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Do you have passwords that can be cracked in your password file? Why? Why not?

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Turn-In Requirements:
Lab reports will be 5 to 8 pages in length (single-spaced in font size 12). The title page does not count as one of the pages for the report. The bibliography will not count as one of the page requirements. Appendices will not count as pages for the report. All references will be properly cited throughout the report.

2) Download the SAM and SHADOW files to crack.
3) The recommended environment is Kali VM
4) Crack the Shadow file using John the Ripper (JTR) or Johnny.
5) Crack the SAM file using ophcrack (or SamInside).
6) Experiment with online hash cracking site Crack Station to see if you can produce similar results.
7) Next, find your computer’s password file
a. What is the filename?
b. Where is it located?
c. Can you copy it? Why? Why not?
d. Do you have passwords that can be cracked in your password file? Why? Why not?
e. How can you crack the passwords in your password file?
8) Provide a 5- to 8-page lab report, which must include:
a. A discussion about the password cracker programs you used and any issues you had running the software
b. The cracked passwords and a discussion as to why each individually may not have been a good password
c. Answers to the questions in Step 7.
d. A discussion on what makes a good password policy, an assessment of the policy enforced in your work or school environment, and how passwords are related to identity access management systems

Importance for research, practice and education – is the scientific value and contribution of the framework evident?

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A conceptual framework for educational design at modular level to promote transfer of learning

Yvonne Botma,G.H. Van Rensburg,I.M. Coetzee &T. Heyns

Pages 499-509 | Published online: 02 Dec 2013

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Abstract

Students bridge the theory–practice gap when they apply in practice what they have learned in class. A conceptual framework was developed that can serve as foundation to design for learning transfer at modular level. The framework is based on an adopted and adapted systemic model of transfer of learning, existing learning theories, constructive alignment and the elements of effective learning opportunities. A convergent consensus-seeking process, which is typical of a qualitative approach, was used for expert review. The final conceptual framework consists of two principles: establishing a community of learning and the primacy of a learning outcome. The four steps entail the following: (1) activation of existing knowledge; (2) engaging with new information; (3) demonstrating competence; and (4) application in the real world. It is envisaged that by applying the framework educators in health care will design for transfer of learning, resulting in quality of care and optimal patient outcomes.

Keywords: conceptual framework, modular design, theory–practice gap, transfer of learning

Introduction

The unifying aim of all educators in health care is to enable students to render quality health care and to apply what they have learned in the classroom and simulation laboratories to real-world situations (Lauder, Sharkey, & Booth, 2004). This process of application in the real world is known as ‘transfer of learning’ or ‘theory–practice integration’. Holton, Bates, Bookter, and Yamkovenko (2007) state that transfer of learning is the degree to which students apply to their jobs the knowledge, skills, behaviours and attitudes they have gained in training. Transfer of learning is demonstrated by a competent student. Goudreau et al. (2009) summarise competency as follows ‘… thus allows one to deal with different situations by drawing on concepts, knowledge, information, procedures, and methods. It incorporates many elements, mobilises knowledge, and strategically marshals capabilities in accordance with the specific nature of the situation’ (p. 3). Facilitation of problem solving, reflection, decision-making, critical reasoning and relevant other skills is necessary to give students the opportunities to become (Jerlock, Falk, & Severinsson, 2003). However, transfer of learning does not always occur. Many organisations have found that about 10–20% of training is ever applied in the real world (Ford, 2009; Kirwan & Birchall, 2006). Failure to transfer learning occurs for several reasons, and these may be grouped as factors within the student, design of the learning sessions, and organisational climate or workplace environment. The relationship of these factors is illustrated in Figure 1. Student characteristics, educational design and workplace culture influence students’ motivation to learn and to transfer learning and, in this way, performance in the clinical environment.

Figure 1. Systemic model of transfer of learning, adopted and adapted from Donovan and Darcy (2011).

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In order to promote transfer of learning, the educator must consider these factors when designing at modular level. For many educators, it becomes a daunting task, and they do not know where to start. It is the purpose of this article, therefore, to provide the conceptual framework that could serve as the foundation to design module themes in such a manner that it will promote transfer of learning.

Methodology

Developing conceptual frameworks involves identifying specific concepts, defining these concepts and then linking, integrating and aligning these to form a framework (Brink, Van Der Walt, & Van Rensburg, 2006; Rycroft-Malone & Bucknall, 2010). Initially, the first author of this article developed a conceptual framework of how to seamlessly incorporate simulation as a teaching and learning technique because the higher education institution she is affiliated with acquired authentic learning spaces with a number of human simulators.

Conceptual frameworks can be abstract, broad or skeletal in order to provide tapered information on a specific theme (Rycroft-Malone & Bucknall, 2010, p. 27). An in-depth literature review was conducted with regard to learning theories, competence, educational design and simulation. The literature review was later extended to include transfer of learning and/or learning and the theory–practice gap. In other words, the focus of the initial conceptual framework was changed from simulation to transfer of learning, because simulation is but one technique to promote transfer of learning. This framework provides a frame of reference to organise the thinking, problem solving and application needed in the clinical and non-clinical educational modules or themes.

The efficiency and usefulness of the conceptual framework is to assist and guide educators to describe the principles of a particular field to enhance the transfer of learning in a context. The use of the conceptual framework is set out in a systematic manner, which leads to the potential to explore and investigate the transfer of learning in different contexts.

Influential theories

Learning theories have reshaped themselves from behaviourism to information processing to constructivism. Recognising that context and culture influence memory and cognition forced researchers to explain personal meaning and the nature of reality and its representations. Consequently, social and radical constructivism developed with the following four principles:

• Learning is an active process according to which learners construct their own knowledge;
• Cognition is an adaptive process;
• Meaning making is a subjective process and does not render an accurate representation of reality; and
• Social, cultural, language and biological/neurological processes influence knowing (Yilmaz, 2008).

Educators usually have an eclectic approach to learning theories because they seldom support only one theory but consider instead what each has to offer. Therefore, Piaget’s view of learning, Vygotsky’s theory of interactional learning and Ausubel’s concept of meaningful learning may all be considered relevant by an educator. Cognitive science and cognitive psychology confirm that the process of constructing knowledge is dependent on existing knowledge, the context or situation, and internalisation of information in an organised cognitive structure (Bruce, Klopper, & Mellish, 2011). This constructivistic approach interrelates well with Kolb’s experiential learning theory, which postulates that knowledge is created from understanding to transforming experience (Kolb, Boyatzis, & Mainemelis, 2000). Kolb’s model postulates that observations and reflections occur upon concrete experiences. These reflections are internalised and abstract concepts are formed with associated possible consequences of action. The possible associated consequences can be actively tested for validity and inform future actions in similar situations (Kolb et al., 2000). On the basis of these viewpoints of learning, it is clear that the focus of learning outcomes has shifted from content to competence (Braband, 2008; Brandon & All, 2010).

