Public health is a complex and interdisciplinary field. In Canada, public health is defined as the organized efforts of society to keep people healthy and prevent injury, illness, and premature death (Public Health Agency of Canada [PHAC], 2008a). It is a combination of programs, services, and policies that protect and promote the health of all Canadians. The public health workforce is necessarily complex and interdisciplinary; it is based on community-oriented services, healthy public policy, prevention, promotion, and protection. An effective mix of public health professionals (or health human resources) has been the focus of recent policies and literature (Baumann et al., 2016, Health Canada, 2013; Regan, MacDonald, Allan, Martin, & Peroff-Johnston, 2014; Villeneuve, 2017). However, creating the right mix of public health professionals to provide an appropriately balanced continuum of services requires dedicated planning and coordination (Public Health Manitoba, n.d.).
Clinical nursing is often associated with treatment-based medical care; nurses also provide essential services in public health, such as health promotion, that require them to possess advanced skills and competencies outside the more traditional, treatment-based approach (Kulbok, Thatcher, Park, & Meszaros, 2012). A study conducted by the Canadian Association of Schools of Nursing (CASN) Task Force on Public Health Education reported that baccalaureate-level nursing students may feel discouraged to pursue community health nursing because of a general feeling that acute care nursing was more valued (CASN Task Force on Public Health Education, 2007). Funding has also been reduced for community health education, and curriculums have been dominated by an acute care focus. In addition, a shortage of qualified faculty to teach students about public health nursing has been reported (CASN Task Force on Public Health Education, 2007). Nursing graduates have reported a theory-practice gap when entering the workplace due to a lack of exposure to community health education (Pijl-Zieber, Barton, Awosoga, & Konkin, 2015). Yet, public health nursing is an essential profession in the domain of public health, directly responsible for ensuring the delivery of high-quality public health services.
Public health nursing includes community-based interventions, health promotion, and health education, as well as political and social advocacy and change. According to Philibin et al. (2010), public health nurses (PHNs) strategically deliver four central components of community care: (1) primary health care, (2) community development, (3) education and outreach, and (4) research. PHNs focus on population-level interventions and require specific competencies, skills, and knowledge (public health and nursing sciences, leadership, and communication) to be effective and successful (Canadian Public Health Association [CPHA], 2010). PHNs are responsible for supporting the health and well-being of communities by interacting with schools, neighborhoods, workplaces, families, and homes. In addition, PHNs act as community leaders by negotiating partnerships in the community and building collaborative initiatives.
Despite the impact of public health workers on their communities, the composition of the public health work-force is difficult to capture: how many public health workers exist, where they are employed, what services they provide, and what skills they rely on. This information is a key component to assessing the capacity of the public health workforce and the ability of providers to deliver services. To our knowledge, no large-scale efforts have been made to collect information about the Canadian public health workforce. A nationally implemented survey would assist in surge capacity efforts, evaluating the success of work-force development strategies, and recruitment/retention efforts in public health. To address this gap, the CPHA conducted a survey of public health practitioners in Canada with an aim to inform future decision making around the public health workforce.
This article reports on a subsection of the survey participants, PHNs, and explores current education and training preferences and practices for PHNs across Canada. The results provide insight into potential direction for new programs to support the work of PHNs in public health practice.
The Canadian Public Health Workforce Survey, a Web-based questionnaire, was distributed in 2015 by the CPHA, in collaboration with the PHAC. This survey was originally conducted to inform an evaluation concerned with the development of the PHAC's public health work-force.
