Public health nurses’ perceptions and experiences of emergency preparedness, responsiveness, and burnout during the COVID‐19 pandemic

Abstract

Objective(s): To describe PHNs’ perceptions and experiences of the COVID‐19 pandemic, including training, response activities, and work‐related challenges.

Design: This was a qualitative study using interpretive description for analysis.

Sample: PHN participants who worked in public health departments in Wisconsin were recruited using purposive sampling. A total of 15 PHNs participated in the study, including both general and supervisor‐level PHNs.

Measurements: Data were collected via semi‐structured interviews from March to May 2021. Interview questions focused on PHNs’ perceptions, experiences, response activities, and burnout in relation to the current pandemic as well as perceptions and experiences of emergency preparedness and response in general.

Results: Five themes emerged in the study. These were: (1) experiences and observations of the COVID‐19 pandemic, (2) organizational changes and their impacts, (3) public health emergency preparedness and response, (4) public health emergency response activities, and (5) role strain and burnout.

Conclusions: Findings presented here have important implications for PHN training and support in emergency preparedness and response. A wide array of strategies focused on developing and supporting the PHN workforce in response to the public health crisis this area need to be implemented at the organizational, community, and policy levels.

1. INTRODUCTION

The COVID‐19 pandemic has been identified as the worst global public health crisis this century in confirmed cases and deaths (Wilder‐Smith, 2021). As of July 27, 2022, a total of 90 million confirmed COVID‐19 cases and one million deaths have been officially documented in the United States, more than any other country (Centers for Disease Control & Prevention, 2022; World Health Organization, 2022).

Public health nursing practice aims to promote population health through assessments of determinants of health, implementation, and evaluation of evidence‐based programs emphasizing primary care for health equity (American Nurses Association, 2013). Per the Council of Public Health Nursing Organizations, now the community/public health nursing competencies include assessment and analytic skills, policy development, and program planning skills, communication skills, community partnership skills, and leadership and system thinking skills (Campbell et al., 2020). Approximately, 28,370 (PHNs) are practicing in state and local health departments in the United States, accounting for 18% of the public health workforce (National Association of County and City Health Officials, 2020; State Health Agency Workforce by Occupation, 2020). PHNs have been on the frontline of pandemics. In the late 19th to early 20th century, PHNs played crucial roles in preventing and managing infectious disease outbreaks to reduce health disparities in the most vulnerable communities of the United States (Brainard, 1922, 1985; Fee & Bu, 2010; Lundy & Janes, 2014; Milio, 1970).

In response to the COVID‐19 pandemic, PHNs have provided direct service and leadership in contact tracing (Jochem, 2020), administration of tests (Cooper, 2020), health education on social distancing and quarantine (Edmonds et al., 2020), and oversight of vaccination distribution plans (Herz, 2021; Smith, 2021).

Researchers have reported that, as a major consequence of working in the COVID‐19 environment, hospital nurses in the United States have suffered overwhelmingly from various challenges at work including psychological distress (Shechter et al., 2020), increased workloads, burnout, and intent to leave (Lasater et al., 2021; LeClaire et al., 2022; McClurg, 2020; Raso et al., 2021; Sinsky et al., 2021). However, there are severe gaps in our understanding of the impact of COVID‐19 on the PHN workforce, in particular on PHNs’ burnout and intent to leave. Preventing and addressing PHNs’ turnover are critical, given that the length of their service (Gwon et al., 2020) and their presence in public health leadership (Kett et al., 2022) significantly contribute to improving population health outcomes nationwide. It is important to understand PHNs’ responsibilities and activities during the pandemic, as well as their experiences of burnout and intent to leave related to their emergency preparedness to better define who needs to know how to do what in an unexpected emergency situation (Gebbie & Qureshi, 2002) and ensure adequate training and support for PHNs. The objectives of this study were to (1) describe PHNs’ perceptions of the pandemic; (2) describe PHNs’ perceptions and experiences of emergency preparedness and response, and response activities; and (3) describe PHNs’ perceptions and experiences of role‐related difficulties and burnout in relation to the pandemic.

