Strengthening Laboratory Partnerships, Enhancing Recruitment, and Improving Retention Through Training and Outreach Activities: The Minnesota Experience

Medical laboratory professionals are integral to health care systems in the United States, performing testing to guide clinical care.¹ The need for skilled medical laboratorians has been rising steadily, with increased access to health care and demand for laboratory testing services and increased need for testing and monitoring of chronic diseases.^2,3 The shortage of medical laboratorians is well known; calls to action to address the shortage began in the 1980s.^4,5 This shortage affects clinical laboratories and public health laboratories (PHLs), because both draw from the same applicant pool. In clinical laboratories, medical laboratorians focus on diagnostic testing to guide patient care. At PHLs, medical laboratorians may perform diagnostic testing for less common diseases (eg, tuberculosis or measles). However, the primary focus in PHLs is surveillance and characterization of diseases that affect a population (eg, outbreak detection, antibiotic resistance testing, genotyping). PHLs are also affected by the laboratory workforce shortage, although they may face different challenges than clinical laboratories.⁶

Staffing Challenges Facing the Public Health Laboratory Workforce

The 2018 American Society for Clinical Pathology (ASCP) Vacancy Survey reported an average vacancy rate of 8.6% in US medical laboratories,⁷ up from 7.2% reported in the 2016-2017 ASCP Vacancy Survey.⁸ This vacancy rate is paired with a projected 13% increase in the need for medical laboratorians between 2016 and 2026 (a total of 42 700 vacancies).⁹ Other factors contributing to the projected gap include an aging workforce, low awareness of laboratory science careers, and difficulty retaining qualified staff.¹⁰

One challenge to the recruitment and retention of medical laboratorians is a shortage of qualified applicants. Although the number of certified medical laboratorians increased by 42.0% from 2000 to 2016 (4802 to 6818), the number of new medical laboratorians entering the workforce is not keeping up with future demand.^11,12 Exacerbating this nationwide supply-and-demand problem is a decrease in the number of available training programs.^13,14 According to the 2017 National Accrediting Agency for Clinical Laboratory Science annual survey, there are about 500 accredited medical laboratory programs in the United States, down from more than 1000 programs in 1970.¹² Likewise, the number of clinical laboratory rotations offered for training students in a laboratory facility has decreased.¹⁵ To combat this shortage, programs have reduced the duration of the 4 required rotations from 22 weeks to 12 weeks, which affects the readiness of students to enter the workforce properly trained.^16,17

Another challenge for the PHL workforce is an increased demand for health care services. Clinical laboratories have seen an increase in the demand for testing services as the incidence of chronic conditions rises.^15,18,19 With more persons using health care because of population changes and increased accessibility, the demand for laboratory services has increased, in both clinical care and PHL testing.^6,20 Because they draw from the same candidate pool, the heightened demand in the clinical laboratory sector affects the number of applicants in the PHL sector. Volume of testing performed at PHLs has also increased, with the need to monitor for antibiotic-resistant microbes, testing for less common illnesses (eg, measles, babesia), and advancements in technology allowing detection of a broader panel of chemical compounds and genetic disorders. For example, the number of test results reported from the Minnesota Department of Health (MDH)-PHL Infectious Disease Laboratory (IDL) increased by 35.7% from 2015 to 2017, from 45 281 to 61 429 tests (unpublished data, MDH-PHL).

Further affecting the applicant pool is low awareness of clinical laboratory science.²¹ Career awareness for science, technology, engineering, and mathematics is on the rise, and numerous programs target adolescents in middle school and high school.²² However, most awareness for health care–related careers centers on well-known professions, such as physicians, nurses, and pharmacists. Clinical laboratory work is the “unseen” profession.²¹

Finally, laboratories face challenges in retaining qualified medical laboratorians. According to the 2018 ASCP Vacancy Survey, about 15% of laboratorians are expected to leave the workforce by 2023.⁷ A 2016 Association of Public Health Laboratories (APHL) survey estimated that 30% of state public health laboratorians would leave the workforce by 2021.²³ Among non–retirement-age laboratorians, the most frequently cited issues related to staff retention were limited career mobility and noncompetitive salaries.²³ In addition, new millennials entering the workforce do not expect to stay long at any one job.²⁴ The 2016 APHL survey found that employees aged <35 who were satisfied with their work environment or valued the salary, benefits package, or flexible work schedule found at their PHL were less likely to report an intent to leave PHL practice within 5 years than employees who were dissatisfied with these factors.²³ This intent to stay in a job indicates that job satisfaction also affects vacancy rates, because retention and recruitment initiatives are negatively affected by staff members who are dissatisfied with their work.