The survey content was reviewed by CPHA and the PHAC teams and piloted internally by employees. Measures were taken to ensure that questions were clear and that the branching logic (a feature that directs respondents through a defined survey pathway, revealing questions only relevant to their responses to maintain flow), was appropriate (University of Florida Health, 2017). The final version of the survey was conducted using an online survey tool, FluidSurveys™. The final survey consisted of 12 pages and 154 questions. Seven main pages collected information on demographics, professional role and responsibilities, educational background, training environment, core competencies, and ability in core competency categories. The question types included multiple choice, dropdown, checkbox, yes/no, text response, and ranking. The survey was offered in both English and French. CPHA is a bilingual organization, and surveys are translated by a professional external translator after the English version is produced, edited, and reviewed. Surveys are tested externally to ensure flow and that translation makes sense. Respondents who access the survey are offered the language of their browser setting or can select language on the landing page. It was estimated that completion time would take 15 to 20 minutes.
Sample and Setting
The target population for this survey included anyone who identified as being a member of the public health workforce. It is expected that through the various dissemination channels, which would have included overlaps in audience, no less than 5,000 members of the workforce would have received a copy of the survey invitation.
The Public Health Workforce survey was available online between December 2015 to January 2016. CPHA disseminated the public health workforce survey link by e-mail to CPHA members (n = 1,229) and PHAC employees (n = 1,971) in the CPHA weekly update (n = 3,925) on a weekly basis throughout the 2-month period. Requests were also submitted to partner organizations (including the Community Health Nurses of Canada, the Canadian Institute of Public Health Inspectors, the Public Health Physicians of Canada, and Provincial/Territorial Public Health Associations) to disseminate the survey among their members.
Protection of Human Subjects
Formal ethics approval was not sought for data collection as it was nonexperimental, voluntary, and conducted under the auspice of quality improvement. In addition, no personal or identifying information was collected.
All study responses were analyzed using Microsoft Excel®. Simple statistical calculations were computed, including frequencies and means. Further statistical analysis was only conducted on questions where more than 50 responses were given. For the purpose of this article, statistical analysis was done only for participants that indicated their professional designation as PHNs.
A total of 2,074 survey participants responded (40% estimated response rate), and a total of 470 respondents (22.7%) identified as PHNs. PHNs were the largest group of respondents for this survey (Table 1).
Public Health Nurse Participant Demographics
Most PHNs (97%, n = 456) reported having a professional designation. Of the total respondents, 94% (n = 441) were English speaking and 97% (n = 455) were females. Of all respondents who started the survey (regardless of location), 138 (or 6.65%) chose to respond using the French version of the survey; of those, 2.2% submitted and completed.
Most respondents (30%, n = 140) were age 45 to 54 years and had been working for 10 to 19 years (33%, n = 156). In terms of place of employment, nearly all (91%, n = 426) PHNs reported being employed by a public health unit or a regional health authority. A large portion of the respondents resided in Ontario (44%, n = 209) and worked in urban areas (45%, n = 22 of 49). Most of the respondents worked at the provincial/territorial level (54%, n = 19 of 35), and three respondents (0.6%) indicated working for First Nations/Inuits/Metis on reserve. The majority (88%, n = 413) of PHNs reported that their primary responsibilities were in health promotion and education, and they reported being the least involved in public health system support functions and environmental health (10%, n = 47). The majority (82%, n = 256 of 314) of PHNs reported being familiar with the Core Competencies for Public Health in Canada.
Ninety-seven percent (n = 458) of nurses had completed more than 10 hours of training per year, most of which was for personal interest and development training, primarily provided by employers (77%, n = 362). Participants indicated that employers provided support for training, such as travel-related expenses, registration expenses, and paid time to participate in external training. Of all respondents, 44% (n = 206) stated there were gaps in the training provided, noting leadership training as the largest gap (23%, n = 109). Health equity training (19%, n = 91) and program planning (18%, n = 84) were reported as missing from current educational offerings. Seventeen percent reported gaps in training around healthy public policy, assessment and analysis, and evidence-informed public health. Finally, knowledge synthesis, translation, and exchange (16%, n = 74) were also reported as gaps in current training. The highest rated preferences for how to receive training and professional education were practicums and traineeships, followed by employer-provided training.
