The New to Public Health Residency Program Supports Transition to Public Health Practice

Abstract

Training and retaining a competent public health workforce are challenging. Residency programs for new and transitioning professionals are effective in other fields, but rare in governmental public health. The New to Public Health Residency Program is a residency program for professionals entering public health practice. Based on the Foundational Public Health Services model, the program was designed using adult learning principles and best practices from nurse residency programs. Content created by public health experts is delivered over 12 months through online course sessions that include interactive learning activities. Additional program components include monthly synchronous online discussions and support from a mentor. Residents apply their learning through implementation of an evidence-based practice project at their workplace. The program is accredited for continuing professional development contact hours. Agencies with limited resources to support new public health employees may find the New to Public Health Residency Program a vital training resource.

Introduction

A competent, diverse public health workforce is essential for addressing community health issues and promoting health. Despite the many disciplines and educational backgrounds of the public health workforce, only 14% have a formal public health degree.¹ Retaining a competent public health workforce is challenging due to dissatisfaction with pay, team communication, and insufficient training.¹ The 2017 Public Health Workforce Interests and Needs Survey (PH WINS) revealed that despite relatively high job satisfaction, about half of public health workers were considering leaving their jobs.¹ The prolonged demands of the SARSCoV2 pandemic response along with the related psychological toll and undermining of public health authority have worsened the situation, resulting in turnover that threatens the infrastructure of public health.²

Efforts to boost capacity of the public health workforce have emphasized the need for crosscutting competencies and interagency and community partnerships.³ Despite the availability of many public health-focused trainings, relatively few incorporate the full scope of public health foundational areas and capabilities.⁴ Historically, public health workforce development efforts have focused on individual disciplinary and specialized training in the form of certification programs, short courses, conferences, e-learning, workshops, and on the job trainings.^3,5 Comprehensive training programs designed specifically for individuals transitioning into the governmental public health workforce from any educational degree program or another area of practice are rare. Public health requires and is comprised of expertise across various disciplines, yet public health professionals who have been trained in fields other than public health (i.e. nursing, health education, nutrition), may not have received comprehensive public health training prior to starting their employment in public health.¹

The field of nursing uses nurse residency programs (NRP) to support new graduate nurses as they transition from an academic degree program to their workplace. NRP are intended to increase confidence, job satisfaction, retention, and support recruitment.⁶ Hospitals rely on NRP to onboard new graduate nurses to acute care settings, and these programs have demonstrated effectiveness in building competency for practice, increasing job satisfaction, and reducing turnover and organizational costs.⁶ Based on this evidence, the Institute of Medicine (now the National Academy of Medicine) recommended NRP be expanded across all practice settings and evaluate their effectiveness for increased retention and competency.⁷

The New to Public Health Residency Program (N2PH) is a novel transdisciplinary and comprehensive workforce development program, created to address the gap in comprehensive training opportunities for new public health professionals in their first year of practice at a governmental public health organization. Drawing on best practices from NRP, the N2PH Residency Program was developed by a team from the University of Wisconsin-Madison School of Nursing, School of Medicine and Public Health, and the Wisconsin Department of Health Services and was implemented in September 2021. This practice brief describes the development, content, and structure of the N2PH Residency Program which enhances traditional orientation practices and supports newly hired public health employees in ways that do not currently exist in other programs.

New to Public Health Residency Program

Program Development

The N2PH Residency Program was adapted from the Southeastern Wisconsin Public Health Nurse (SEWPHN) Residency Program developed in 2016 by a group of public health nurses in Southeastern Wisconsin. The original program was designed using the Foundational Public Health Services (FPHS) model. It was delivered through four-hour, in-person, monthly sessions over six months, and was attended by new and veteran public health professionals employed at urban local health departments.^4,8 Content experts lectured and lead discussions on each of the five foundational areas within the FPHS model.⁴ This program encouraged all public health professionals to attend one or all sessions based on their individual interest. Between July 2017 and February 2020, over 120 people attended at least one session of the program; 22 attended all six sessions. A comparison of pre- and post-competency assessments from 14 individuals who attended all six sessions showed a 25.1% increase in proficiency according to the Quad Council’s Tier 1 Public Health Professionals Competency Assessment.⁸ Of the 22 participants who attended all six sessions between December 2017 and December 2019, all 22 remained in public health by February 2020 and 13 remain with their organization as of April 2022.

Adaptation of SEWPHN was initiated in 2019 to assure that the residency program would be relevant for public health professionals from educational backgrounds in addition to nursing, and in rural and urban settings in Wisconsin. The adaptation was guided by community advisory teams that included local and state public health staff. Adaptations to content, case-studies, and handouts were made to the program to assure broader applicability. Planned implementation of the adapted program using face to face workshops was canceled due to the beginning of the SARSCoV2 pandemic in 2020. The adapted program was subsequently redesigned and developed for fully online delivery.