2. METHODS

2.1. Design and sample

Interpretive description using a descriptive qualitative study design (Thorne, 2013) was used for this study. PHN participants in the state of Wisconsin were recruited through purposive sampling. Wisconsin is a midwestern U.S. state with 5.90 million people in 72 counties (1.50 million in 45 rural counties; U.S. Census Bureau States, n.d.; Wisconsin Office of Rural Health, n.d.). As of 2020, a total of 2327 nurses practice in public health or community health areas, accounting for 3.2% of the total nurses in Wisconsin (Zahner et al., 2021). In Wisconsin, the total confirmed cases and deaths per 100,000 ranked 26th and 37th, respectively, out of 50 states as of July 27, 2022 (New York Times, 2022). Inclusion criteria were (1) a self‐identified PHN; (2) at least 1‐year full‐time experience as a PHN in Wisconsin as of the date a participant scheduled the interview; and (3) ability to speak and read in English. Both general PHNs in local health departments (frontline PHNs) and PHNs at a manager or supervisor level (supervisor PHNs) were invited to participate.

2.2. Data collection

An online survey was developed to obtain informed consent, to ask basic demographic questions, and to allow the participants to schedule an interview for a date and time they preferred. Email invitations were sent out to an initial group of frontline PHNs and supervisor PHNs by the Public Health Nursing Consultant in the Division of Public Health at the Wisconsin Department of Health Services. PHNs who participated in the study then referred the invitation to their colleagues. Semi‐structured interviews were conducted with a total of 15 PHNs by the second author. This yielded code saturation (Hennink et al., 2017) and provided the various perspectives required for interpretive description (Thorne, 2013). Data collection occurred between March and May 2021, with each interview lasting between 50 and 120 min. Participants were asked about perceptions, experiences, response activities, role‐related difficulties, and burnout in relation to the current pandemic as well as perceptions and experiences of emergency preparedness and response in general (see Table 1). Interview questions were pilot‐tested with the first two participants and their feedback was used to refine the interview questions. All interviews were conducted using Zoom without video and participants’ voices were recorded. Only the participant and researcher were present in the interviews. A distress protocol was in place in case the participant exhibited acute distress, safety concerns, or imminent danger to self or others (Draucker et al., 2009).

TABLE 1.

Interview questions

Objective	Example interview questions
Perceptions of pandemic	How would you describe this pandemic as a public health nurse? How do you feel about this pandemic in relation to your department?
Perceptions and experiences of emergency preparedness and response, response activities	What and how did you prepare for emergencies in general and for a pandemic as a public health nurse? How well do you feel you as a public health nurse are prepared for this pandemic? How has your disaster/emergency preparedness and response education/training guided your actual response activities to this pandemic? What are the roles you have performed during the pandemic?
Perceptions and experiences of role‐related difficulties and burnout in relation to pandemic	Have you experienced any role‐related challenges, such as role strain, or role conflict during this pandemic? Have you experienced any emotional exhaustion or burnout in response to the pandemic? Have you thought about quitting this job because of the pandemic‐related reasons? Do you know some colleague public health nurses you know who experience burnout or intent to leave?

2.3. Data analysis

Audio recordings were transcribed verbatim by trained research assistants in a private space using a secured password‐protected computer. All personal identifiable information in the recordings was removed. The transcripts were verified by the first and second authors for accuracy. Data analysis occurred concurrently with data collection using a directed approach to qualitative content analysis with the aid of NVivo 12. Directed content analysis was categorized as a deductive use of theory guiding the analysis (Hsieh & Shannon, 2005). For this study, data analysis began with coding immediately with the predetermined codes (e.g., emergency preparedness training, emergency response activity, years of experiences in the public health field). Then, new codes derived from the data were generated. To ensure data‐driven coding and categorizing, the data analysis process followed the five analytic strategies (Neergaard et al., 2009). First, each transcript was read and reread by the primary data coder (second author). Notes, reflective memos, insights, and reflections on the data were recorded while reading. Second, four transcripts were analyzed by the first and second authors to establish intercoder agreement, with differences in coding resolved through consensus. Third, the remaining transcripts following the coding agreement were subsequently analyzed. Next, the data were scrutinized and sorted to identify key features, similar phrases, patterns, and themes according to commonalities and differences. Last, themes were gradually formed to provide greater insight into PHNs’ experiences with regard to emergency preparedness, responsiveness, role domains, and burnout. To assure the credibility of the qualitative findings (Birt et al., 2016), two participants were invited to provide comments on the results and interpretation of the analyzed data whether researchers’ understandings and interpretations were good representations of the participants’ viewpoints. The study protocol was reviewed and approved by the University of Wisconsin–Milwaukee Institutional Review Board. Research data are not shared.