A small portion (19%, n = 89.3) of PHNs reported wanting to pursue a master's degree (e.g., Master of Public Health) as a way to support career advancement within the public health system. The respondents identified barriers toward pursing continuing education in general, including the cost of training (49%, n = 230), the cost of travel and/or lodging (35%, n = 164), the inconvenient approval process (30%, n = 141), and an already overburdened workload (29%, n = 136).
The results of this study can provide insight into the type of directives needed to support the work of PHNs locally, regionally, and nationally. Although our study reports on only a small subsection of professionals working in public health (i.e., PHNs), our results provide three key lessons: (1) the need for targeted and flexible training, (2) the need for an increase in dedicated resources for training and education, and (3) the need for a coordinated approach to training and education. Our results echo findings in the literature that can support the planning of training and education for public health professionals.
Targeted and Flexible Training
PHNs revealed their desire to pursue further education and training, but there was no clear indication of what that would look like. Leadership was often selected as a topic area gap within current continuing education programs, along with evidence-informed practice, knowledge translation, program planning, healthy public policy, and health equity. We thought targeted and flexible education could support the diverse needs of PHNs who wanted to continue their education and training. Online adult training is a feasible option to support professionals in continuing education (Atack & Rankin, 2002; Karaman, 2011). Many organizations offer online asynchronous training to employees that either want or need more training (Atack & Rankin, 2002).
Training should also be flexible to meet the changing needs of PHNs. Although most of our participants were familiar with the Core Competencies, it is less clear how comfortable and confident PHNs are at applying and using them. The Core Competencies for Public Health in Canada: Release 1.0 was made available by the PHAC in 2007 (PHAC, 2008b). This 10-year gap may explain some of the lack of awareness that remains among practicing PHNs that received training prior to the release. The Core Competencies have now been applied directly to the nursing curriculum, and all nursing students should acquire this knowledge during their undergraduate education (CASN, 2014). Continuing education efforts should provide a forum to increase awareness around the Core Competencies and their application in practice. On a broader scale, research has suggested that educational strategies and programs should ensure that graduates from all public health related professions understand the value of public health nursing (Danaher, 2010).
PHNs in our survey indicated a preference for practicums or traineeships for continuing education. Placements prepare students to take on the PHN role more competently and encourage role clarity (Danaher, 2010; Stricklin, 2016). Some authors have suggested this should begin at the baccalaureate level, where quality clinical placements should be available to all students (Orchard, 2010). There is an associated need for a more coordinated effort amongst training programs to provide this form of training to future and current PHNs.
Employers of PHNs require significant funding and resources to deliver the appropriate community-level interventions (PHAC, 2008a). Nurses have reported the belief that employers do not view continued education and training as a priority and that funding support is often not available (Price & Reichert, 2017). A previous report by the Canadian Health Services Research Foundation (CHSRF, 2010) also stated that employers need to work harder to support PHNs in continued education and maintenance of their professional competencies. Barriers such as lack of funding and dedicated support from employers exist, which can stifle efforts to provide or pursue continuing education. We think, as do others, that employers need to adequately support continuous improvement and practice among PHNs (CHSRF, 2010). A significant element in this is providing adequate support to allow PHNs to attend training. Support should be financial, but it can also include improving access.
Recently, the PHAC Skills Online portal was closed. Skills Online was created in 2002 to build capacity in Canada's public health workforce through easy-to-access online continuing education. Part of the decision to close this resource was due to the increase of dedicated MPH programs across the country, as well as a strategic direction of PHAC to get out of the business of public health professional development. This closure has left a gap in available training resources for PHNs (and indeed all public health professionals).
Other existing resources, such as the National Collaborating Centre for Methods and Tools (NCCMT; http://www.nccmt.ca/), exist to meet the continuing education and training needs of the public health workforce. This primarily online portal facilitates and supports the development of knowledge and capacity to use the best available evidence in practice among public health professionals. Training can be developed to suit the needs of participants and, in doing so, address targeted gaps in training and education such as those noted by our participants. Of note, many of the reported training gaps in our survey exist as training webinars on the NCCMT website.