With the constructivist approach, the educator becomes a facilitator of learning. For this reason, the responsibility of the educator–facilitator is to create learning opportunities for students to process new information and link it to existing mental frameworks through individual or social activity. However, prior knowledge needs to be retrieved before the student is able to link the new knowledge to it. Through this process, the new information is comprehended, and meaning making occurs or knowledge is constructed.

Learning opportunities are created within a complex system that consists of the educator, student, teaching context, teaching and learning activities, outcomes and student assessment tasks (Biggs, 1996) and should take the clinical environment into consideration. The starting point for creating learning opportunities is to clarify the learning outcome or competence (Biggs, 1996) that the professional person must demonstrate. Kouwenhoven defines competence as the capacity to demonstrate up to a predetermined standard the key occupational tasks that characterise a profession (Kouwenhoven, 2010). According to Braband (2008), students are competent when they have the capacity to apply their knowledge and skills with an appropriate attitude in various environments and circumstances. In other words, when foundational knowledge (content), procedural knowledge (how to do) and conditional knowledge (when to do) become functional knowledge (Biggs, 1996).

The elements of learning opportunities that promote competence are activation of existing knowledge to serve as a foundation for new knowledge; application of knowledge in real-world settings; active engagement of students in real-time and real-world situations; practicing of assessment, critical thinking, communication and leadership skills through collaborative learning processes; multiple authentic formative assessments to ensure mastery of the complete competence; and objective assessment measures that are clearly aligned with expected competencies (Carraccio, Wolfsthal, Englander, Ferentz, & Martin, 2002; Merrill, 2002). It is the responsibility of the educator to ensure that all teaching and learning activities are aligned with the outcome, reality and assessment tasks whilst it is students’ responsibility to actively engage with the learning material in order to internalise the theory and skills and in this way construct new knowledge (Reaburn, Muldoon, & Bookallil, 2009).

Development, evaluation and refinement of conceptual framework

From an extensive literature review, a conceptual framework was drafted by the first author, who is a member of a community of practice with a focus on scholarship of teaching and learning. This first author of this article presented the initial conceptual framework and supporting literature exploration to the rest of the team for a purposive review. In an attempt to refine and finalise the conceptual framework, a process of expert review was utilised. The community of practice consists of educators in health care that have experience in: personal research, supervising postgraduate students, developing guidelines and being active practitioners who facilitate learning.

The purpose of the critical review was to assess whether the framework could be accepted as it was described; found acceptable but with recommendations for change or improvement; or found not to be acceptable at all. The group entered into a process of expert evaluation by critiquing the conceptual framework based on criteria set by Tastle, Wierman, and Dundum (2005). These criteria entailed:

• Clarity, simplicity and consistency – are constructs concrete and precise with clear descriptions?
• Appropriateness, relevance and comprehensiveness – are all aspects of transfer of learning addressed?
• Applicability, practicality and usability – are there potential barriers in terms of implementation- and cost implications?
• Adaptability and transferability – are constructs transferable to various contexts and circumstances?
• Credibility – is the framework based on an extensive and critical literature review?
• Importance for research, practice and education – is the scientific value and contribution of the framework evident?
• Trustworthiness/validity – has a correct interpretation of the available evidence been drawn up to support the implementation of the framework?

To facilitate a well-informed review, a process was followed that involved reading, re-reading and internalising the initial framework and supportive literature, followed by academic debate. The criteria listed immediately above were kept in mind. Agreement and consensus building are complex processes that require a thorough understanding of what is to be reviewed or assessed. The review was approached in a qualitative manner through a convergent process. Convergent processes include consensus formation regarding topics or aspects of topics that need to be addressed, their significance and the most effective means to address them. Tastle et al. (2005) describe consensus as a function of shared team feelings towards an issue. Although these authors suggest a rating scale to capture these feelings [views] and to measure the extent to which a person agrees or disagrees with the issues put forward, the principle of consensus formation could also be applied to a qualitative approach to the review process.

The review discussions were based on an understanding of convergence amongst the members as experts and focused on the key constructs of a well-structured conceptual framework. These constructs were regarded as clear, appropriate, applicable, adaptable, practical and credible and have value as proposed by Polit and Beck (2008). Polit and Beck’s (2008) criteria are in accordance with those of Tastle et al. (2005) that were initially used for review. The review process enabled the members of the community of practice to refine and finalise the conceptual framework. Changes were made to the extent of the framework so as not to limit it to the clinical environment. Focus was placed more on principles of transfer of learning rather than specific activities. It was agreed that these changes would make the framework more useful in a broader context of teaching and learning.

Conceptual framework

On the basis of the principles of constructivism as a learning theory, constructive alignment and the elements of effective learning opportunities, a conceptual framework was developed to guide educators on how to design themes for modules that would promote transfer of learning.

The conceptual framework consists of four steps – the activation of existing knowledge, engagement with new information, demonstration of competence and application in real-world practice. (Refer to inner circle in Figure 2). Criteria for successful implementation can be identified for each of these steps. (Refer to the four squares in Figure 2). These four steps or phases are dependent on two principles – the primacy of learning outcomes and the demand that learning takes place within a community of learning. The four steps have as their objective the transfer of learning.

Figure 2. Conceptual framework for educational design at modular level to promote transfer of learning.

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Principles

Establish a community of learning

Fellow students, facilitator(s) and experts in the field constitute a community of learning that assists in developing students’ communication, critical thinking skills and the ability to elaborate and defend their views to others of different opinions (McLoughlin, 2001). Interaction amongst members of the learning community may occur face to face or through the use of electronic media (Kala, Isaramalai, & Pohthong, 2010) and helps to build cognitive bridges (Brandon & All, 2010). The quality and quantity of engagement and interaction are amongst other factors dependent on the degree of the presence of the facilitator (Reaburn et al., 2009).

The primacy of learning outcomes

Researchers in cognitive psychology have shown that deep learning occurs when learners solve authentic problems, in such a way realising the relevance of what they have learned (Merrill, 2002). For this reason, the educator should identify what a person at entry level into a profession should be able to do. Once that has been identified, it becomes the completion of the following stem sentence: ‘On completion of this module/theme the student will be able to …’.