3. RESULTS

Participants included eight individuals who identified themselves as frontline PHNs, five who identified as supervisor PHNs, and two who identified as having both roles. Participants reported a range of years of experience in public health (1–3 years: 33.3%, 4–6 years: 20.0%, 7–9 years: 13.33%, 10+ years: 13.33%, and no report: 20.0%). A total of 73.3% of the participants had previously worked as a nurse in other health settings prior to their current job in public health, and for 22.7% public health, nursing was their first job (see Table 2).

TABLE 2.

General characteristics of participants

Demographic characteristics	N	%
Gender
Female	15	100
Male	0	0
Role in public health nursing
Frontline	8	53.34
Supervisor/Consultant	5	33.33
Both	2	13.33
Years of work experience in public health
1–3	5	33.33
4–6	3	20.0
7–9	2	13.33
10 and above	2	13.33
Did not report	3	20.0
Prior work experience
Worked as a nurse in other settings	11	73.33
Public health nurse as first job	4	22.67

3.1. Themes

Five themes emerged in the study, including (1) experience and observations during the pandemic, (2) organizational changes and their impacts, (3) public health emergency preparedness and response, (4) public health emergency response activities, and (5) role strain and burnout (see Table 3). These themes were identified at least once by each of the groups (i.e., frontline PHNs, supervisor PHNs), and all themes were identified by more than one participant.

TABLE 3.

Themes and categories emerged

Objective	Themes	Categories
Perceptions of the pandemic	Experiences and observations of the pandemic	1.1. Experiences of the pandemic
		1.2. Observations of the pandemic
	Organizational changes and their impacts	2.1. Incident Command System
		2.2. Hiring new staff
Perceptions and experiences of emergency preparedness and response, and response activities	Public health emergency preparedness and response	3.1. Emergency preparedness and response training
		3.2. Emergency drills and volunteer management plans
	Public health emergency response activities	4.1. COVID‐19‐related emergency response activities
		4.2. Challenges in emergency response activities
Perceptions and experiences of role‐related difficulties, and burnout in relation to pandemic	Role strain and burnout	5.1. Role strain in public health practice
		5.2. Experience of burnout
		5.3. Turnover in public health nurses

1. Experiences and observations during the pandemic

1.1. Experiences of the pandemic. Most of the participants in both frontline and supervisor PHNs perceived that the COVID‐19 pandemic heightened their stress and anxiety. They reported feeling: “crazy”; “I had never seen things like this. At first, it was not a big deal. This wasn't going to spread. Now, it's been pretty scary.”; “It's a constant discussion. It feels like sometimes I'm doing it 24 hours a day. I'm sleeping and thinking about the pandemic (Participant 4: dual roles of frontline and supervisor PHNs).”; “It's very different from what I experienced during H1N1 and Ebola. We definitely weren't expecting to be pulled from our roles for that length of time. We didn't have to track some people coming through our community (Participant 1: supervisor PHN).” Two frontline PHNs perceived this pandemic as a fitting testament to PHNs, with one sharing, “It has been a perfect time to exercise all the many plans, memorandums of understanding, a collection of data that we so often review in public health. Of course, nobody wants to have a pandemic (Participant 4: dual roles).”

1.2. Observations of the pandemic. Many of the participants commented on the disproportionate impact of this pandemic on the health of vulnerable individuals and communities (e.g., people living in poverty, homeless, and people with minoritized backgrounds): “Our pregnant women, especially Black, low‐income clients, were telling us that they were going very long periods of time without OB care (Participant 13: frontline PHN).” One frontline PHN remarked, “I see more families experiencing poverty and homelessness and not having employment. They were experiencing COVID in their household. They do not have two beds, two baths to quarantine (Participant 14: frontline PHN).”

