Supporting Nursing and Public Health During the COVID-19 Pandemic and Other Public Health Emergencies

As the director of the Division of Nursing and Public Health (DNPH) in the Bureau of Health Workforce (BHW) at the Health Resources and Services Administration (HRSA), I welcome you to this special issue of Public Health Reports, “Expanding the Health Workforce Capacity and Responding to Public Health Emergencies.”

The COVID-19 pandemic created a global public health emergency, one of the worst of our lifetime. The ongoing response to the pandemic in the United States has highlighted the need for a well-trained, high-quality health workforce that serves all communities and reflects the diversity of the nation’s population. ¹ At the onset of the pandemic, health care workers at many levels identified and treated patients affected by COVID-19, monitored those exposed to or at high risk of infection, and developed and implemented preventive measures to slow the spread of disease. ² Once vaccines became available, the health workforce mobilized to make them accessible to all communities across the country as quickly as possible and provided evidence-based information to address vaccine hesitancy. ³ All the while, nurses, physicians, and other health care professionals and community health support staff continued to meet the everyday physical, behavioral, and mental health needs of the populace and developed innovative methods to maintain safe, effective patient care under rapidly changing circumstances.

Even before the pandemic, however, the country struggled with shortages and maldistribution of the health workforce and faced long-standing challenges in the recruitment and retention of nurses and other essential health care workers, particularly in the areas of primary care, maternal health, and behavioral health. In 2019, HRSA’s National Center for Health Workforce Analysis projected that the demand for primary care professionals, including physicians, nurse practitioners, and physician assistants, would increase 13% by 2030, resulting in a shortage of >17 000 primary care professionals. The National Center for Health Workforce Analysis has projected substantial shortages by 2025 for at least 5 behavioral health occupations: psychiatrists, psychologists, social workers, school counselors, and marriage and family therapists. ⁴

Strengthening the Nursing, Behavioral Health, and Public Health Workforce

The mission of BHW is to improve the health of the nation by strengthening the health workforce and connecting skilled health care providers to communities in need. As a part of BHW, DNPH provides leadership and oversight in the administration of nursing, behavioral health, and public health workforce development programs. DNPH focuses its efforts on building the workforce pipeline for nursing and behavioral health, promoting diversity of the health workforce to advance health equity, addressing health workforce shortages, and enhancing access to quality health care. The primary impact of DNPH in the field has been to fund innovative programs that expand nursing and other health professional training programs, develop academic–practice–community partnerships, improve clinical training, and promote faculty development and other continuing education opportunities. Through these programs, DNPH demonstrates a commitment to addressing the social determinants of health, alleviating health disparities, and promoting health equity. During academic year 2020-2021, DNPH supported nearly 40 000 trainees who provide nursing, behavioral health, and public health services, with a focus on rural communities and other communities underserved for access to primary health care and social and other services (hereinafter, “underserved”).

From the federal response to the COVID-19 pandemic, DNPH received increased investments through the Coronavirus Aid, Relief, and Economic Security Act, ⁵ the American Rescue Plan Act, ⁶ and other sources. With this additional funding, DNPH developed or expanded several programs to replenish the nursing, behavioral health, and public health workforce, while working to stabilize and strengthen the health care system as a whole. In partnership with its stakeholders and grantees, DNPH is committed to improving health care access in underserved areas, providing leadership dedicated to interprofessional collaboration, and preparing the health workforce to respond to the evolving needs of health care and anticipate future public health challenges.

Building Resilience

The pandemic has further highlighted the ongoing stresses on nurses and health care workers that are driving many from the health care field. In particular, the shortage of skilled and experienced nurses has reached crisis levels, as hospitals and other health care organizations struggle to retain licensed staff. ⁷ To strengthen the workforce and improve both recruitment and retention, DNPH recently funded >30 grants under the Health and Public Safety Workforce Resiliency Training Program ⁸ and related programs to plan, develop, and implement training activities using evidence-based strategies that can help reduce burnout, decrease suicide risk, and promote mental health care and resiliency among nursing and other health care professionals, trainees, and students. Many initiatives developed by recipients of Workforce Resiliency grants have a special focus on rural and underserved communities.

