We must practice what we preach: a framework to promote well-being and sustainable performance in the public health workforce in the United States

Abstract

The COVID-19 pandemic, along with efforts to address systemic racism and social injustice, has required the public health workforce to mobilize an unprecedented and extensive frontline response while simultaneously delivering core services and addressing natural disasters and other emergent threats. Research conducted among health care professionals during the COVID-19 pandemic indicates an increase in anxiety, depression, and burnout, but mental health effects of the pandemic on the public health workforce are less well understood. Left unaddressed, secondary traumatic stress resulting from exposure to the trauma of those we serve, as well as burnout stemming from work-related factors, may hinder our ability to fulfill our mission to serve the population at large. This Viewpoint provides a framework for shifting our culture to prioritize the well-being and sustainable performance of the public health workforce to foster resilience and mitigate stressors.

Key message

1. The public health workforce in the United States is reporting increased levels of burnout as a result of the pandemic.

2. The prolonged nature of the pandemic has increased work urgency and scope, while further straining resources.

3. Effective approaches for the mitigation of workplace stressors prevention and management of secondary traumatic stress and burnout must incorporate action at multiple levels.

Introduction

The well-being of public health professionals has undoubtedly been impacted by the overlapping effects of a global pandemic and critical efforts to address racial and social injustice. The nature and extent of this impact across all sectors of public health, however, is not well understood. In a 2020 study of frontline workers focused and prevention and management of COVID-19 in China, one in five reported depression or anxiety, or both, and having worked through the night for at least 3 days in February–March 2020 [1]. A survey of workers in epidemiology and other areas of public health practice in the United States (U.S.) conducted in August–September 2020 found that two-thirds of respondents were experiencing burnout, with a greater prevalence among those who had been in their role for 1 to 4 years (as opposed to less than one), and those who worked in academia (as opposed to practice) [2]. The number of state public health department respondents in the U.S. who reported intentions to leave their organizations in the next year increased from one in four in 2014 to one in three in 2017 [3], with one in four citing stress or work overload and burnout as contributing factors in 2017. Intentions to leave these positions increased further in September 2021 amidst the COVID-19 pandemic [2].

Public health professionals are faced with many pressures as COVID-19 increases the urgency and scope of their work and reduces their capacity to carry out core services [4]. The effects of this ongoing crisis on economic stability, food security, stress, and health services will likely influence health outcomes such as chronic disease [5], requiring a long-term response. It is imperative to attend to the well-being of public health professionals. The purpose of this Viewpoint is to examine contributors to stress and burnout and highlight existing efforts to address these issues in the US. It will present a framework for a multilevel systemic approach to promote well-being and sustainable performance among those who serve to protect population health.

Stress and burnout in public health professionals in the United States

It is critical to understand how the effects of the pandemic, as well as concurrent events of social unrest and political turmoil, may exacerbate pre-existing stressors among public health professionals. Public health in the U.S. focuses on efforts at the population level, with the workforce spanning multiple sectors including local and state health departments, universities, and nonprofit organizations. Public health capacity was a concern prior to the pandemic, due to funding cuts and an increase in workers’ plans to leave their jobs [6]. Professionals of color are underrepresented in public health, particularly in leadership roles, even as we serve an increasingly diverse population [7]. They report lower satisfaction with their roles, compensation, and supervisor support of work-life balance compared to their non-Hispanic white peers. They are subject to ongoing effects of systemic racism and social injustice while working in a field intended to address these issues [8]. During the pandemic, efforts to reduce deaths and protect the most vulnerable, such as recommendations to wear masks, physically distance, and stay-at-home orders, are increasingly politicized. Many public health officials, particularly in leadership roles, have resigned, citing work overload, scrutiny, and pressure to prioritize individual rights over the common good [9, 10]. Some have received death threats.

A major stressor among helping professionals is exposure to the traumatic experiences of the populations they serve. This can lead to secondary traumatic stress (STS) [11] with symptoms similar to those of post-traumatic stress disorder[12], including intrusive thoughts, avoidance, and hyperarousal when exposed to stressful stimuli, if steps are not taken to establish boundaries between one’s own emotions and those of the person in care. Secondary traumatic stress arises in a relationship; burnout is rooted in how one’s work is organized or delivered. Burnout refers to the long-term effects of chronic stress driven by emotional and interpersonal stressors at work [13]. The World Health Organization’s International Classification of Diseases (ICD-11) for standardizing diagnoses, identifying health trends, and in the U.S. for billing, now classify burnout as an occupational phenomenon:

“a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” occurring across three dimensions: 1) “feelings of energy depletion or exhaustion”; 2) “increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job”; and 3) “reduced professional efficacy” [14].

Burnout can lead to outcomes such as anxiety, depression, coronary heart disease and premature mortality [15, 16]. Stress and emotional exhaustion, a dimension of burnout, predicted secondary traumatic stress among health care workers during COVID-19 [17].