2. Organizational changes and their impacts

2.1. Incident Command System (ICS). All participants indicated that the ICS organizational structure had been operated from the outset of the pandemic and it continued to be implemented at the time of this study. During the pandemic, staff within the ICS system were moved around according to primary needs (COVID‐19‐related services or primary public health services): “The ICS took a lot of the public health … prenatal nurses (Participant 15: frontline PHN).”; “We had to tell our clients that the pandemic is happening, and we need to do that now (Participant 9: frontline PHN).”

Allocating staff according to the organizational needs alone produced unequal experiences and frustration among staff. One participant described it this way:

Some of us have been working nonstop for now, a year and a half, doing crazy schedules, doing things that we've never done before, adapting our schedules to the pandemic, while other people have continued to just work normal programs, like Monday through Friday, and never had to change their schedule once (Participant 13: frontline PHN).

The movement due to the ICS structure was especially difficult for new PHNs: “The ICS structure makes it really confusing for who you report to. I had just started in public health. My manager that I got hired on with technically has never even been my manager (Participant 13: frontline PHN).”

Several frontline PHNs expressed unfavorable views of the authoritative nature of the ICS's organizational structure. Negative perceptions were mainly caused by their experience of witnessing the emergency response activities assigned to staff without asking their opinions or willingness. When participants attempted to voice their concerns about the chain of command, their inputs were not well received: “It doesn't operate in a very [pause] equitable and fair way. It became clear pretty quickly that you really couldn't make comments or try to (Participant 11: frontline PHN).” One participant reported knowing about a colleague who received a written report after attempting to provide input about the ICS structure and operations.

2.2. Hiring new staff. All participants discussed that it was a crucial approach for their departments to ask for volunteers and to hire new staff, called limited‐term employees (LTE), for COVID‐19‐related services, such as vaccine clinic support, case management and follow‐up, and answering phone calls. Participants described: “We hired hundreds of contact tracers through a staff agency (Participant 9: frontline PHN).”; “We hired new staff, maybe 10 case managers with the Cares Funding. We have maybe five interns, a clinic manager, and they are paid. We also have a bunch of volunteers to help us do all of the vaccines (Participant 6: frontline PHN).”; “We did hire surge staff. We have 14 surge staff members, and they have to have some type of medical background. I know we have like a pharmacist, we have some retired nurses, and nurses who still are working (Participant 10: supervisor PHN).” As the pandemic lasts longer than expected, a few participants recognized that budgetary allocation for the continuity of hiring new staff can be insufficient: “Eventually they're going to have to let them [LTEs] go. So, I fear that when they do that, we're going to have to take over all the COVID follow up, and I think that'll be us (Participant 9: frontline PHN).”

3. Public health emergency preparedness and response

3.1. Emergency preparedness and response training. All frontline PHNs reported receiving online training for emergency preparedness and response at least once a year. Supervisor PHNs also described emergency preparedness and response training that is mandatory practice for PHNs in the state. The online training was comprised of content modules related to (a) ICS; (b) Electronic Surveillance Systems; and (c) partnerships, resources, and volunteers. Participants discussed that the routine general training programs provided “a good base (Participant 2: frontline PHN)” for a “good understanding of what everyone's role and responsibility (Participant 3: dual roles).” During the pandemic, a few participants received additional training focusing on contact tracing, which helped them feel more prepared.

The emergency preparedness and response training on the ICS provided participants with basic knowledge about the operating system and roles of individuals within the system:

One of the biggest things I took away from the training … was learning the hierarchy. You have your Incident Command, and then it goes down from there, all the different branches that are involved with emergency preparedness. That helped a lot (Participant 10: supervisor PHN).

One participant gave detailed comments regarding the utility of the ICS emergency preparedness and response training:

The concept was harder to grasp [initially] because there was no real framework for it. They give some examples like if there's a flood, you'll have a section chief, and you'll have these people doing logistics and these people doing operations. I was not expecting … to be involved in a really big scale response. So, it was good to have had that. It made it much clearer [when] operating within that system (Participant 9: frontline PHN).