Highlighting a Range of Efforts to Expand Access to Care

This supplemental issue of Public Health Reports presents articles that highlight several novel strategies developed by DNPH grantees to respond to public health emergencies and address health equity, all during the COVID-19 pandemic. The articles focus on the following themes:

• Assessing mental and behavioral health needs and integrating mental health care into primary care

• Enhancing efforts to improve workforce flexibility

• Developing interprofessional, collaborative team-based care

In one article, Emerson et al ⁹ discuss the process by which a primary care practice with limited behavioral health services transitioned into a comprehensive integrated clinic through the addition of a behavioral health care program led by advanced practice registered nurses (APRNs) as the result of an HRSA grant. They review the development of the program, including the primary care practice environment, feedback from the clinic staff and primary care providers, and funding support, as well as the major challenges and barriers encountered in the initial months of the program. During the first 9 months of the program, the behavioral health team was able to see >300 patients, including 40 urgent same-day consultations, leading to diagnoses that included depression, posttraumatic stress disorder, and substance use disorder (SUD). With the nurse-led behavioral health team in place, patients were able to start treatment or receive medication right away or be referred for further evaluation. In addition, the primary care providers in the practice reported increased satisfaction with access to behavioral health services for their patients. The description of this successful nurse-led program could encourage other primary care clinics to pursue an interprofessional, integrated care model.

Leibowitz et al ¹⁰ note that the COVID-19 pandemic created many challenges for people with mental health conditions. In particular, those receiving treatment for SUDs that required in-person visits often found their treatment interrupted, putting them at risk of relapse. Steps to treat patients with SUDs include medication-assisted therapy and effective alternatives to pain management, along with opiate overdose reversal interventions. The US Department of Health and Human Services recommends a 5-point harm-reduction strategy that includes prevention, treatment, recovery, pain management, and use of pharmacotherapy, along with more effective data collection. This course of care benefits from a team-based approach in which primary care providers, behavioral health specialists with the required medication-assisted therapy waivers, social workers, and others work together to address all identified medical and psychosocial needs. The authors describe a project in which a federally qualified health center, using a team approach with a psychiatric mental health nurse practitioner and a social worker, partnered with the graduate nursing and social work schools at a local university in New York State to improve access to services in the community while providing interprofessional training opportunities for behavioral health trainees. During an 18-month period spanning 2019-2020, outcomes from the federally qualified health center’s SUD treatment program showed a high retention rate; patients reported reductions in drug use and injection use, as well as increased quality of life and energy levels for life activities.

O’Malley et al ¹¹ present initial findings on the use of teledentistry services during the pandemic. Teledentistry allows dentists to provide screening, consultation, and follow-up care during video or telephone conferences, particularly for rural and other underserved populations that may have transportation and financial barriers to accessing oral health services. In a 2020 survey of >3500 health care consumers, nearly 30% of respondents reported using teledentistry during the previous 12 months; 68% had used teledentistry for the first time. These results indicated that teledentistry improved the availability of dental services in the early months of the COVID-19 pandemic. However, the authors note that structural barriers, such as lack of broadband internet access, low income, and poor digital literacy, may limit uptake of teledentistry and other telehealth services.

Several other articles in this supplemental issue cover related programs and research designed to strengthen the public health workforce during the pandemic response and prepare for future public health emergencies. Esperat et al ¹² discuss the benefits of implementing an interprofessional chronic disease management and behavioral health integration model in a primary care clinic serving a medically underserved population. This model showed improved outcomes in hypertension control and depression screening. Choi and colleagues ¹³ used data from the 2018 National Sample Survey of Registered Nurses to explore differences in the practice characteristics, job satisfaction, and training needs of registered nurses and APRNs working in public health as compared with registered nurses and APRNs working in other settings. Public health nurses reported lower earnings but comparable job satisfaction with their non–public health colleagues and were more likely to desire additional training in the social determinants of health, population health, working with underserved communities, and mental health. These findings can help inform efforts to expand the public health infrastructure and support the public health nursing workforce in addressing health inequities and promoting community health.

As the nation enters the next phase of the COVID-19 pandemic, DNPH is working to identify and disseminate successful efforts and lessons learned. The articles in this supplemental issue present programs and other activities that aim to expand the health care and public health workforce; broaden access to primary care; and provide prevention, treatment, and recovery services for behavioral health issues, including substance use and opioid use disorders. These long-standing systemic health problems and social inequities are exacerbated for members of racial and ethnic minority groups during times of public health emergencies.

DNPH values the insights and themes of articles in this supplement. They will inform DNPH programs in adapting to a complex and ever-changing health care system. DNPH sees this public access supplement as an opportunity to share a diverse group of voices and to encourage future collaborations in this broad mission of expanding and building an agile workforce. We at DNPH call on all of our partners and other interested parties to work with us so that we can continue to prepare the health workforce to meet today’s needs while having the strength and flexibility to adapt to future challenges and respond quickly to public health emergencies.