm et al⁹ and was administered by using SurveyMonkey.

^cFor each of 57 skills, respondents indicated the level of importance to their work and the degree to which they were capable of carrying out the skill (capacity) on a 5-point Likert scale, from 0 (not applicable or I don’t know) to 4 (highly important). Responses of 1 or 2 were categorized as “low,” and responses of 3 or 4 were categorized as “moderate to high”; the percentages of all respondents who perceived the skill to be of moderate-to-high importance and of those who perceived it to be of moderate-to-high capacity were determined. The need for training and education in a skill was then defined as when the percentage of respondents who perceived the skill to be of moderate-to-high importance was at least 15 percentage points higher than the percentage of respondents who perceived the skill to be of moderate-to-high capacity (marked with an “X”). If the need for training and education in a skill was not identified by even 1 division, then that skill was not listed in the table.

^dThe percentage results for each skill were combined by domain. The need for training and education in a domain was then defined as when the percentage of respondents who perceived the domain to be of moderate-to-high importance was at least 15 percentage points higher than the percentage of respondents who perceived the domain to be of moderate-to-high capacity (for each division determined to be a domain training need).

^eIdentifies a training need for the entire domain.

^fFor the financial planning and management domain, 56% (69 of 124) of respondents indicated that each skill in this domain was not applicable to their work, thereby invalidating the identification of training needs in this domain.

Discussion

An estimated 40% of local health department staff members in the United States will retire within the next decade.¹⁴ We found that nearly half of LLCHD professional staff members planned to retire within the next decade. Such workforce turnover will require that local health departments continually monitor the knowledge, skills, and abilities of their workforces, and that these departments develop and implement workforce development plans.¹⁵ These plans will need to include strategic approaches to the education and training of not only new staff members but also existing staff members, particularly those moving into more senior leadership positions.

These workforce development plans will need to be based on accurate assessments of workforce skills and training needs. Previous education and training assessments have fallen short for the following reasons: They have been conducted only in state health departments, they have lumped state and local health departments together, they have provided results only at the level of domains (and not the individual skill level), or they have been used to offer one-size-fits-all solutions.^5-10 However, we found that the gaps and training needs determined for LLCHD as a whole or for domains (and not the individual skills in each domain) did not tell the entire story. For example, for LLCHD as a whole, we identified training needs in only 2 of 8 domains. However, the health promotion and outreach division of LLCHD had training needs in all 8 domains. Thus, if the health department developed its workforce training plan based solely on data at the department level, subsequent training opportunities offered to staff members, particularly in the Health Promotion and Outreach division, would not address all of their needs or be comprehensive.

In addition to finding differences in the domain-level training needs between the department and its divisions, these needs varied when we compared the 7 LLCHD divisions, ranging from training needs in 0 domains in the Animal Control division to training needs in 8 domains in the Health Promotion and Outreach division. Perhaps more importantly, several divisions that did not qualify as having training needs in certain domains had skill-level training needs in those domains. Because each division in a health department is likely to have unique skill-level training needs, assessments that provide only domain-level results may not provide enough information to be used for workforce development planning.

Ensuring a competent health department workforce requires more than just defining training needs in skills and divisions. Health department leaders should also commit to taking the results of an assessment such as the LLCHD assessment and creating a workforce development plan tailored to each division. In creating the plan, leaders and their teams should identify high-priority gaps in skills to address. Identifying these gaps can help health departments determine how to invest their time and financial resources and which high-quality training opportunities to offer. In crafting the plan, leaders should also consider preexisting training opportunities, such as through the Public Health Foundation’s Training Finder Real-Time Affiliate Integrated Network Learning Network and the Regional Public Health Training Centers Program, which provide education and training options for staff members with diverse learning styles. In developing the plan, leaders should also be aware of training and education activities in which some staff members already regularly participate (eg, conferences, webinars, programs to meet licensure requirements). Health departments could partner with their local schools or programs of public health to assist with this part of the process. For their part, staff members should seek guidance on how to be intentional about the educational courses and programs they choose, how to improve documentation when they attend training and education activities, and how to include in that documentation a linkage to the skills that these activities cover. Organizations that offer educational opportunities or conferences, such as state public health associations, could also help with these processes by being aware of the skills that local health departments have prioritized for training each year and by linking their course or conference learning outcomes to as many of these skills as possible. Each small step could help improve the quality of health department workforces.

Local health departments should continually reassess their workforce capacity and document any changes in that capacity. The workforce development plan that we created for LLCHD was a 3-year plan (2016-2019). We plan to repeat this process in 2019 to assess any changes in capacity in those skills for which training was deemed a priority. We expect that focused training opportunities that target the skills-level training needs identified by each division at LLCHD will improve the capacity and satisfaction of its department workforce.

Our results make a strong case for a workforce development strategy that is more focused on training, that is customized for both skills and departmental divisions, and is less focused on entire department and staff member training that is not relevant for all staff members and divisions. This strategy would allow health department leaders to identify skills in the domains in which staff members need additional training, better focus training offered to staff members in each division, avoid offering training to staff members who do not need it, and use scarce training resources more efficiently.

Limitations

This study had several limitations. First, a comprehensive assessment process requires a substantial investment of time and energy from health department staff members. The high response rate and the quality of the responses we obtained may have been due at least in part to participants being aware that the resulting workforce development plan would be used by LLCHD to fulfill one of the requirements for national health department accreditation. Response rates may not be as high at another organization that chooses to implement the same assessment. Second, the assessment tool relied on perception-based responses, which may be biased when assessing personal skills. Third, the assessment tool that we used was not as robust as the Public Health Workforce Interests and Needs Survey, which provides a comprehensive examination of aggregate training needs for various health departments. However, our assessment tool appeared to allow for a deeper examination of these needs at the division and individual skill levels. Fourth, the process that we described may not translate well to health departments with smaller staffs. In 2018 and 2019, we attempted to perform a similar assessment for a smaller rural health department and found that although we were able to provide results on training needs at the skill level, the small number of divisions and staff members made it virtually impossible to keep responses confidential.

Conclusions

When performing public health workforce assessments, medium-to-large public health departments can obtain detailed results on workforce training needs that pertain to core competencies skills and are tailored to each division in their department. Such detailed results may help health departments customize and improve the quality of workforce development plans, which in turn may help ensure that the public health workforce has the necessary skills to do its job.