Four steps

Step 1: activate existing knowledge

As stated earlier, knowledge construction occurs when new information is integrated into existing mental schemas. Clark and Harrelson (2002) state that instructional events that activate relevant prior knowledge in long-term memory and stimulate internalisation in working memory supports knowledge construction. However, in practice, many educators immediately start with new learning material without identifying the students existing knowledge. It is therefore essential to determine whether the students have had any relevant experience and what that experience entailed. Information-orientated pretests are unproductive in activating prior experience (Merrill, 2002). In order to incorporate new information, existing schemas need to be recalled and modified. Existing knowledge and its related schema is often activated through story telling of lived experiences and guided reflection (Biggs, 1996). Doolittle and Camp (1999) state that it may be necessary to deconstruct an existing ‘incorrect’ concept and then to (re)construct the appropriate concept before continuing with the desired teaching and learning activities (Doolittle & Camp, 1999). This description fits with Mezirow’s transformative learning as cited by Clapper (2010, p. e10); namely, that ‘it is a process of using a prior interpretation to construe a new or revised interpretation of one’s experience in order to guide future action’ (Clapper, 2010). The motivation to learn increases when students realise the relevance of the theoretical content.

Step 2: engage with new information

Learning is enhanced when the learning activities are aligned with the outcome or expected competence (Biggs, 1996). The engagement phase is student centred and outcome focussed because deep learning is promoted when students are actively engaged with the aim of making sense of the information by seeking integration between content and tasks (Pascoe & Singh, 2008; Rust, 2002; Sefton, 2006). Students demonstrate engagement when they discuss information, think about it, or use and apply the information to solve real-life problems or challenges. Sefton (2006) recommends that students develop these skills progressively throughout the educational programme. Furthermore, students should know their learning style and preferred learning techniques to become life-long learners (Biggs, 1996; Boud & Falchikov, 2006; Fink, 2003; Pascoe & Singh, 2008).

Content and skills should be pared down to what is essential to meet the learning outcome (Brandon & All, 2010; Pascoe & Singh, 2008). Forbes and Hickey (2009) advise that educators should ask themselves whether the information will be used in the majority of situations in the specified context. When planning engaging learning activities, the facilitator should take into consideration that learning occurs best when more than one sense is involved – for example, when students see and hear (Clark & Harrelson, 2002). Engagement should occur in all domains of learning and students should be offered opportunities to observe and practice how to perform certain skills correctly, because personal experiences are necessary for enhanced functioning within one’s professional environment (Doolittle & Camp, 1999). The emphasis during the engagement phase is on mastering content, becoming proficient in certain tasks and being actively engaged in the process of learning through various student-centred teaching methods. After the engagement phase, students should be given the opportunity to demonstrate what they have learned.

Step 3: demonstrate competence

All learners within a professional programme progress from a novice to competent practitioner (Benner, Sutphen, Leonard, & Day, 2010). Novices are characterised by strict adherence to rules or plans with little situational perception and little ability to make discretionary judgments. At this level, students need much guidance and support. At a competent level, students have a broader understanding of the situation and can make more intuitive decisions (Roberts, Gustavs, & Mack, 2012). Expertise is acquired through extensive involvement in activities that are specifically designed to improve performance (Ward, Hodges, Starkes, & Williams, 2007). Educators should, however, recognise that this involvement is still part of the learning cycle and students also learn through their mistakes (Allan, Smith, & O’Driscoll, 2011). When students are not skilled in what they need to do the specific incompetency should be identified and strategies implemented that give the student the opportunity to deliberately practice to become competent in those identifies areas (Clapper & Kardong-Edgren, 2012).

Step 4: apply in real world

Health care systems are workforce- and service orientated rather than learning oriented (Allan et al., 2011). Therefore, the workplace climate or organisational culture influences learning and is not always conducive to learning. Maben, Latter, and Clark (2006) describe the pressures and constraints of the system and professionals as organisational and professional sabotage. The sabotage may be due to time pressure, role constraints, staff shortage and poor skills mix, work overload, task orientation and high patient turnover. It is therefore essential to plan during the educational design phase how to support students in the workplace in order to enhance transfer of learning, thus applying it in the real world.

Discussion

Following the principles and the steps in this conceptual framework may enable students to apply what they have learned independently in different contexts over an extended period of time. In other words, the students will demonstrate their functional knowledge when they know when and how to use the content and skills that they have learned appropriately.

Known learning theories have been used to underpin the framework that could assist educators to design at modular level in order to enhance transfer of learning or bridge the well-described theory–practice gap (Allan, 2011; Maben et al., 2006). Although the initial conceptual framework was widely used in the institution where the first author works, the refined conceptual framework needs to be applied outside that institution in clinical and non-clinical contexts. The rigour of the review process was enhanced by the fact that none of the experts are associated with the higher education institution of the first author. Furthermore, an independent skilled moderator facilitated the review process and thus reduced bias.

It is envisaged that by applying the framework, educators in health care will design for transfer of learning, resulting in quality of care and optimal patient outcomes. Furthermore, the principles and steps of the framework may culminate in a standardised educational design template used during the design process. This conceptual framework should become an integral part of curriculum development and could be applied in any professional educational context.

It is recommended that the conceptual framework be evaluated once it has been implemented to determine whether transfer of learning occurred. Strategies to strengthen educators and clinical facilitators in applying the principles underlying the framework will become key to the value and contribution of this framework. The conceptual framework can be utilised to guide and contribute to the methodological approach for future research in the transfer of knowledge.

Conclusion

In order to address the challenge that educators face in designing for transfer of learning the conceptual framework was developed that could serve as the foundation to educational design. This framework provides principles and steps that could assist in developing modular themes in such a manner that students are able to apply in practice what they have learned in theory. Existing mental schemas are recalled in preparation for the creation of new knowledge. Competence and expertise are developed within a community of learning during the engagement phase during which students are actively involved with learning activities that are well designed and aligned with the outcome and their learning needs. Students are afforded the opportunity to demonstrate their competence through various techniques of which simulation is an example. The framework further emphasises that learning in the workplace is part of the educational design and educators must consider how to support students in the workplace. Student support in the workplace can no longer be relegated to the service provider. The approach described in this article could assist educators in health care in applying overlapping principles of learning theories.

The principality of sound outcomes and a community of learning is emphasised in this conceptual framework. A health care professional needs to demonstrate functional knowledge, which is the attainment of a sound learning outcome. As a result, it is envisaged that successful application of this framework could cultivate a culture of lifelong learning that is a desired outcome for students studying for a professional degree.