How MDH-PHL Is Addressing This Shortage

In Minnesota, the total number of PHL staff members was constant from 2013 to 2017, whereas the number of tests reported increased by 35.7% in the IDL section alone. The vacancy rate for MDH-PHL in 2016 was 21%, based on the number of open positions and total number of positions. MDH-PHL uses numerous strategies to counteract the shortfall in qualified staff members. Training and outreach activities target all education levels and include school projects, classroom-level training, hands-on laboratory training, and internships. These activities are designed to raise awareness about laboratory careers in public health while allowing internal staff members to refine their skills and take a leadership role in developing curriculum. These efforts may help retain current employees by improving job satisfaction through staff development.

From 2016 through 2018, MDH-PHL hosted 7 high school students. Students worked on small projects throughout the laboratory and met with epidemiologists and laboratory staff members to discuss career opportunities. MDH-PHL also participates in Scrubs Camp.²⁵ The project, sponsored by Health Force Minnesota and Minnesota State Colleges and Universities, introduces middle school and high school students to various health science careers. Students interact directly with health care professionals and industry partners, including clinical laboratorians and public health laboratorians. Because these students have not entered the workforce, it is too soon to tell whether these efforts will increase recruitment to the PHL. However, these efforts raise awareness of the PHL as a place to work at and allow students to learn about the educational requirements and technical skills needed before they begin their college education.

To give college students an in-depth look at a career in PHL science, MDH-PHL routinely hosts student interns, student workers, and fellows. Internships and fellowships provide opportunities to work with a laboratory mentor on a project, and student worker positions involve students in routine laboratory functions. Agency-wide, 104 of 1550 (6.7%) MDH employees began as student workers (MDH, unpublished data). In the PHL, 5 of 155 (3.2%) current employees began working at MDH as students, including the current IDL section manager, who started as an undergraduate student worker and completed a doctor of philosophy degree before returning to MDH (MDH-PHL, unpublished data). The success of these student work opportunities is measured by the number of students who return for full-time employment at MDH as positions become available, either in the laboratory or elsewhere in the agency. Many student interns are pursuing careers in epidemiology and use the opportunity to better understand the role of the laboratory in public health.

MDH-PHL has offered clinical laboratory rotations for undergraduate students pursuing degrees in medical laboratory science since 2009. Students are at MDH-PHL for 3 weeks, working with staff members in all areas of the laboratory. They focus on learning hands-on laboratory skills in microbiology and virology, as well as learning molecular surveillance techniques and emergency preparedness activities. They meet with epidemiology partners to understand how laboratory testing helps identify outbreaks and affects surveillance activities. Two current IDL staff members completed their medical laboratory science microbiology rotations at MDH-PHL. Many of the students who had clinical rotations now work in clinical laboratories throughout Minnesota. Their experience at MDH-PHL provides them with a better understanding of the importance of their work and its relationship to public health.

MDH-PHL has also hosted fellows with master’s degrees, doctor of philosophy degrees, or doctor of medicine degrees. Fellowships are supported by APHL, the Centers for Disease Control and Prevention, the Department of Energy, and partnerships with medical facilities in Minnesota. Depending on program length, fellows work on projects, participate in routine laboratory functions, and meet with epidemiology subject matter experts. Four of 65 (6.1%) current full-time employees in the IDL were fellows at MDH-PHL. The current PHL director was a training fellow in the IDL.

In addition to educational opportunities, from July 1, 2016, through June 30, 2017, MDH-PHL developed and hosted 8 national and local trainings for 509 clinical and public health laboratorians from Minnesota and across the country. Topics included biosafety, bioinformatics, antibiotic resistance, and hands-on laboratory training to recognize potential bioterrorism agents and refer them to MDH-PHL for identification. These activities benefited the trainees by raising career awareness and providing training required for ASCP certification. By hosting such trainings, MDH-PHL supports its recruitment and retention efforts. Historically, 4 staff members have been hired at MDH-PHL after attending training outreach activities. Current PHL staff members also benefit from the opportunity to mentor and train new laboratorians. For many staff members, opportunities to continue their education and training through mentoring activities may contribute to their job satisfaction.²³

Staff retention is important for combating the workforce shortage. Although limited in salary and career mobility compared with clinical laboratories, MDH-PHL has found other ways to increase job satisfaction and retain staff members. Laboratorians may create an individualized development plan, allowing staff members to maximize job duties that play to their strengths, prioritize learning objectives, and identify leadership opportunities. Staff members are encouraged to help plan and develop the projects they work on, rather than merely providing laboratory data. A 2018 MDH employee survey indicated that the areas that most affect job satisfaction are “stretch” assignments that challenge their abilities, such as mentoring assignments, short-term projects, and career development opportunities. Of 122 PHL respondents, 73 (60%) indicated that these areas most heavily affected employee job satisfaction.