Strategies to prevent and manage burnout

Strategies to manage stress and prevent burnout often foster resilience through practices such as self-care (individual actions to promote well-being) and mindfulness (awareness of the present moment and the ability to observe one’s thoughts and feelings with acceptance rather than judgment) [18]. Resilience mediates the relationship between burnout and negative mental health outcomes [19], and partially mediates the relationship between stress and burnout attributed to COVID-19 in adults [20]. Research conducted among an interdisciplinary group of health care professionals and trainees in the U.S. found a positive association of mindfulness and self-compassion with sleep and resilience [21]. Individual-directed efforts are more effective if combined with organization-level approaches to address and mitigate underlying stressors [22]. A reduction in the public health workforce dating back to the 2008 recession has burdened those who remain with increased scopes of work and longer hours, with little time for self-care, hereafter referred to as wellness practices to be inclusive of efforts at multiple levels to foster well-being. Programming to address wellness in public health requires a shift to prioritize the well-being of professionals, supported by policies and financial resources. We must identify approaches that are feasible, sustainable, and will allow professionals to engage in wellness practices on a regular basis [23].

A framework to promote well-being and sustainable performance

A culture of well-being in public health requires self- and community-oriented care, with a multi-level approach cognizant of environmental factors that shape individual behavior. The socioecological framework, used widely in health promotion, recognizes the influence of factors that shape health behavior and outcomes at four levels: individual, relationship (interpersonal), community, and societal [24]. I offer this framework to guide for adjusting the culture of public health to prioritize well-being of the workforce.

Individual

Public health professionals need to be aware of risk factors that can worsen well-being and recognize and respond to early signs of secondary traumatic stress (STS) and burnout. Practices to cultivate mindfulness such as reflection, committing reflections to writing in journals, and meditation can help individuals recognize and address stress. Individuals can develop a wellness plan using tools such as the University of Buffalo self-care starter kit, which helps individuals evaluate their stress coping behaviors, both positive (e.g. breathing exercises) and negative (e.g. yelling, assess current wellness practices (e.g. exercise, writing in a journal), identify areas of focus based on their needs and preferences (e.g. physical, emotional), and troubleshoot potential barriers (e.g. lack of time) [25]. Organizations can hold informal sessions to practice wellness techniques and reflect on the importance of one’s well-being in carrying out an organization’s mission.

A wide range of organizations have created content to support the well-being of public health professionals during the pandemic [26–29]. These include training programs to address important topics such as practicing first aid for mental health, responding to trauma at the individual and organizational level, understanding how racism is perpetuated by institutional policies and practices, and processing negative public reactions to public health professionals [30]. It is critical to ensure, over time, that workforce development efforts are evidence-based and rigorously evaluated for effectiveness. During the 2008 economic downturn, a lack of objective evaluations and studies of effectiveness in the area of public health preparedness and emergency response left this area vulnerable to funding cuts [31].

Interpersonal

Research shows that social support can mediate the relationship between stress and burnout among health care workers [32]. How do social norms in important relationships (family, friends, peers, colleagues) and other elements of one’s sociocultural context (identity characteristics, lived experiences, cultural roots) shape perceptions of and willingness to engage in wellness practices? It is important to understand the impact of interlocking systems of oppression on those who belong to multiple marginalized subgroups (such as race, gender, class, citizenship status) shapes the unique stressors in one’s life and an individual’s response thereto. We should encourage professionals to nurture relationships where they can support each other in practicing wellness, in service of developing a professional norm that workforce well-being is requisite for serving the larger population.

Community

We should take into consideration the role that environment (home, schools, workplaces, neighborhoods) can play in shaping norms and access to resources for engaging in wellness practices, including safe environments for exercise. At the community level, seek preventive strategies rather than wait until burnout manifests to optimize effectiveness and retain our workforce. In a resilient organization, such as a workplace, leaders act with emotional intelligence and practice transparent and open communication, and employees believe their leadership addresses their concerns and prioritizes their well-being. Such organizations embrace trauma-informed practices and equip individuals with skills to manage stress. Organizations can address primary, secondary, and tertiary prevention of secondary traumatic stress and burnout [33].

Society

Societal factors include policy and laws at the local, state, and national level, as well as policies issued to govern a profession (e.g. medicine). To date, no profession’s accrediting body requires the integration of professional wellness into their educational curriculum. Public health has an opportunity to lead in this area by integrating wellness into the Council for Education in Public Health (CEPH) competencies for undergraduate and graduate programs, and core competencies for public health professionals. Furthermore, while we continue to advocate as a collective for policies that can ensure availability of and access to resources that allow individuals to properly care for themselves (e.g. health insurance), we must also advocate for our own well-being. By proactively addressing each of these layers, we can reduce stressors at the organizational level as well as enhance individuals’ ability to effectively cope with existing stressors.

Primary prevention activities include interventions enacted by workplaces to address those at particularly high risk for burnout, and create policies to ensure reasonable workloads and breaks for personal care, or physical or mental stress reduction practices such as meditation. Given that public health challenges often arise outside of working hours, it is essential for leadership of organizations to enforce professional boundaries to combat growing pressure to be available for work and responsive to communication around the clock.