Notes on contributors

Yvonne Botma is an associate professor with an interest in educational strategies to enhance theory–practice integration. She teaches research methodology and trains clinical preceptors to support nursing students in applying their classroom knowledge in practice.

Gisela H. Van Rensburg is a professor in health studies and teaches research methodology at an open distance learning university. Her research focus is innovative student support strategies, including support of postgraduate students through group facilitation and various reflective practices.

Isabel Coetzee is a critical care nurse educator who promotes practice development in critical care units in public and private hospitals. She facilitates postgraduate students in critical care nursing to become competent nurse clinicians.

Tanya Heyns is keen on practice development, especially in emergency care rooms and critical care units as she teaches emergency care to postgraduate nursing students. She is a firm believer of appreciation and the strength of positive reinforcement.

References

  1. Allan, H. T. (2011). Using psychodynamic small group work in nurse education: Closing the theory–practice gap? Nurse Education Today,31, 521–524. doi:10.1016/j.nedt.2010.09.00610.1016/j.nedt.2010.09.006

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. Allan, H. T., Smith, P., & O’Driscoll, M. (2011). Experiences of supernumerary status and the hidden curriculum in nursing: A new twist in the theory–practice gap? Journal of Clinical Nursing,20, 847–855. doi:10.1111/j.1365-2702.2010.03570.x10.1111/jcn.2011.20.issue-5-6

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Fransisco, CA: Jossey-Bass.

[Google Scholar]

  1. Biggs, J. (1996). Enhancing teaching through constructive alignment. Higher Education,32, 347–364.10.1007/BF00138871

[Crossref], [Web of Science ®]

, [Google Scholar]

  1. Boud, D., & Falchikov, N. (2006). Aligning assessment with long-term learning. Assessment & Evaluation in Higher Education,31, 399–413. doi:10.1080/02602930600679050

[Taylor & Francis Online]

, [Google Scholar]

  1. Braband, C. (2008). Constructive alignment for teaching model-based design for concurrency. Lecture Notes on Computer Science,5100, 1–18.10.1007/978-3-540-89287-8

[Crossref]

, [Google Scholar]

  1. Brandon, A., & All, A. (2010). Constructivism theory analysis and application to curricula. Nursing Education Perspectives,32, 89–92.

[Google Scholar]

  1. Brink, H., Van Der Walt, C., & Van Rensburg, G. (2006). Fundamentals of research methodology for health care professionals(2nd ed.). Cape Town: Juta.

[Google Scholar]

  1. Bruce, J., Klopper, H., & Mellish, J. (2011). Teaching and learning the practice of nursing(5th ed.). Cape Town: Pearson Education.

[Google Scholar]

  1. Carraccio, C., Wolfsthal, S. D., Englander, R., Ferentz, K., & Martin, C. (2002). Shifting paradigms: From Flexner to competencies. Academic Medicine: Journal of the Association of American Medical Colleges,77, 361–367.10.1097/00001888-200205000-00003

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. Clapper, T. C. (2010). Beyond Knowles: What those conducting simulation need to know about adult learning theory. Clinical Simulation in Nursing,6, e7–e14. doi:10.1016/j.ecns.2009.07.00310.1016/j.ecns.2009.07.003

[Crossref]

, [Google Scholar]

  1. Clapper, T. C., & Kardong-Edgren, S. (2012). Using deliberate practice and simulation to improve nursing skills. Clinical Simulation in Nursing,8, e109–e113. doi:10.1016/j.ecns.2010.12.00110.1016/j.ecns.2010.12.001

[Crossref]

, [Google Scholar]

  1. Clark, R., & Harrelson, G. L. (2002). Designing instruction that supports cognitive learning processes. Journal of Athletic Training,37, S152–S159.

[PubMed]

, [Google Scholar]

  1. Donovan, P., & Darcy, D. P. (2011). Learning transfer: The views of practitioners in Ireland. International Journal of Training and Development,15, 121–139.

[Crossref]

, [Google Scholar]

  1. Fink, L. (2003). A self-directed guide to designing courses for significant learning. San Fransisco, CA: Jossey-Bass.

[Google Scholar]

  1. Forbes, M. O., & Hickey, M. T. (2009). Curriculum reform in Baccalaureate nursing education: Review of the literature. International Journal of Nursing Education Scholarship, 6(1), Article 27. doi:10.2202/1548-923X.1797

[Crossref], [PubMed]

, [Google Scholar]

  1. Ford, L. (2009). Improving training transfer. Industrial and Commercial Transfer,41, 92–96. doi:10.1108/0019785091093913510.1108/00197850910939135

[Crossref]

, [Google Scholar]

  1. Goudreau, J., Pepin, J., Dubois, S., Boyer, L., Larue, C., & Legault, A. (2009). A second generation of the competency-based approach to nursing education. International Journal of Nursing Education Scholarship, 6, 1–15. doi:10.2202/1548-923X.1685

[Crossref]

, [Google Scholar]

  1. Holton, E. F., Bates, R. A., Bookter, A. I., & Yamkovenko, V. B. (2007). Convergent and divergent validity of the Learning Transfer System Inventory. Human Resource Development Quarterly,18, 385–419. doi:10.1002/hrdq10.1002/(ISSN)1532-1096

[Crossref]

, [Google Scholar]

  1. Jerlock, M., Falk, K., & Severinsson, E. (2003). Academic nursing education guidelines: Tool for bridging the gap between theory, research and practice. Nursing & Health Sciences,5, 219–228.

[Crossref], [PubMed]

, [Google Scholar]

  1. Kala, S., Isaramalai, S.-A., & Pohthong, A. (2010). Electronic learning and constructivism: A model for nursing education. Nurse Education Today,30, 61–66. doi:10.1016/j.nedt.2009.06.00210.1016/j.nedt.2009.06.002

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. Kirwan, C., & Birchall, D. (2006). Transfer of learning from management development programmes: Testing the Holton model. International Journal of Training and Development,10, 252–268. doi:10.1111/j.1468-2419.2006.00259.x10.1111/(ISSN)1468-2419

[Crossref]

, [Google Scholar]

  1. Kolb, D. A., Boyatzis, R. E., & Mainemelis, C. (2000). Experiential learning theory: Previous research and new directions. In R. Sternberg & L. Zhang (Eds.), Perspectives on cognitive, learning, and thinking styles(pp. 1–40). London: Lawrence Erlbaum.

