Alaska’s depleted public health nurse program is evolving amid chronic job vacancies and burnout

State officials are looking for new ways to operate Alaska’s decades-old public health nursing program as they struggle to fill scores of empty positions two years into a pandemic.

They say the program, established in 1943, needs to evolve to address emotional fatigue and burnout, as well as better meet the needs of the communities served by public health centers.

But the shift is drawing concern from some former health officials and advocates over fears it could lead to fewer nurses on the job after years of budget cuts that already compromised Alaska’s response to high rates of suicide, substance abuse and disease outbreaks.

Alaska’s public health nurses staff 16 community health centers and visit nearly 300 small communities and villages, and they conduct outreach on everything from substance abuse and domestic violence to tuberculosis and sexually transmitted diseases.

They have played a key role in the state’s COVID-19 response, administering tests and organizing large vaccine clinics.

But as of this month, nearly a third of the roughly 160 statewide positions for nurses were empty — a fairly consistent vacancy rate that’s left public health centers understaffed in Bethel, Craig, Fairbanks, Homer, Juneau, Kenai, Ketchikan, Kodiak, Nome and Wasilla.

And while the state strives to improve nurse recruiting, officials plan to convert at least three existing nurse positions to other duties as they work on filling nearly 50 vacant spots.

The section was already struggling to contain diseases such as TB and chlamydia before COVID-19 hit, according to Sean Armstrong, a former deputy chief of nursing who left Alaska last year.

During the pandemic, the section hired well over 50 people to staff a busy call center, handle contact tracing and other duties, Armstrong said recently.

Much harder was hiring for long-term permanent positions, complicated by the state’s difficult job posting process and internal delays over job descriptions or other issues.

“We can hire. We can get people out in the field doing the work and we did it during the pandemic,” he said. “But hiring for permanent positions has always been a challenge for us, and recently even getting those positions posted is a challenge.”

Change at the top

Top state health officials say they’re making changes to support the public health nursing section and people who work there.

“We have asked them to do more in less time. They know how valuable they are,” Heidi Hedberg, director of the state public health division, said of the nursing section she oversees. “We’ve learned a lot over the past two years. How do we take those lessons learned and how do we improve our work?”

Any changes will be enacted with a new leader at the top: Public health nursing section chief Tim Struna resigned this month, effective March 4.

Struna was not available for comment. It’s not clear what, if any, role the discussion of new ways of operating the section played in his decision.

Struna spent 18 years with the public health division, the last four as chief of public health nursing, according to Clinton Bennett, spokesman for the Alaska Department of Health and Social Services. Struna leaves state service “in good standing” and program leaders are working on a transition plan, Bennett said.

Struna mentioned family obligations as a reason for his departure in an announcement to his staff, saying “it’s been a true honor to work alongside each of you.”

‘Prevent people from going to the hospital’

Glory Dollerhide started a job as a public health nurse in 2020, just before the pandemic started, after working as a hospital nurse for several years.

Dollerhide, a 39-year-old registered nurse from Wasilla who works at the Mat-Su Public Health Center, said the work public health nurses do to keep Alaskans healthy appealed to her.

“It was the preventative care aspect — when you can prevent people from going to the hospital,” she said.

Still, a state nurse recruiting video shot in and around Bethel makes it clear: Public health nursing in rural Alaska is incredibly rewarding but not for everyone.

It’s “much more than giving shots in a clinic,” as one nursing student notes. New arrivals are given survival kits in case of small plane crashes as they travel to remote villages. The work can be intense. Orange juice costs $18.85.

Colleen Osterhaus travels to Russian Mission — her flight delayed by a weather hold — where she visits with residents amid images of fireweed in bloom, four-wheelers zipping past, and salmon strips drying on smokehouse racks.

Community leaders share the toll alcohol and drugs are taking on the village.

It takes community involvement and strong leadership to address substance abuse, suicide prevention, immunization and violence, Osterhaus tells the camera as a kid rides by on a bike.

“It’s not just about a single sole public health nurse coming in and changing the world, because people don’t need changing,” she says. “They just need support.”

Attrition and abuse

Now it’s nurses who need support.

Nationally, state and local health departments lost 15% of their essential staff in the last 10 years, limiting their ability to “plan for and respond to emergencies like the COVID-19 pandemic and to meet the daily needs of their communities,” according to an October report commissioned by the Public Health National Center for Innovations.