Provincially, there are also resources available for PHNs and other health professionals to access (e.g., Public Health Ontario offers regular seminars on a variety of topics). Agencies such as NCCMT, Public Health Ontario, and others need to ensure regular and tailored communication to PHNs to increase awareness of course offerings.
Coordinated Approach to Training and Education
When developing future educational strategies or programs, the results of this survey suggest not only considering increased access to training but also increasing resource support to attend (e.g., travel). Specifically, future educational strategies and programs should consider financial and time barriers for practicing PHNs. This is not unique to PHNs; many health professionals face similar barriers in pursuing continuing education.
The survey asked respondents to identify topic area gaps within continuing education. Leadership was often selected as a gap, along with evidence-informed practice. Other gaps, such as knowledge translation, program planning, healthy public policy, and health equity, were identified. Expertise in these areas is available and, as previously mentioned, are offered through webinars, workshops, and conferences (such as the NCCMT and Public Health Ontario). Future research could further explore identified gaps and possible reasons why PHNs feel certain needs are not being met by current training and education programming. Improvements in educational strategies or programs should assess how to fill current gaps for practicing PHNs.
There is a definite need for a more coordinated and strategic approach to PHN training and education. A recent Government of Canada evaluation of the role of the PHAC in public health workforce development echoed lack of coordinated approaches and reinforced the current opportunity for a more strategic role for the PHAC (Government of Canada Office of Audit and Evaluation, 2016). They also pointed to the essential role of existing structures and networks to support the outcomes of public health education for the workforce. One example is the Network of Schools and Programs of Population and Public Health, Canada (NSPPH). The NSPPH is a growing network that connects institutions that educate and train population and public health professionals in an effort to provide leadership, build capacity, and share information. The NSPPH should take an interest in the findings of this study and think critically about their role in not only supporting the advancement and enhancement of the future of public health but also in providing a voice and venue for those currently in public health practice to learn and collaborate. Another opportunity rests with Master of Public Health schools and programs seeking, or having, accreditation from the Council on Education for Public Health. A requirement of Council on Education for Public Health accreditation is supporting education of the public health workforce. Master of Public Health schools and programs could consider training and education opportunities that are tailored to PHNs.
The main limitations of this study are the poor distribution of responses across the region (i.e., majority of responses are from the province of Ontario) and the length of the survey. Given that most responses came from within Ontario, results may not be representative of PHNs across the country. Similarly, the number of respondents who completed the survey in French may not reflect the proportion of the Canadian population because Ontario speaks primarily English; however, many professionals will speak both languages. The survey was promoted in both languages, but we did not ask if respondents were bilingual or whether French or English was their mother tongue or spoken most frequently at home. There are a few caveats for our distribution in Quebec as distribution was limited due to rules related to federally funded projects (i.e., people/organizations are not allowed to circulate or participate in them). We had a very low response rate from PHNs identifying as indigenous. It is essential to understand barriers and gaps to all PHNs; further effort to capture and increase representation across Canada is warranted. In addition, throughout the survey there were many blank sections or sections with low response rates that could not be analyzed or reported on. Given that there were 546 inputs required and participants spent an average completion time of 27 minutes (or 18.2 inputs per minute), participant fatigue may have decreased response to certain questions and therefore decreased accuracy and completeness of the data set. Future surveys should limit the number of questions to maximize the quality of answers.
Implications for Education, Practice, and Research
There is a need to support all public health professionals in continuing education and training in a targeted and purposeful way. Although current initiatives exist (e.g., NCCMT, PHO), there is an opportunity to tailor training to meet the needs of particular professionals within public health, such as PHNs. Training needs to be relevant to the provider's interests and skill set but also sensitive to gaps and future trends. Frequent analysis and evaluation are recommended, as well as considerations for how PHNs would like to receive training (i.e., in person, at work, off-site). In our survey, motivation appears to be high in PHNs for online training.