[Google Scholar]

  1. Kouwenhoven, W. (2010). Competence-based curriculum development in higher education: Some African experiences. In M. Cantrell, M. Kool, & W. Kouwenhoven (Eds.), Access & expansion: Challenges or higher education improvement in developing countries(pp. 125–146). Amsterdam: VU University Press.

[Google Scholar]

  1. Lauder, W., Sharkey, S., & Booth, S. (2004). A case study of transfer of learning in a family health nursing course for students in remote and rural areas. Nurse Education In Practice,4, 39–44. doi:10.1016/S1471-5953(03)00017-910.1016/S1471-5953(03)00017-9

[Crossref], [PubMed]

, [Google Scholar]

  1. Maben, J., Latter, S., & Clark, J. M. (2006). The theory-practice gap: Impact of professional-bureaucratic work conflict on newly-qualified nurses. Journal of Advanced Nursing,55, 465–477. doi:10.1111/j.1365-2648.2006.03939.x10.1111/jan.2006.55.issue-4

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. McLoughlin, C. (2001). Inclusivity and alignment: Principles of pedagogy, task and assessment design for effective cross-cultural online learning. Distance Education,22, 7–29.10.1080/0158791010220102

[Taylor & Francis Online]

, [Google Scholar]

  1. Merrill, M. D. (2002). First principles of instruction. Educational Technology Research and Development,50, 43–59. doi:10.1007/BF0250502410.1007/BF02505024

[Crossref], [Web of Science ®]

, [Google Scholar]

  1. Pascoe, M., & Singh, S. (2008). ‘By the end of this course you should be able to …’: Towards constructive alignment in the slp curriculum. The South African Journal of Communication Disorders,55, 91–110.

[PubMed]

, [Google Scholar]

  1. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice(8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

[Google Scholar]

  1. Reaburn, P., Muldoon, N., & Bookallil, C. (2009, December). Blended spaces, work based learning and constructive alignment: Impacts on student engagement.In Same places, different spaces. Proceedings Ascilite Auckland. http://www.ascilite.org.au/conferences/auckland09/procs/raeburn.pdf

[Google Scholar]

  1. Roberts, T. V., Gustavs, J., & Mack, H. G. (2012). Becoming an expert: A review of adult learning theory and implications for vocational training in ophthalmology. Clinical & Experimental Ophthalmology,40, 519–526. doi:10.1111/j.1442-9071.2011.02716.x

[Crossref], [PubMed], [Web of Science ®]

, [Google Scholar]

  1. Rust, C. (2002). The impact of assessment on student learning: How can the research literature practically help to inform the development of departmental assessment strategies and learner-centred assessment practices? Active Learning in Higher Education,3, 145–158. doi:10.1177/146978740200300200410.1177/1469787402003002004

[Crossref]

, [Google Scholar]

  1. Rycroft-Malone, J., & Bucknall, T. (2010). Models and frameworks for implementing evidence-based practice: Linking evidence to action. Oxford: Blackwell.

[Google Scholar]

  1. Sefton, A. J. (2006). New approaches to medical education: An international perspective. Medical Principles and Practice: International Journal of the Kuwait University, Health Science Centre,13, 239–248. doi:10.1159/000079521

[Crossref], [Web of Science ®]

, [Google Scholar]

  1. Tastle, W., Wierman, M., & Dundum, U. (2005). Ranking ordinal scales using the consensus measure. Issues in Information Systems, VI, 96–102.

[Google Scholar]

  1. Ward, P., Hodges, N. J., Starkes, J. L., & Williams, M. A. (2007). The road to excellence: Deliberate practice and the development of expertise. High Ability Studies,18, 119–153. doi:10.1080/1359813070170971510.1080/13598130701709715

[Taylor & Francis Online], [Web of Science ®]

, [Google Scholar]

  1. Yilmaz, K. (2008). Constructivist suggestions constructivism: Its theoretical underpinnings, variations, and implications for classroom instruction. Educational Horisons, Spring, 161–172.

[Google Scholar]

 

What is the P/E ratio of this company? How does the P/E ratio compare to other companies in this industry?

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For your second SLP assignment, continue to do research on the company you chose to write about for your Module 1 SLP. This time you will be doing research about the valuation of the company to try to determine if its stock price is overvalued or undervalued. You can use Google Finance, Yahoo Finance, or similar Web pages to find the financial information about this company.
Write a 2- to 3-page paper with the following items:
1. What is the P/E ratio of this company? How does the P/E ratio compare to other companies in this industry? Based on the P/E ratio, do you think the company is overvalued or undervalued?
2. Find the company’s balance sheet. Calculate the book value of each share. This can be done by taking the total assets and subtracting total liabilities. Then divide the number you get by the total number of outstanding shares. Is the number you get higher or lower than the current price of the share? Based on what you’ve found, would you say the stock is overvalued or undervalued?
3. Finally, do a search on what different analysts have to say about your company. Do they generally recommend buying the stock or selling the stock? What reasons to they give for their assessment? Find at least three analyst reports about this company.
NOTE: Module 1 SLP paper is attached for reference to ensure the same company is used.

What is the strategic and operational issue touched upon and how did they materialize?

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You will find the question and instructions in the file uploaded.
when looking at 4 articles make sure they are all linked to a particular issue. Also please make sure the first statement in the review makes it clear what aspect you are looking at and how the four articles will address that.
preferably for the articles to be based under crisis management
on the second page of the file uploaded you will find a list of topics you can choose from. the paper can be structured as follows. A short overview and a 200-250 words per artice. For example, sub topic article 1, article 2 etc
you can find articles that may help under this link https://www.theisrm.org/en/documents-archive . Please note you can only access this library for free before 30th November.
Also, you mind find these points helpful
1. What is the strategic and operational issue touched upon and how did they materialize?
2. How did the organizations deal with this issue or what risk management practices was suggested by the article to deal with the issue?
3. What could they have done better or improved?
Lastly, please attach the articles or links at the end of the paper. for example, a screenshot of the article if it’s not too long.

How do we keep out fighting force at acceptable levels to avoid drastic personnel surplus and deficiencies all while working within the national debt limit U.S Congress is trying to manage?

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Topic Specified: Navy Recruiting and Retention

  • Main Point I

The Navy like most organizations has fluctuations in their manning. At times of war, standards are sometimes lowered such as ASVAB score requirements, age waivers, and physical fitness standards changes. From the retention aspect, bonuses are offered for under manned Navy occupations that deal with combat and maintenance. The Navy needs more aviation personnel, submariners and other sea going rates to be filled.