A Centers for Disease Control and Prevention report published in December found that the pandemic is taking a deep emotional toll on public health workers in the form of depression, anxiety, post-traumatic stress disorder and thoughts of suicide — not to mention exposure to COVID-19.

Among more than 26,100 state, tribal, local and territorial public health workers surveyed as part of the study, just over half reported symptoms of at least one mental health condition in the past two weeks. They felt overwhelmed by workload or family-work balance, received job-related threats and felt bullied, threatened or harassed.

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Alaska for years has struggled to recruit public health nurses amid competition with other employers in the state and around the country.

A budget amendment introduced this week by Rep. Liz Snyder, D-Anchorage, would add $520,000 in to nursing section recruitment and retention efforts including a $5,000 sign-on bonus and $5,000 in relocation support for each of the roughly 50 vacant public health nursing positions, using money appropriated for positions but not used last fiscal year.

Nurses in general are “just really hard to recruit” around the country now, said Alaska’s chief medical officer, Dr. Anne Zink.

An exhausted and pandemic-weary public health nurse workforce has left Alaska less prepared than ever, Zink said.

“We are very much thinking about how do we build the system, so that this isn’t asking people to do more,” she said. “We need to spend some time to think about how to make the system better so you can do your work more efficiently and have the support you need and not take the whole world on your shoulders.”

‘Listening phase’

Changes to the nursing program are still evolving.

Zink and Hedberg say at least some of the concerns they’re hearing from former employees and longtime staff are driven by the “trauma” from budget cuts of past years.

This session, they say, there are no public health nurse staffing cuts as part of the state budget process.

Health officials are re-evaluating 12 vacant positions, however, and reclassifying three nurse positions into research analysts based on input from communities that asked for more data collection, according to Hedberg. The rest are nurses and program staff who are shifting to a different job class but not out of nursing, she said, noting the positions are fluid and reflect community needs.

Of the remaining 40 vacant slots in the nursing section now, four have recently been hired, 10 are undergoing application review, 12 are posted on a state jobs site, three are expected to be posted soon and 11 involve a job announcement that expired with no applicants, according to a state chart updated on Feb. 24.

More broadly, ideas circulating to reform the nursing section were generated by a series of meetings with tribal and community leaders as well as “listening sessions” at public health centers around the state, officials say. More recently, they briefed the entire section and asked for feedback.

“There is no master plan,” Hedberg said. “We literally are in the listening phase.”

Feedback included a need to modernize data collection to move away from paper systems, improve collaboration internally and externally, raise the level of communication with the public, and recruit new workers while supporting existing staff, she said.

Some of the possible changes to result include recruiting and retention efforts such as loan repayment or moving expenses and new collaborations with hospitals, the University of Alaska and the Alaska Native Tribal Health Consortium. A new public health nurse residency is already underway.

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Another potential shift for the section involves diversifying funding streams to leverage other sources such as federal funds.

Right now, Alaska’s public health nursing section is uniquely dependent on “volatile” state general funds especially compared to other states where counties also handle the function, Zink said.

“How do we become more resilient so that we can respond to this pandemic and not have to go through that trauma of this very volatile ... funding source that no other state has?” she said.

Concerns about losing nurses

Public health advocates say they still don’t know what specifically some of the nursing changes may involve — one described it as “shrouded in mystery” — but they’re concerned that any loss of nurses will weaken the program.

Jayne Andreen, a former program manager in the state public health division, said top health officials aren’t doing enough to recruit nurses now to move positions out of nursing.

There are about 107 filled public health nurse positions in a state of about 730,000 people — as many as worked back in 1993, when Alaska’s population was just under 600,000.

“They were already down almost 25% of their staffing coming into the pandemic,” said Andreen, a past president of the Alaska Public Health Association who was speaking on her own behalf.

As co-chair of the association policy committee, Andreen co-signed a 2019 letter to legislators noting that nearly $6 million in recent public health nursing budget cuts had already led to a “significant level of service reduction” including eliminating health centers in Cordova, Fort Yukon, Seward, Haines, Wrangell and Galena; eliminating 20% of personnel; restricting vaccinations, well-child exams and STD prevention efforts; and reducing contracted services with the North Slope Borough, Maniilaq and Anchorage Health Department.

Andreen said she’s concerned now that the state could “further decimate” the section if nurse positions convert into non-nurse jobs.

The idea she’s heard of expanding public health centers to partner with regional or local entities is “fantastic,” she said. “They just cannot further marginalize public health nursing because the role they play is so key.”