• Although all participants reported receiving emergency preparedness and response training, the duration, depth of content, and continuity of training varied. One participant emphasized how such a training tended to be more of an introduction, with the need to learn much of the content on the job:

  So when I first started, I went through a 3‐hour long training of emergency preparedness, to give a background on it. But it mostly was just learning by experience. It was good to jump in having a 3‐hour training, but it [pause] was difficult. Because in public health, there's a lot of different acronyms and community partnerships, and others (Participant 10: supervisor PHN).

• A common perspective from the participants was that emergency preparedness and response was essential for public health. The training provided participants with practical tools (e.g., how to operate a testing site and vaccine clinic, and how to perform contact tracing and case reports) to curb the spread of COVID‐19. Participants voiced concerns about psychological preparations to work in an emergency situation that was long and chronic: “I'm not really sure anyone could have technically prepared you for how long this was (Participant 13: frontline PHN).”; “Our health department has some staff come and go, which has made it a challenge and not all the newer staff are fully trained in that area (Participant 2: frontline PHN).” One participant described:

  We were as prepared as we probably could have been, but going through what you have experienced, you learn from it. You learn what works, you learn what you will do differently for the next pandemic. Hopefully that's not going to ever happen or not happen for a very long time (Participant 11: frontline PHN).

3.2. Emergency drills and volunteer management plans. Emergency drills and volunteer management plans were department specific. Learning to operate flu clinics, mass clinic exercises, or drills about other communicable diseases (e.g., anthrax) were the types of drills identified by a majority of the participants. Participants indicated that practicing drills were the most helpful strategy in managing COVID‐19 vaccine clinics.

4. Public health emergency response activities

4.1. COVID‐19‐related emergency response activities. During the data collection period, most participants were involved in COVID‐19‐related services (e.g., mainly contact tracing and vaccine clinic management). Participants described: “Our priority is getting shots in arms for whatever‐ vaccine the state will release to us (Participant 3: dual roles).”; “Ninety percent of our time is mainly COVID for now. It's not only contact tracing, but vaccination clinics (Participant 5: supervisor PHN).”

PHNs made an effort to raise public awareness about infection prevention and control by communicating with local community partners: “… working with schools, local businesses to stop outbreaks. Again, communication, communication, communication [emphasis] with all of these other partners (Participant 4: dual roles).”; “I worked on the school collaborative team. So we focused on how to prevent the spread of COVID in the schools and how to safely bring back kids to the schools and kind of awareness how to bring awareness (Participant 10: supervisor PHN).”

4.2. Challenges in emergency response activities. More than half of the participants described their understanding and recognition of COVID‐19‐related policy and the clinical guidelines that had been constantly changing. This posed difficulties in implementation: “Information changes very quickly and there wasn't always an agreement in it (between the Federal and the state agency; Participant 10: supervisor PHN)”: “I would be like, there may be some guidance on that. It was school, childcare businesses, or long‐term care facilities. [frustrated] All of them had different recommendations, very different situations (Participant 7: dual roles).” One participant identified a technology‐related challenge due to different systems:

We're in a county that has a large city in it. A conglomeration of health departments has seven municipalities within a county, and they have their own health department. We had like data on two different servers that you couldn't access from the other place (Participant 6: frontline PHN).

Other challenges were related to practical aspects, such as setting up mobile COVID‐19 testing sites and getting supplies (e.g., vaccines, gowns, marks).

Due to the express focus on activities related to COVID‐19, participants shared concerns regarding other essential services that were put on hold. One participant shared, “A lot of public health is outreach. I do injury prevention, community outreach with bike helmets, and bicycle safety and community. Right now, these are things that we've had to push to the side (Participant 4: dual roles).” In addition to the COVID‐19‐related activities, PHNs continued to perform other essential services: “I am still managing more long‐term care facilities that are involved with the COVID‐19 outbreaks. But on top of that, I'm doing every other communicable disease that comes through like STI, TB, latent TB, measles, mumps (Participant 2: frontline PHN).”

5. Role strain and burnout

5.1. Role strain in public health practice

Adapting to and meeting the public health expectation of a new assigned role were commonly discussed by frontline PHNs. This was the key factor contributing to role strain. Participants described stress related to lack of skills, experience, and/or support for doing what was required of them. As one participant stated:

You are supposed to be the instant expert on everything for anybody that called about anything. You were on the front lines. I'm trying, but I don't even have time to read the information I'm supposed to be giving you right now because I'm answering thousands of phone calls a day (Participant 6: frontline PHN).