When we are in a drawdown, the budget usually changes, and the number of bonuses given are in decline, promotion quotas slowly dwindle down, and manning is loss due to a change in the global conflicts. How do we keep out fighting force at acceptable levels to avoid drastic personnel surplus and deficiencies all while working within the national debt limit U.S Congress is trying to manage?

Subpoint A – Current recruiting effort (source cited): Rosendale, J. A., & Leidman, M. B. (2015). Locked-in on Our Youth: An Inquiry into American Military Recruiting Media (1st ed., Vol. 4). Retrieved from http://www.aijssnet.com/journals/Vol_4_No_1_February_2015/4.pdf

Subpoint B – Retaining our current workforce? (source cited): Eskreis-Winkler, L., Shulman, E., Beal, S., & Duckworth, A. (2014). The grit effect: Predicting retention in the military, the workplace, school and marriage. Frontiers in Psychology, 5, 36.

  • Main Point II

Bringing aboard recruits that are desirable is essential in workforce balancing. It will come done to select the most qualified and placing them in the field they may thrive in the most. The issue with job placement comes with what the recruit expects the job is like versus the reality of the job itself.

Subpoint A – Testing and selecting standards (source cited):

Eakman, A. (2014). A Prospective Longitudinal Study Testing Relationships between Meaningful Activities, Basic Psychological Needs Fulfillment, and Meaning in Life. OTJR: Occupation, Participation and Health, 34(2), 93-105.

Cassenti, D., Rice, V., & Rose, P. (2015). The Relationship between U.S. Military Aptitude Testing and Academic Performance during Army Combat Medic Training (Vol. 59). Los Angeles, CA: SAGE Publications.

Subpoint B – Job satisfaction and morale (source cited):

Bysted, R. (2013). Innovative employee behavior. European Journal of Innovation Management, 16(3), 268-284.

  • Main Point III

The plan to keep the personnel we have and bring on new talent to keep vigor in the workforce. Ultimately, even with the advancement in technology, there is a need for human involvement in day to day naval operations. There are plans being researched and put evaluated to perpetuate the vigor of the naval workforce.

Subpoint A – Implemented more programs to promote mental and physical health (source cited): Woods, M. (2017). 4 Ways HRIS Can Improve Employee Engagement: Keeping employees happy is a top-level priority. Core HR, HRIS and Payroll Excellence Essentials, Core HR, HRIS and Payroll Excellence Essentials, Mar 2017.

Palm, R. (2016). Thinking Outside The Network: How benefits managers can save money while keeping employees happy. Employee Benefits and Wellness Excellence Essentials, Employee Benefits and Wellness Excellence Essentials, Mar 2016.

Conclusion

In conclusion, implementing some of these plans should show an increase in recruitment to meet the Department of Defense fiscal year goals and also retain valuable assets within the organization to sustain the naval workforce.

 

The effects caused by Santander introducing technology to traditional banking.

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Hello, below are my aims! I have attached a file which goes into further detail of what is expected of this literature review and the guidelines. Please follow this as strictly as possible! Thank you for your efforts in advance!!
1. Investigate what is the new technology that has been recently implemented in Santander (across all departments) and how this compares to traditional banking.
(including profits and losses of what these technologies have caused Santander)
2. To examine the effects of these technologies on Santander’s customers and to have a better understanding of what the customer’s connotations/opinions with e-banking etc are. (to be included: does the older generation have a more negative opinion and why that could be?, how many of Santander’s customers use online banking and other technologies within Santander)
3. To research the effects of e-banking within the labour market on a whole e.g how many jobs will be lost (and have been lost already) and gather the worries employees have about these recent technologies.
I cannot have any plagiarism whatsoever it must be 100% original content, please!
References must only be academic journals, books, consultancy reports and minimal online sources expect from Santander’s annual, strategic report etc which must be included.

Many Thanks

Does it relate to and build on other research in the same field?

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Please strictly follow the guidelines below, under any circumstance the literature review must be 100% original and can not contain any plagiarism.

  1. What is the marking criteria :

Literature Review

  1. i) Is the literature relevant to the topic?
  2. ii) Does it relate to and build on other research in the same field?

iii)        Is the literature review critical?

  1. iv) Does it inform the hypotheses/research questions?
  2. v) If appropriate, is the framework of analysis clearly specified

 

  1. Please choose the best approach for the literature review, ensuring it flows throughout the 4000 words. I am using a mix method approach when I collect my primary data in the sense of methodology, I am conducting surveys and focus groups at the bank itself.

 

  1. The structure is extremely important it should have a thematic structure focusing on key areas.

 

  1. Finally a clear argument for both for and against must be demonstrated including recurring themes. It should also establish ‘my’ position in the argument for the project and organisation of the review

 

  • Define trends: gaps in research, foundational research and theory.

 

 

Sources to be used

The sources must be academic and should only include no more than 5 sources from the Santander websites and the rest of them from academic journals, consultancy reports, strategic reports.

Referencing – should be done solely in Havard style.

 

Many thanks once again, I’m certain you will do a marvellous job and I look forward to working with you in the near future.

 

 

 

How much will a trade war launched by America’s president, Donald Trump, exacerbate it? What will global commerce look like in the aftermath?