Secondary prevention activities include early and regular screening for indicators of stress and burnout, using tools such as the professional quality of life scale (PRO-QOL 5) [34] and Maslach Burnout Inventory [13]. Organizations should implement appropriate interventions for those exhibiting chronic stress or high levels of compassion fatigue or burnout. The secondary traumatic stress organizational assessment (STS-OA) may help organizations assess the extent to which they are prepared to acknowledge and address trauma incurred by staff, and be responsive to trauma in the populations they serve [35]. The San Francisco Department of Public Health developed a Trauma-Informed Systems (TIS) initiative to move organizations along a three-step continuum, from (1) “trauma organized” organizations which perpetuate and inflict trauma, to (2) “trauma informed” organizations that understand trauma and its effects, to reach (3) “healing” organizations which acknowledge their own trauma and take meaningful steps to reduce trauma in the populations they serve [36]. In healing organizations, the culture shifts through engagement among leaders who are committed to change and enact these efforts through training of leaders and staff, changes in policy and practice, and evaluation.

Tertiary prevention efforts include interventions to treat individuals experiencing mental or physical health effects of chronic stress or burnout reduce the likelihood of negative sequalae such as anxiety, depression, or chronic disease. Organizations looking to help those dealing with the effects of STS should ensure access for individuals to medical care and mental health care, with time to attend appointments and to counseling resources, amplifying and expanding existing benefits. They should decrease exposure by reducing caseloads and increase autonomy, flexibility, and choice in workers’ roles, and time to recover [37]. To maximize use of these resources organizations should assure policies support preventive care and affordable health care.

Implications for practice

Job-related factors such as an overwhelming workload and lack of autonomy may contribute to burnout in public health professionals. Those who are seeing clients may be exposed to the traumas of those they serve, which can lead to STS. Efforts to prevent and manage STS and burnout should be directed toward all three tiers of the public health workforce: front line staff and entry level (Tier 1), program management and supervisory level (Tier 2), and senior management and executive level (Tier 3) [38]. Initial efforts should be addressed toward Tier 3, identifying champions within organizations who can review current policies, practices, and procedures to identify opportunities for improvement, and model practices for achieving sustainable performance [10]. The example they set and the tone they establish will determine whether individuals feel it is permissible and worthwhile to engage in recommended practices.

Public health core competencies are used in the United States to highlight eight domains of skills that are essential to public health practice [38]. Efforts to prevent and manage burnout are foundations for each of the eight domains of public health core competencies, particularly leadership and system thinking skills, in line with the vision of Public Health 3.0—a call to work across sectors to address social determinants of health [39]. Tier 3 professionals can proactively address workload factors that contribute to burnout and intentions for workers to leave their jobs by promoting a supportive culture to sustain them in current jobs. Positive steps include enforcing breaks in work communications during off hours and vacation, promoting programming on well-being as professional development (Competency 8C6-7), and fostering development of change management skills to help individuals navigate an increasingly complex climate (8C8) [10]. Tier 3 leaders should empower Tier 2 staff to carry out directives from senior leadership to ensure manageable workloads for each worker and a culture that encourages delegation of tasks, asking for help, and cross-training for knowledge transfer. They should discourage practices that increase risk for burnout, such as working excessive hours without downtime to recover.

Managers should establish a mechanism of accountability between Tiers 2 and 3 to ensure compliance with these directives. Those in Tier 1 working directly with clients are most prone to absorbing the trauma of those they serve, with negative consequences for their own health. Simply delegating tasks downward will increase burdens for front line and entry level staff who may lack autonomy in their roles and control of their tasks, compared to those in leadership. Opportunities for professional development and growth are essential components of job satisfaction. Appropriate checks and balances (anonymous surveys) can inform organizations how changes to policies, practices, and procedures impact professionals across tiers.

Conclusion and recommendations

We must take steps to protect the well-being of public health professionals now and establish a sustainable and systematic approach for the long-term. While public health focuses on the population level, much of our workforce deals directly with clients and pressures similar to those in other helping professions. We propose a list of recommendations:

• Promote the holistic well-being of our workforce.

• Organize research to assess the prevalence of STS and burnout and identify contributing and protective factors

• Engage national public health associations to assess the well-being of their membership

• Expand existing research on the public health workforce to assess well-being of those in local health departments.

• Move beyond a focus on work-related burnout to reflect the impact of caregiving responsibilities, racialized trauma, health status, and other factors.

• Create educational tools that reflect a more holistic view of well-being and burnout.

• Incorporate well-being into our existing core competencies:

  • Encourage inclusion of training on wellness,
  • Educate professionals to recognize signs of STS and burnout and enact individual and organizational level strategies for prevention and management

By addressing policies, practices, and procedures within organizations with attention to mitigating stressors and fostering resilience, we can equip our workforce to fulfill our mission while maintaining sustainable levels of engagement.