A few participants were switching back and forth between their existing primary public health and COVID‐19 focused services. Although switching or being pulled away from primary duties was inevitable according to needs during the emergency, expressions from the participants conveyed an unmistakable burden caused by role strain. As one participant said, “A lot more work fell to the people that were still working [in their primary role]. The quantity of work didn't decrease… Two nurses covered all of the families that those 10 nurses would normally see (Participant 14: frontline PHN).”

A few participants who technically were not emergency preparedness coordinator (EPCs) stepped up to the EPC position due to the urgent need to provide emergency preparedness training to staff: “because nobody knew what they were doing. I became one of the main trainers for onboarding new staff. … (Participant 13: frontline PHN)” Participants also discussed that frequent role switches negatively impacted their previously established trustworthy relationships with clients. As one nurse remarked:

I went back to my regular program. It was stressful doing that because you wonder if they're going to pull you again because you don't want to make a promise to clients and family. If you get pulled again, there's no real trust (Participant 15: frontline PHN).

Being pulled away from their primary public health responsibilities to be focusing on COVID‐related services left participants feeling less fulfilled and dissatisfied in their role. Participants noted that many of the roles they were asked to take on failed to capture the totality of their skills as PHNs. As one participant shared about their experience with contact tracing, “One of the major feelings … was that as nurses, we were not practicing nursing to the top of our license (Participant 11: frontline PHN).” Another expressed concern about what had been left undone, “I felt like we had just kind of abandoned our community (Participant 12: frontline PHN).”

5.2. Experience of burnout

Feeling “overwhelmed,” “too tired,” and “underappreciated” were the central messages described by seven of the participants. One participant described their feelings more deeply: “It's even more than just ‘I'm tired of working.’ It's more that I put so much into working. I have sacrificed so much, but the country doesn't get it. It is a moral injury (Participant 14: frontline PHN).” Another participant shared the ways their mental health was affected: “I felt so alone to the point where I went on antidepressants and got counseling therapy. I really thought I was losing my mind. [upset] (Participant 12: frontline PHN)”

Drivers underlying these expressions included being constantly in demand, not being able to keep up with the amount of work, and the continuing duration of the pandemic. Illustrated examples were “the length of how long this has gone on. The whole side of the pandemic that has put a lot of stress on our lives as public health workers (Participant11: frontline PHN).”; “We are working many, many extra hours a week even when they've hired new staff. There's no downtime at all because it's constant (Participant 4: supervisor PHN).” One participant stated:

It feels like it's 24/7. My family asks me about it. I have friends calling me for advice. I have to worry about the children and my family, myself, then go to work and do it all day and get calls after hours [exhaustion] (Participant 4: dual roles).

Participants explained that having formal and informal supports were helpful in reducing emotional exhaustion. Mental health services, Employee Assistance Programs, and supports from public health partnerships were formal supports mentioned by participants as helpful support resources:

We have more resources available to us. We do have a mental health counselor that we have access to. If we want to schedule a video chat with her, they absolutely are open to any discussions that (Participant 11: frontline PHN).

Informal supports mentioned by participants included self‐care activities and teamwork/organizational culture: “Some of us, two of my colleagues, try to do our morning exercises. During a conference call, we're up and stretching. So, we're trying to practice mindfulness and incorporate those activities that brings down our stress level Participant 3: dual roles).” Another participant stated:

I work with fabulous coworkers. It has been the only reason we've been able to survive together as a team. When there is a too much on one caseload, others are willing to pick up and help that person out, which is absolutely fantastic (Participant 2: frontline PHN).

5.3. Turnover in PHNs. Nine of 15 participants discussed knowing someone leaving the department because of the impact of the pandemic: “We've actually had one staff member leave and then another one that will be leaving [due to the pandemic]. Most of us have not had time off (Participant 2: frontline PHN).”; “We have seen a couple of people. For sure, we've one nurse leave the health department since COVID started (Participant 10: supervisor PHN).”