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The Economist January 26th 2019 23
1
LARGE AND sustained increases in the
cross-border flow of goods, money,
ideas and people have been the most important
factor in world affairs for the past
three decades. They have reshaped relations
between states both large and small,
and have increasingly come to affect internal
politics, too. From iPhones to France’s
gilets jaunes, globalisation and its discontents
have remade the world.
Recently, though, the character and
tempo of globalisation have changed. The
pace of economic integration around the
world has slowed by many—though not
all—measures. “Slowbalisation”, a term
used since 2015 by Adjiedj Bakas, a Dutch
trend-watcher, describes the reaction
against globalisation. How severe will it
become? How much will a trade war
launched by America’s president, Donald
Trump, exacerbate it? What will global
commerce look like in the aftermath?
There have been periods of more and
less globalisation throughout history. Today’s
era sprang from America’s sponsorship
of a new world order in 1945, which allowed
cross-border flows of goods and
capital to recover after years of war and
chaos. After 1990 this bout of globalisation
went into warp speed as China rebounded,
India and Russia abandoned autarky and
the European single market came into its
own. Containerising freight sent shipping
costs plummeting. America signed nafta,
helped create the World Trade Organisation
and supported global tariff cuts. Financial
liberalisation freed capital to roam
the world in search of risk and reward.
Harder blew the trade winds
World trade rocketed as a result, from 39%
of gdp in 1990 to 58% last year. International
assets and liabilities rose too, from 128%
to 401% of gdp, as did the stock of migrants,
from 2.9% to 3.3% of the world’s
population. On the first two of those measures
the world is far more integrated than
in 1914, the peak of the previous age of globalisation.
Nonetheless, parts of the world
remain poorly integrated into the global
economy. About 1bn people live in countries
where trade is less than a quarter of
gdp. World trade can be split into tens of
thousands of separate potential corridors
between pairs of countries: America and
China, say, or Gabon and Denmark. In a
quarter of those corridors there was no recorded
commerce at all.
When did the slowdown begin? Consider
a dozen measures of global integration
(see chart 1 on next page). Eight are in retreat
or stagnating, of which seven lost
steam around 2008. Trade has fallen from
61% of world gdp in 2008 to 58% now. If
these figures exclude emerging markets (of
which China is one), it has been flat at
about 60%. The capacity of supply chains
that ship half-finished goods across borders
has shrunk. Intermediate imports
rose fast in the 20 years to 2008, but since
then have dropped from 19% of world gdp
to 17%. The march of multinational firms
has halted. Their share of global profits of
all listed firms has dropped from 33% in
2008 to 31%. Long-term cross-border investment
by all firms, known as foreign direct
investment (fdi), has tumbled from
3.5% of world gdp in 2007 to 1.3% in 2018.
As cross-border trade and companies
have stagnated relative to the economy, so
too has the intensity of financial links.
Cross-border bank loans have collapsed
from 60% of gdp in 2006 to about 36%. Excluding
rickety European banks, they have
been flat at 17%. Gross capital flows have
fallen from a peak of 7% in early 2007 to
1.5%. When globalisation boomed, emerging
economies found it easy to catch up
The global list
Globalisation has faltered and is now being reshaped
Briefing Slowbalisation
24 Briefing Slowbalisation The Economist January 26th 2019
2
1
with the rich world in terms of output per
person. Since 2008 the share of economies
converging in this way has fallen from 88%
to 50% (using purchasing-power parity).
A minority of yardsticks show rising integration.
Migration to the rich world has
risen slightly over the past decade. International
parcels and flights are growing fast.
The volume of data crossing borders has
risen by 64 times, according to McKinsey, a
consulting firm, not least thanks to billions
of fans of Luis Fonsi, a Puerto Rican
crooner with YouTube’s biggest-ever hit.
Braking point
There are several underlying causes of this
slowbalisation. After sharp declines in the
1970s and 1980s trading has stopped getting
cheaper. Tariffs and transport costs as a
share of the value of goods traded ceased to
fall about a decade ago. The financial crisis
in 2008-09 was a huge shock for banks.
After it, many became stingier about financing
trade. And straddling the world
has been less profitable than bosses hoped.
The rate of return on all multinational investment
dropped from an average of 10%
in 2005-07 to a puny 6% in 2017. Firms
found that local competitors were more capable
than expected and that large investments
and takeovers often flopped.
Deep forces are at work. Services are becoming
a larger share of global economic
activity and they are harder to trade than
goods. A Chinese lawyer is not qualified to
execute wills in Berlin and Texan dentists
cannot drill in Manila. Emerging economies
are getting better at making their own
inputs, allowing them to be self-reliant.
Factories in China, for example, can now
make most parts for an iPhone, with the exception
of advanced semiconductors.
Made in China used to mean assembling
foreign widgets in China; now it really does
mean making things there.
What might the natural trajectory of
globalisation have looked like had there
been no trade war? The trends in trade and
supply chains appear to suggest a phase of
saturation, as the pull of cheap labour and
multinational investment in physical assets
have become less important. If left to
their own devices, however, financial flows
such as bank loans might have picked up as
the shock of the financial crisis receded
and Asian financial institutions gained
more reach abroad.
Instead, the Trump administration has
charged in. Its signature policy has been a
barrage of tariffs, which cover a huge range
of goods, from tyres to edible offal. The revenue
America raised from tariffs, as a share
of the value of all imports, was 1.3% in 2015.
By October 2018, the latest month for which
data are available, it was 2.7%. If America
and China do not strike a deal and Mr
Trump acts on his threats, that will rise to
3.4% in April. The last time it was that high
was in 1978, although it is still far below the
level of over 50% seen in the 1930s.
Tariffs are only one part of a broad push
to tilt commerce in America’s favour. A tax
bill passed by Congress in December 2017
was designed to encourage firms to repatriate
cash held abroad. They have brought
back about $650bn so far. In August 2018
Congress also passed a law vetting foreign
investment, aimed at protecting American
technology companies.
America’s control of the dollar-based
payments system, the backbone of global
commerce, has been weaponised. zte, a
Chinese technology firm, was temporarily
banned from doing business with American
firms. The practical consequence was
to make it hard for it to use the global financial
system, with devastating results. Another
firm, Huawei, is being investigated
as a result of information from an American
monitor placed inside a global bank,
who raised a flag about the firm busting
sanctions. The punishment could be a ban
on doing business in America, which in effect
means a ban on using dollars globally.
The administration’s attacks on the
Federal Reserve have undermined confidence
that it will act as a lender of last resort
for foreign banks and central banks
that need dollars, as it did during the financial
crisis. The boss of an Asian central
bank says in private that it is time to prepare
for the post-American era. America
has abandoned climate treaties and undermined
bodies such as the wto and the global
postal authority.
On the counterattack
Other countries have reciprocated in kind
if not in degree. As well as raising tariffs of
its own, China used its antitrust apparatus
in July to block the acquisition of nxp, a