The resulting N2PH Residency Program incorporated content aligned with the foundational areas and cross-cutting capabilities of the FPHS model to support equitable, healthy communities.⁴ Session content was reviewed by a health equity consultant utilizing the American Public Health Association’s factsheet ‘Key Principles for Advancing Health Equity’ to identify gaps in course materials and assure inclusive excellence.⁹ Online session content was beta-tested to determine the number of accredited contact hours. The Centers for Disease Control and Prevention’s Quality Training Standards were used to guide the development of assessments, program content, evaluations, and ongoing participant support to ensure relevant, engaging, and accessible learning opportunities.¹⁰ Evidence-based components of nurse residency programs, including matching residents with trained mentors, based on professional interests, experiences, culture, and gender identity preferences, and completion of a quality improvement or evidence-based practice project, were built into the program. See Supplemental Digital Content Table 2 (available at http://links.lww.com/JPHMP/A989) for examples of how the N2PH Residency Program incorporates each principle, standard, or component described above.

Program Content and Delivery Structure

Based on adult learning principles, N2PH content was created to be meaningful, problem-centered and relevant to each resident.¹⁰ For example, interactive case studies demonstrate realistic scenarios and scavenger hunts allow residents to locate information and resources specific to their organization, region, or state. The program structure was designed to provide comprehensive online training accessible and applicable to individuals from diverse educational backgrounds working as new employees in local, tribal, regional, or state health departments.¹⁰ Public health professionals in their first year of practice are accepted to the program and placed with a cohort of 25 to 30 residents. The program supports residents as they develop insights and expertise for public health practice within the evolving and diverse expectations of governmental public health agencies. Each session includes a pre/post knowledge check assessment, interactive self-paced online learning activities, discussion post(s), case studies, a synchronous facilitated discussion, reflective journaling prompts and a “scavenger hunt” to find local, regional, or state specific policies, procedures, data, or resources. Table 1 describes the N2PH session topics and expectations for resident learning. Program content and pre/post assessments are delivered in monthly sessions on the University of Wisconsin Interprofessional Continuing Education Partnership (ICEP) platform. The N2PH course is accredited through Joint Accreditation™ with professional development contact hours for nurses, health educators, and other professionals.¹¹

Table 1:

New to Public Health Residency Program Session Topics and Expectations for Resident Learning

Session*	Competencies and Skills Gained by Residents
Orientation	Residents are introduced to each other, and program expectations are discussed. Residents gain access to online content and a workbook of resources to help guide them through the program. Residents are connected with a mentor within the first two months of the program.
Session 1: Public Health Overview	Residents learn about the background of public health practice, laws, and policies. During this session, they complete a competency self-assessment and the Casey-Fink Retention Survey. Discussions reflect on resilience and empowerment in the public health profession.
Session 2: Accountability and Performance Management	Residents focus on governmental accountability, interpreting statutes, budgeting, strategic planning, and evidence-based practice. The residents are introduced to the evidence-based practice project. Discussions reflect on evidence-based practice. FPHS: Accountability/Performance Management Foundational Capability
Session 3: Health Equity	Residents focus on an overview of health equity, conditions of health, stigma and discriminatory processes, neighborhoods and health, community engagement, cultural humility, health in all policies, and the role of public health to build capacity and sustain efforts to advance health equity. Discussions use reflective practice to discuss these concepts. FPHS: Organizational Administrative Foundational Capabilities
Session 4: Communicable Disease	Residents learn the public health roles in monitoring/preventing communicable disease, outbreaks, electronic health data, and electronic disease surveillance. Discussions reflect on motivational interviewing. FPHS: Communicable Disease Control Foundational Area
Session 5: Chronic Disease and Injury Prevention	Residents develop skills in preventing chronic disease and injuries, including substance misuse, with an understanding of models of behavioral change. They are introduced to processes and resources to support the community health assessment (CHA) and community health improvement plan (CHIP) process and engage in simulation around these topic areas. FPHS: Chronic Disease and Injury Prevention Foundational Area
Session 6: Environmental Health	Residents are introduced to the built environment and its impact on health. They explore the public health role in monitoring environmental safety in the community. They complete a competency self-assessment and the Adapted Casey-Fink Retention Survey. Discussions reflect on climate change and environmental justice and the impact on health. FPHS: Environmental Health Foundational Area
Session 7: Maternal, Child, & Family Health	Residents develop a deeper understanding of maternal and child health policies and practice with a focus on trauma-informed care, life course theory, and reproductive justice. Childhood vaccinations and WIC are included. Discussions reflect on vaccine hesitancy and conspiracy theories using a trauma-informed approach that builds on principles of motivational interviewing. Reflective practice is used to allow the residents to explore their experiences with these theories and concepts. FPHS: Maternal and Child Health Foundational Area
Session 8: Access to and Linkage with Clinical Care	Residents explore the roles and opportunities for public health professionals to work with clinical health systems and community partners toward addressing population health. Discussions use case studies to reflect on examples of linking public health and clinical health. FPHS: Access to and Linkage with Clinical Care Foundational Area
Session 9: Emergency Preparedness	Residents are introduced to the public health responsibility of leading an emergency response. They simulate activating incident command. They focus on the critical importance of effective communication. Residents complete a module on psychological resilience during times of emergencies. Discussion reflects on these exercises and explores community readiness and resilience. Reflective practice is used to engage them in exploring their personal experiences and potential stress triggers. FPHS: Emergency Preparedness and Response Foundational Capability
Session 10: Leadership and Policy Development	Residents learn about public health leadership including the policy cycle, role of professional organizations, and leadership skills. Discussion reflects on health in all policies. Using reflective practice, residents are invited to reflect on how public health professionals navigate and influence policy and change. FPHS: Policy Development and Support Foundational Capability FPHS: Organizational Administrative Competencies Foundational Capability
Session 11: Communication and Community Partnership Development	Residents learn skills in framing communication and developing strategies to effectively disseminate communication to diverse audiences. They also focus on key factors to support community coalitions and partnership development. The critical role between community partnerships and public health is emphasized. Discussions reflects on public health messaging and community partnership development. FPHS: Communications Foundational Capability FPHS: Community Partnership Development Foundational Capability
Session 12: Presentation of Evidence-Based Practice Projects	Residents learn about the sources of data that can be accessed to inform practice. They explore using data to understand population health and recognize disparities. They complete a competency self-assessment and the Adapted Casey-Fink Retention Survey. Residents present their evidence-based practice projects to their peers, mentors, and manager/supervisor/ health officer.