This study highlighted the current gaps in education and training for PHNs in Canada and supports the need for improved training and continuing education for PHNs. Training needs to be coordinated, tailored, and accessible to PHNs across the country.
A greater emphasis on coordinated and tailored PHN training and education will better equip PHNs with the necessary skill sets to provide high-quality public health care. PHNs, like many public health professionals, are required to work in a complex and changing environment; providing training that matches the demands of their work has the potential to improve overall confidence and capacity. We think this can provide a ripple effect, influencing not only the public health workforce but also the services being provided to our communities.
Our study has provided a deeper understanding of the context of PHNs and the gaps in education and training that they currently face. There remains a need to explore potential solutions to meet the training and education needs of PHNs. Increasing awareness of existing education and training opportunities is one way to leverage existing resources for the public health workforce. Speaking to PHNs in practice will help us better understand why gaps still exist and how best to mediate them.
The public health workforce is complex and interdisciplinary. The original aim of our survey was to gather comprehensive information from across the Canadian public health workforce to assess capacity, identify gaps in public health service, assist in surge capacity efforts, and help to evaluate the success of workforce development strategies and recruitment/retention efforts. Our article has reported on a small piece of the complexity surrounding public health practice (i.e., PHNs' training and education). PHNs play a critical role in evaluating and promoting health. High-quality public health depends on highly trained professionals. There is a need for improved planning and coordination around PHNs' training and education from the start of training through to continuing education. Despite the survey being long and potentially complicated for participants, the lessons learned suggest a tailored approach to PHNs' continuing education could improve uptake and effectiveness. We identified several gaps, as well as proposed strategies and considerations to improve targeted education and training for PHNs. More research is needed to provide specific guidance and future direction to support PHNs within the public health work-force. Canada is a large country, with an expansive need for high-quality public health; however, it is also resource-rich and equipped with the necessary skills and expertise to provide excellent public health for all.
- Atack, L. & Rankin, J. (2002). A descriptive study of registered nurses' experiences with web-based learning. Journal of Advanced Nursing, 40(4), 457–465. doi:10.1046/j.1365-2648.2002.02394.x [CrossRef]12421405
- Baumann, A., Crea-Arsenio, M., Akhtar-Danesh, N., Fleming-Carroll, B., Hunsberger, M., Keatings, M. & Kratina, S. (2016). Strategic workforce planning for health human resources: A nursing case analysis. The Canadian Journal of Nursing Research, 48(3–4), 93–99. doi:10.1177/0844562116680715 [CrossRef]
- Canadian Association of Schools of Nursing. (2014). Entry-to-practice public health nursing competencies for undergraduate nursing education. Ottawa, ON: Author.
- Canadian Association of Schools of Nursing Task Force on Public Health Education. (2007). Final report: Public health nursing education at the baccalaureate level in Canada today. Retrieved from http://casn.ca/wp-content/uploads/2014/12/1FinalReportPublicHealthSeptember2007.pdf
- Canadian Health Services Research Foundation. (2010). Maximizing community health nursing capacity in Canada. Ottawa, ON: Author.