Current nonsupervisory staff members are encouraged to consider participating in the MDH Everyday Leaders Program (ELP). This 10-month program is coordinated by the MDH Human Resources Management division to provide leadership training to staff members agency-wide. Classes include conflict resolution, team building, collaboration, coaching, and career development planning, and participants complete a group project that addresses an agency-wide initiative. From its inception in 2009 through 2017, 170 MDH staff members participated in the training, including 27 (15.9%) from the PHL. Of the 27 PHL employees who participated in ELP, 20 (74.1%) were promoted at least one classification level since participation and 4 moved into supervisory positions (MDH, unpublished data). In comparison, 73 of 149 (49.0%) MDH-PHL non-ELP participants were promoted during this timeframe (MDH, unpublished data). Although program participation positively affects career mobility, the program’s success comes with several caveats. First, because of the employee information tracking mechanism, data are not available for employees who left MDH but did not participate in ELP, making it difficult to compare historical retention rates between the 2 groups (ELP participants and nonparticipants). Second, it is possible that persons who participated in ELP would have had similar career mobility without participating in the program. Finally, career advancement in the laboratory is limited, as evidenced by 2 ELP participants who left MDH-PHL to pursue career advancement opportunities elsewhere in the public health sector.

In the process of implementing recruitment and training approaches at MDH-PHL, we identified several lessons learned and areas for improvement. One area in need of improvement is that MDH-PHL currently waits for groups to approach it for education and training. MDH-PHL plans to seek younger students more actively, to provide educational experiences that expose middle school and early high school students to the field of public health.

The initiatives described take time to coordinate and implement. Hosting students, whether summer projects, internships, clinical rotations, or training activities, requires an investment of time from staff members to teach new skills and to guide projects. The return on investment may not be immediate, and some tasks may need to be redirected while the trainee is learning. However, a benefit is that trainees can be hired, as MDH-PHL has done with several training participants. Funding for new positions is not always available to hire a promising trainee, but establishing trainees’ interest in the PHL and maintaining contact with past trainees provide opportunities for future hiring.

MDH-PHL has taken advantage of the ELP to grow the next generation of laboratory leaders, consistently sending 2 or more staff members each year to participate. It requires an investment of time away from technical work, with the benefit of enhancing nontechnical leadership skills. A limitation to this program is that staff members still reach the top of their job classification with few options for career advancement. Initiatives to address this limitation are underway (eg, expanding job classification series).

MDH-PHL is not alone in experiencing recruitment and retention issues. The fall 2018 edition of APHL’s Lab Matters newsletter describes approaches that other PHLs have used to address these challenges.²⁶ The Texas state PHL implemented a job shadowing program that allows staff members to observe a trained and experienced employee on a given task (Grace Kubin, personal communication; see also Monahan et al²⁷ for an example). This program provides an opportunity for staff members to learn about different areas of the laboratory and connects staff members in a way that may not otherwise occur. In Tampa, Florida, senior PHL staff members shadow a bench laboratorian for a day to see how the work is changing and how improvements can be made.²⁶ Another example is a program implemented at the Washington, DC, PHL that recognized the value of frequent “rewards” for staff members with events such as a family day, yearly awards program, and an agency-wide crab feast.²⁶ To increase career awareness among younger students, the State Hygienic Laboratory at the University of Iowa offers a robust mentorship program for junior and senior high school students.²⁸ Other ideas for engaging staff members include encouraging younger generations of laboratorians to investigate new technologies or help enhance a laboratory’s social media presence.²⁶

With laboratory workforce shortages predicted to continue through at least 2026, recruitment and retention of qualified staff members is important. To address this shortage, MDH-PHL couples recruitment and retention activities with training and outreach activities held throughout the year. Training activities strengthen partnerships with clinical laboratory partners and allow trainees to gain competence in all areas and at multiple levels in the laboratory. Outreach to undergraduate- and graduate-level trainees aids in recruitment and retention efforts by introducing new trainees to public health and providing staff leadership and training opportunities. By nurturing collaboration with laboratory partners and providing current staff members with continuing development opportunities, Minnesota is able to stay ahead of workforce recruitment issues and retain current staff members. These practices, which have helped MDH-PHL overcome workforce challenges, can be used by others to overcome challenges in their own laboratories.