^*Sessions are organized and developed based on the Foundational Public Health Services model’s foundational areas and capabilties.¹

Table 1 Description: Each session of the N2PH Residency Program is organized by a foundational area or capability of the Foundational Public Health Services model.¹ Each session includes asynchronous online learning activities (e.g.: interactive learning modules, case study/studies, a scavenger hunt, knowledge checks, a discussion post) and synchronous discussion with a peer cohort.

Program Evaluation

The N2PH Residency Program launched its first cohort of residents in September 2021, with additional cohorts in November 2021, January 2022, and April 2022, totaling 99 residents from 12 states. Resident backgrounds include nursing, health education, epidemiology, nutrition, community health worker, health strategy, environmental health, program coordination, and disease investigation.

Evaluation of the N2PH Residency Program is informed by the Kirkpatrick Model as it applies to learning and professional development.¹² A variety of evaluations, surveys, and knowledge check assessments are used to evaluate four levels of outcomes including 1) reaction; 2) learning; 3) behavior; 4) results (see Supplemental Digital Content Table 3, available at http://links.lww.com/JPHMP/A990).¹² Specifically, the Modified Version of the Core Competency for Public Health Professionals is used to gauge a change in perceived competence in public health skills and the adapted Casey Fink Nurse Retention Survey is used to examine residents’ intent to stay working in the field of public health.^13,14

Discussion

Despite the expansion of undergraduate and graduate public health education programs, people hired into public health positions continue to enter the workforce from a variety of disciplines and educational backgrounds. Most have insufficient public health training prior to starting their employment in public health.¹ Many have started public health positions in the pandemic era and likely have primarily done SARSCoV2 related work. To address ongoing public health workforce challenges, professional development must extend beyond trainings that often only address individual competency-building and instead focus on cross-cutting competencies and collective community action.³ Residency programs have been effective in other health professions but have been rare in public health.

The N2PH Residency Program aims to increase the confidence and competence of new public health professionals while supporting their professional socialization and identity formation through interactions with peers and mentors. The N2PH Residency Program has the potential to fill a gap in public health training resources available to new employees in governmental public health agencies in the United States. Agencies with limited resources for new employee training may find N2PH a vital training resource. Efforts are underway to ensure the program is widely accessible and sustainable. Future evaluation is planned to assure the program helps improve recruitment, retention, and competency of the public health workforce.

Supplementary Material

Supplemental Digital Table 3

• Supplemental Digital Content Table 3. Table that outlines tools used to evaluate the N2PH Residency Program informed by four levels of the Kirkpatrick Model. pdf

Supplemental Digital Table 2

• Supplemental Digital Content Table 2. Table that outlines frameworks and evidence-based components used to develop N2PH Residency Program content. pdf

Implications for Policy and Practice

• Given the current environment and imminent threat of an exodus of experienced public health professionals, there is significant need to build cross-cutting competencies to recruit and retain a qualified and resilient workforce.

• Nurse residency programs are an evidence-based practice tool used to build competence and confidence, increase job satisfaction, and reduce organizational costs associated with staff turnover.

• The New to Public Health Residency Program adopted components of nurse residency programs to build a workforce development solution designed for new public health professionals across the United States.

• Based on the Foundational Public Health Services model, the New to Public Health Residency Program guides residents in applying each of the foundational areas and cross-cutting capabilities to their own practice and community.

• The New to Public Health Residency Program is accessible to all new public health professions employed at a governmental public health agency across the United States.