- Canadian Public Health Association. (2010). Public health: Community health nursing practice in Canada, roles and activities. Retrieved from https://www.cpha.ca/sites/default/files/assets/pubs/3-1bk04214.pdf
- Danaher, A. (2010). A synthesis of Canadian community health nursing reports. Retrieved from http://neltoolkit.rnao.ca/sites/default/files/A_Synthesis_of_Canadian_Community_Health_Nursing_Reports_CHNC_2010.pdf
- Government of Canada Office of Audit and Evaluation. (2016). Evaluation of the Public Health Agency of Canada's public health workforce development activities 2010–2011 to 2014–2015. Retrieved from https://www.canada.ca/en/public-health/corporate/mandate/about-agency/office-evaluation/evaluation-reports/evaluation-public-health-workforce-development-activities-2010-2011-2014-2015/summary.html
- Health Canada. (2013). Health Canada's human resources strategic plan. Ottawa, ON: Government of Canada. Retrieved from http://publications.gc.ca/collections/collection_2014/sc-hc/H22-1-3-2013-eng.pdf
- Karaman, S. (2011). Nurses' perceptions of online continuing education. BMC Medical Education, 11, 86. doi:10.1186/1472-6920-11-86 [CrossRef]22013974
- Kulbok, P.A., Thatcher, E., Park, E. & Meszaros, P. (2012). Evolving public health nursing roles: Focus on community participatory health promotion and prevention. Online Journal of Issues in Nursing, 17(2), 1. doi:22686109
- Orchard, C.A. (2010). Persistent isolationist or collaborator? The nurse's role in interprofessional collaborative practice. Journal of Nursing Management, 18(3), 248–257. doi:. doi:10.1111/j.1365-2834.2010.01072.x [CrossRef]20546464
- Philibin, C.A.N., Griffiths, C., Byrne, G., Horan, P., Brady, A.M. & Begley, C. (2010). The role of the public health nurse in a changing society. Journal of Advanced Nursing, 66(4), 743–752. doi:10.1111/j.1365-2648.2009.05226.x [CrossRef]
- Pijl-Zieber, E., Barton, S., Awosoga, O. & Konkin, J. (2015). Nursing students achieving community health competencies through undergraduate clinical experiences: A gap analysis. International Journal of Nursing Education Scholarship, 12, 143–154. doi: https://doi.org/10.1515/ijnes-2015-0022. doi:10.1515/ijnes-2015-0022 [CrossRef]26461843
- Price, S. & Reichert, C. (2017). The importance of continuing professional development to career satisfaction and patient care: Meeting the needs of novice to mid- to late-career nurses throughout their career span. Administrative Sciences, 7, 1–13. doi:10.3390/admsci7020017 [CrossRef]
- Public Health Agency of Canada. (2008a). The chief public health officer's report on the state of public health in Canada 2008: Addressing health inequalities. Ottawa, ON: Minister of Health.
- Public Health Agency of Canada. (2008b). Core competencies for public health in Canada 1.0. Ottawa, ON: Author.
- Public Health Manitoba. (n.d.). Health, seniors and active living: Public health. Retrieved from http://www.gov.mb.ca/health/publichealth
- Regan, S., MacDonald, M., Allan, D.E., Martin, C. & Peroff-Johnston, N. (2014). Public health human resources: A comparative analysis of policy documents in two Canadian provinces. Human Resources for Health, 12, 13. doi: . doi:10.1186/1478-4491-12-13 [CrossRef]24564931
- Stricklin, S.M. (2016). Achieving clinical competencies through community-based clinical experiences. Journal of the American Psychiatric Nurses Association, 22, 291–301. doi:10.1177/1078390316646855 [CrossRef]27166415
- University of Florida Health. (2017). Clinical and Translation Science Institute: Branching logic in REDcap. Retrieved from https://www.ctsi.ufl.edu/files/2017/06/Branching-Logic-in-REDCap---How.pdf
- Villeneuve, M. (2017). Public policy and Canadian nursing: Lessons from the field. Toronto, ON: Canadian Scholars.
Public Health Nurse Participant Demographics
| < 20||Not counted||Not counted|
| > 65||2||10|
| British Columbia||11||51|
| New Brunswick||9||43|
| Newfoundland and Labrador||7||33|
| Prince Edward Island||1||6|
| Nova Scotia||7||32|
| Northwest Territories||1||5|
|Respondents working within urban areas||45||22/49|
|Respondents working for the provincial/territorial level||54||19/35|
|Respondents working for First Nations/Inuit/Metis on Reserve||0.6||3|
|Respondents with employment in a public health unit or a regional health authority||91||426|