4. DISCUSSION

To our knowledge, this is the first study that documents PHNs’ perspectives of the pandemic, emergency preparedness and response, actual response activities, role strain, and burnout in the United States. In sharing their perspectives of the pandemic, participants highlighted feelings of stress and anxiety, but also ways the pandemic showcased the role and necessity of PHNs. Overall, this study demonstrates the wide range of experiences and activities of PHNs during the COVID‐19 pandemic. Some of these themes are echoed in other literature reporting constrained hiring capacity and burnout among public health workers in the United States (Scales et al., 2021), burnout among PHNs in South Korea (Kim et al., 2022), and increased workload among PHNs (Honda et al., 2022).

Participants reported engaging in work which demonstrated the important skills and contributions of PHNS for the pandemic response. These activities included coordinating and managing vaccination clinics and campaigns, overseeing large‐scale contact tracing efforts, fostering and leveraging community partnerships, and community mitigation efforts. Nurses are known to have the expertise which makes them good partners in such emergencies, such as care coordination, relationship development, expertise in infection prevention and control, and an ability to rapidly process and disseminate evidence‐based information (Martsolf et al., 2018; Nayna Schwerdtle et al., 2020). However, participants also reported needing to take on roles in addition to prepandemic responsibilities or to fulfill duties outside of their usual scope of activities. As described by participants, the redeployment of PHNs during the pandemic caused essential public health services left undone. Because PHN practices focus on preventing and improving health among vulnerable populations, this redeployment may aggravate health inequities in the communities during and even after the pandemic.

Redeployment also contributed to role strain among participants; role strain was further exacerbated by concern about lack of time for PHNs’ family members due to the increase in workload. Role strain is a concept that has been mainly examined among hospital‐based nurses. Among those nurses, role strain develops when they are frequently asked to manage multiple duties with limited resources and time, resulting in difficulty meeting role demands at work and/or in their personal lives (Craw et al., 2022; Raffenaud et al., 2020). It is associated with increased organizational and professional turnover intentions, and job stress (Labrague & de Los Santos, 2021). Addressing this among PHNs is imperative for maintaining and growing this essential part of the nursing workforce. Mitigation strategies include having clearly defined roles and responsibilities as well as the consistent visibility and presence of leadership (Craw et al., 2022).

Nurses’ burnout is a broad concept characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment following excessive workload, a negative work environment, lack of control, poor leadership, low flexibility, team support, role conflict, and so forth (Dall'Ora et al., 2020). This condition causes job dissatisfaction, lack of confidence in performance, and absenteeism (Henson, 2020). Participants’ experiences and feelings described in our current study reflect these aspects of burnout. Continued role‐related challenges produced feelings of being overwhelmed and extremely tired, and feeling underappreciated, contributing to participants’ emotional exhaustion, a tenet of burnout. This also aligns with a recent study that reported an association between higher emotional labor intensity and burnout among PHNs in South Korea on the frontlines of the COVID‐19 pandemic (Kim et al., 2022) as well as other research examining effects of COVID‐19 on clinical nurses in hospital settings (Arnetz et al., 2020; Guttormson et al., 2022; Kelley et al., 2021) and public health workers (Pfender et al., 2022; Stone et al., 2021). Burnout, like role strain, is associated with greater intention to leave the profession and turnover (Leiter & Maslach, 2009). In addition, it is clear that while the ICS restructure was needed to streamline decision‐making during the pandemic, participants reported it also added ambiguity, which may have further contributed to PHNs’ stress and burnout, as shown elsewhere (Sampaio et al., 2020). Supporting PHNs’ mental and psychological health is crucial to elevate workforce resilience. There are national resources for COVID‐19‐related mental health and wellness, such as American Nurses Association Enterprise's Well‐Being Initiative, Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress Helpline, SAMHSA National Helpline, and the National Suicide Prevention Lifeline.

These role‐related challenges and burnout reported by participants only added to public health workforce issues, which existed prior to the pandemic, such as budget cuts, a shrinking workforce, retirement crises, and inadequate educational preparation (Association of State & Territorial Health Officials, 2020; Beck & Boulton, 2015; National Association of County & City Health Officials, 2020; Reilly et al., 2011). In reality, 60% of the participants in this study stated they knew coworkers who would be quitting the job because of the pandemic. This is similar to studies that reported nurses’ high turnover intentions during the pandemic (Raso et al., 2021) and significantly increasing turnover intentions post‐compared to prepandemic (Falatah, 2021).

