Over the past several years, the severe shortage in the healthcare workforce has been largely overshadowed by political infighting concerning the Affordable Care Act (ACA). Nevertheless, it is a topic that deserves our immediate attention, given the great impact it has on the quality of the health care we receive and to our nation’s overall health. In this article, we review key lessons and strategies Community Science team members have learned while conducting evaluations of healthcare workforce development programs.
The American Public Health Association has been tracking and warning of the impacts that shortages in the healthcare workforce can have since the 1980s, and Healthy People 2020 has estimated that an additional 250,000 public health workers are needed by 2020 to effectively serve a growing U.S. population and to account for baby boomers who are retiring out of key positions (American Public Health Association, 2008). These trends are exacerbated by an historical lack of diversity within the healthcare workforce. Hispanics, American Indians and Alaska Natives, and African Americans continue to be underrepresented in the healthcare workforce. For instance, underrepresented racial and ethnic minorities comprise only 7.36% of doctoral level graduates in health professions (Association of Schools of Public Health, 2005). These gaps in diversity have continued to expand in the last few years as minority populations throughout the United States continue to increase.
What can and has been done to address this current and looming crisis? When looking at the public health workforce, it is widely accepted that to increase diversity, attention needs to be paid to strengthening the pipeline of minority students that enter a career in public health (Mitchell & Lassiter, 2006). However, to make a significant impact requires more than just increasing the number of culturally competent healthcare providers. Leaders must also be developed so they can establish an environment in which cultural competence and equity are created and reinforced. In an article on 21st century healthcare challenges, the authors concluded that “healthcare organizations in the United States need leaders who excel in the context of diversity. Without effective diversity leadership, even the most culturally competent clinicians will not be able to perform to their full potential” (Hobby & Dreachslin, 2007).
Strategies designed to address these shortages have included the funding for scholarship and loan repayment programs, more quality leadership development programs, and the expansion of internship and fellowship programs in public health professions. For instance, the Centers for Disease Control and Prevention offer dozens of fellowship and internship opportunities from public health law to ethics and health communications for recent graduates as well as graduate and undergraduate students. The Robert Wood Johnson Foundation also sponsors a health policy fellowship which, in 2016, placed eight health professionals in a congressional or executive office to be involved with health-related legislation and programs. The W.K. Kellogg Foundation, National Science Foundation, and several other organizations have made commitments to funding training programs to diversify the health field.
Although these programs provide great opportunities for students to advance their careers by offering them a financial incentive as well as access to resources and professional networks, is that sufficient to motivate participants to dedicate their careers to health equity? Community Science has evaluated a number of leadership development programs and found that for these programs to work, a number of key elements need to be emphasized. First, programs must be committed to training students with varying levels of academic achievement. Though attracting the best and brightest students to a given fellowship program is great for that student and that program, success in recruiting the best candidates from the same sized pool year after year is a zero-sum game. In order to truly expand the pool of candidates and ultimately expand the workforce, traditional methods of recruitment and candidate assessment must be rethought. Using inclusive application reviews (i.e., those that rely on an applicant’s whole body of experiences and skills rather than primarily GPA or test scores) has been successful in diversifying the health workforce pool (Grumbach & Mendoza, 2008).
Secondly, networks are an important part of this issue. As in any field, networks matter not only as a means to enter some professional environments, but also in maintaining workforce longevity and success. Providing a diverse set of mentors and building a community of minority fellows are equally important in attaining the long-term success of future public health leaders (Kreuter, et al., 2011). Increasing diversity is important, but so is a collective identity of a diverse workforce that supports leaders in their career progression. That is, healthcare professionals of diverse ethnic and racial backgrounds should collaborate, share ideas, and create platforms to achieve common goals. Mentors and leaders that trainees have met through fellowship programs would aid students to rise into leadership positions as they share a collective identity as culturally competent healthcare fellows while participating in a network of rising healthcare professionals.
Third, training programs should not only increase skills and leadership capacity among the top students, but also introduce a variety of students to the range of careers available in the healthcare field. This requires programs to be open to students outside of health or public health majors and to perhaps engage students below the undergraduate level. This will require the development of marketing materials specifically to students from nonhealth programs, as well as to specific racial and ethnic groups.
Finally, motivation to enter the healthcare field must be a purposeful strategy that is built into training programs and not something that implementers hope will occur by chance. While it is commendable to give resources to students who are on the healthcare track, this alone will not motivate someone to continue. Training curricula should include reasons why the program is being funded and clearly describe the problem the program is trying to impact. Training should also include a discussion of the important role students can play, how they can make a difference by opting to take a path in a specific field, and exposing them to potential paths to leadership given their life experiences and skills. This can be accomplished by having successful leaders share the decisions they made and experiences they had in getting to their leadership positions. An important consideration is to recruit model leaders that reflect a variety of races, ethnicities, backgrounds, specialties, and career progressions. This has been an important point—a key aspect of feedback given by program participants. Participants in these training programs have relayed that they are better able to see themselves in leadership roles if they can relate to the life experiences of the model leader.
The healthcare workforce shortage, particularly as it pertains to diversity in public health leadership, is a crisis without a simple solution. Training programs are an essential part of getting ahead of the problem and should be strategically designed to manage multiple aspects of the shortage issue. Recommendations to address these issues include designing training programs that:
By being purposeful during a training program’s design, funders will be more likely to not only attract the volume of applicants they want to reach, but also to properly motivate participants to make public health and health equity a lifelong commitment.