Preventing PHNs’ turnover is critical in terms of population health outcomes. More strategies need to be considered to help PHNs remain in the profession given Gwon et al. (2020)’s research reporting PHNs’ longer years of employment were significantly associated with improved health outcomes assessed at the county level across the country. Of U.S. nurses, 35% reported an intention to leave direct patient care and 40% felt the pandemic influenced their decision to leave (Berlin et al., 2022). U.S. nurses perceived more recognition for nurse contributions, embedding more breaks, and increased availability of support resources were needed the most for retention (Berlin et al., 2022). The International Council of Nurses suggested the urgent action agenda to support nurse workforce sustainability to improve health system responsiveness and resilience in relation to COVID‐19 (International Council of Nurses, 2022). For example, commitment to support for safe staffing levels and assessments of pandemic impact on individual/overall nurse workforce were encouraged for retention of nurses in response to the pandemic (International Council of Nurses, 2022).

Improving emergency preparedness training for PHNs is also crucial with regard to providing better support to this workforce and encouraging them to stay in the profession. All participants shared that they had some level of emergency preparedness and response training prior to the pandemic, but for many, this training lacked depth and did not adequately prepare them for what they were expected to do during the pandemic. The Quad Council Coalition of Public Health Nursing Organizations (2019; now called Council of Public Health Nursing Organization) documented that emergency preparedness is one of the key action areas for addressing social determinants of health through a public health nursing lens.

A failure to adequately train PHNs during nonemergent times hampers their ability to fully apply their known expertise and also contributes to increased stress, frustration, and burnout. Researchers examining such training have identified a need for federal and state governments, and professional organizations to consider proactive activities for PHNs for public health emergency preparedness to improve readiness and support of this workforce (Veenema et al., 2020). These include funding nursing workforce development for public health emergency preparedness and response, developing metrics for evaluating nursing preparedness, and increased leadership training around crisis response (Veenema et al., 2020). In addition, it may be helpful to increase training around ICS to reduce frustration and increase clarity with this type of restructuring.

Local health departments may also need to consider programs for public health employees to promote team cohesion and group bonding in emergency situations. Team cohesiveness is an important indicator of emergency responders’ resilience and wellbeing, and team performance in the disaster preparedness through the recovery phase (Zarola, 2014). Public health leaders need to promote engagement and foster compassion to mitigate burnout and turnover (Hofmeyer et al., 2020). Leaders who are able to facilitate co‐creation processes with staff and who engage in relational behaviors, such as recognition, coaching and feedback, and interest in staff opinions have been found to be associated with less burnout among staff (Lown et al., 2019). Other organizational measures include assessing the impact of team composition, role and hours worked, and overall workload (Lown et al., 2019).

4.1. Limitations

Efforts were taken to recruit diverse participants in terms of public health roles and years of experience to enhance the potential transferability of the findings; however, there may have been differences in perceptions and experiences in health departments in rural versus urban areas. It is important to note that the themes and categories were created by shared experiences of the participants practicing in specific health departments in one state. Thus, the generalizability of study findings may be limited. Experience of burnout may have been underreported because of the sensitiveness of the issue.

5. CONCLUSION

A wide array of strategies focused on developing and supporting the PHN workforce in this area need to be implemented at the organizational, community, and policy level. Based on the findings of this study, we suggest support for PHNs’ mental and psychological health to improve resilience, support for safe staffing levels of PHNs, assessments of the pandemic impact on the PHN workforce, enhanced emergency prepared training for PHNs, and programs for team cohesion and group bonding. Future research is needed, which focuses on PHNs’ experiences, activities, and mental health during the emergency/disaster recovery phase.

Gwon, S. H. , Thongpriwan, V. , Kett, P. , & Cho, Y. (2023). Public health nurses’ perceptions and experiences of emergency preparedness, responsiveness, and burnout during the COVID‐19 pandemic. Public Health Nursing, 40, 124–134. 10.1111/phn.13141

DATA AVAILABILITY STATEMENT

Research data are not shared.