Dutch chip firm, by Qualcomm, an American
one. Both do business in China. It is
also pursuing an antitrust investigation
against a trio of foreign tech firms—Samsung,
Micron and sk Hynix—which its domestic
manufacturers complain charge
too much. Since November the French
state has taken an overt role in the row between
Renault and Nissan, having sat in
the back seat for years.
Most multinational firms spent 2018 insisting
to investors that this trade war did
not matter. This is odd, given how much effort
they spent over the previous 20 years
lobbying for globalisation. The Economist
Global stops and starts
Sources: IMF; UNCTAD; BIS; OECD; Bloomberg; IATA; UPU; McKinsey *Compared with US GDP per person on a PPP basis
Trade in goods and
services as % of GDP
1
50
55
60
65
2007 18
Intermediate imports
as % of GDP
14
16
18
20
2007 18
Multinational profits
as % of all listed
firms’ profits
20
25
30
35
40
2007 18
FDI flows
as % of GDP
0
1
2
3
4
2007 18
Stock of crossborder
bank loans
as % of GDP
30
40
50
60
2007 18
Share of countries
catching up*, %
40
60
80
100
2007 18
Gross capital flows
as % of GDP
0
2
4
6
2007 18
S&P 500 sales
abroad, % of total
30
40
50
60
2007 18
International parcel
volume, m
0
50
100
150
200
2007 17
Permanent migrants
to rich world, m
0
2
4
6
2007 17
Cross-border
bandwith
Terabits per second
0
200
400
600
800
2007 17
International air
travel, revenue
passenger km, bn
0
2
4
6
2007 17
The Economist January 26th 2019 Briefing Slowbalisation 25
2
1
has reviewed the investor calls in the second
half of 2018 of about 80 of the largest
American firms which have given guidance
about the impact of tariffs. The hit to total
profits was about $6bn, or 3%. Most firms
said they could pass on the costs to customers.
Many claimed their supply chains
were less extended than you might think,
with each region a self-contained silo.
This blasé attitude has begun to crumble
in the past eight weeks, as executives
factor in not just the mechanical impact of
tariffs but the broader consequences of the
trade war on investment and confidence,
not least in China. On December 18th Federal
Express, one of the world’s biggest logistics
firms, said that business was slowing.
Estimates for the firm’s profits have
dropped by a sixth since then. On January
2nd Apple said that trade tensions were
hurting its business in China, and five days
later Samsung gave a similar message.
Temporary manoeuvring by firms to get
round tariffs may have created a sugar high
that is now ending. Some firms have been
“front-running” tariffs by stockpiling inventories
within America. Reflecting this,
the price to ship a container from Shanghai
to Los Angeles soared in the second half of
2018, compared with the price to ship one
to Rotterdam. But this effect is unwinding
and prices to Los Angeles are falling again
as global export volumes slow.
America has had bouts of protectionism
before, as the historian Douglas Irwin
notes, only to return to an open posture.
Nonetheless investors and firms worry
that this time may be different. Uncle Sam
is less powerful than during the previous
bout of protectionism, which was aimed at
Japan. Its share of global gdp is roughly a
quarter, compared with a third in 1985. Fear
of trade and anger about China is bipartisan
and will outlive Mr Trump. And damage
has been done to American-led institutions,
including the dollar system. Firms
worry that the full-tilt globalisation seen
between 1990 and 2010 is no longer underwritten
by America and no longer commands
popular consent in the West.
Few quick fixes
Faced with this, some things are easy to fix.
The boss of one big multinational is planning
to end its practice of swapping board
seats with a Chinese firm, in order to avoid
political flak in America. Supply chains
take longer to adjust. Multinationals are
sniffing out how to shift production from
China. Kerry Logistics, a Hong Kong firm,
has said that trade tensions are boosting
activity in South-East Asia. Citigroup, a
bank, has seen a pickup in deal flows between
Asian countries such as South Korea
and India.
An exodus cannot happen overnight,
however. Vietnam is rolling out the red carpet
but its two big ports, Ho Chi Minh City
and Haiphong, each have only a sixth of the
capacity of Shanghai. Apple, which has a
big supply chain in China, is committed to
paying its vendors $42bn in 2019 and the
contracts cannot be cancelled. It relies on a
long tail of 30-odd barely profitable suppliers
and assemblers of components, which
it squeezes. If these firms were asked to
shift their factories from China they might
struggle to do so quickly—the cost could be
anywhere between $25bn and $90bn.
Over time, however, firms will apply a
higher cost of capital to long-term investments
in industries that are politically sensitive,
such as tech, and in countries that
have fraught trade relations. The legal certainty
created by nafta in 1994 and China’s
entry into the wto in 2001 boosted multinational
investment flows. The removal of
certainty will have the opposite effect.
Already, activity in the most politically
sensitive channels is tumbling. Investment
by Chinese multinationals into
America and Europe sank by 73% in 2018.
Overall global fdi fell by 20% in 2018, according
to unctad, a multilateral body.
Some of that reflects an accounting quirk
as American firms adjust to recent tax reforms.
Still, in the last few weeks of 2018,
one element of fdi, cross-border takeovers,
slipped compared with the past few
years. If you assume that the rate of tax repatriation
fades and that deal flows are
subdued, fdi this year might be a fifth lower
than in 2017.
These trends can be used as a crude indicator
of the long-run effect of a continuing
trade war. Assume that fdi does not
pick up, and also that the recent historical
relationship between the stock of fdi and
trade can be extrapolated. On this basis, exports
would fall from 28% of world gdp to
23% over a decade. That would be equivalent
to a third of the proportionate drop
seen between 1929 and 1946, the previous
crisis in globalisation.
Perhaps firms can adapt to slowbalisation,
shifting away from physical goods to
intangible ones. Trade in the 20th century
morphed three times, from boats laden
with metals, meat and wool, to ships full of
cars and transistor radios, to containers of
components that feed into supply chains.
Now the big opportunity is services. The
flow of ideas can pack an economic punch;
over 40% of the productivity growth in
emerging economies in 2004-14 came
from knowledge flows, reckons the imf.
Overall, it has been a dismal decade for
exports of services, which have stagnated
at about 6-7% of world gdp. But Richard
Baldwin, an economist, predicts a crossborder
“globotics revolution”, with remote
workers abroad becoming more embedded
in companies’ operations. Indian outsourcing
firms are shifting from running
functions, such as Western payroll systems,
to more creative projects, such as
configuring new Walmart supermarkets.
In November tcs, India’s biggest firm,
bought w12, a digital-design studio in London.
Cross-border e-commerce is growing,
too. Alibaba expects its Chinese customers
to spend at least $40bn abroad in 2023. Netflix
and Facebook together have over a billion
cross-border customers.
Services rendered
It is a seductive story. But the scale of this
electronic mesh can be overstated. Typical
American Facebook users have 70% of their
friends living within 200 miles and only
4% abroad. The cross-border revenue pool
is relatively small. In total the top 1,000
American digital, software and e-commerce
firms, including Amazon, Microsoft,
Facebook and Google, had international
sales equivalent to 1% of all global
exports in 2017. Facebook may have a billion
foreign users but in 2017 it had similar
sales abroad to Mondelez, a medium-sized
American biscuit-maker.
Technology services are especially vulnerable
to politics and protectionism, reflecting
concerns about fake news, taxdodging,
job losses, privacy and espionage.
Here, the dominant market shares of the
companies involved are a disadvantage,
making them easier to target and control.
America discourages Chinese tech firms
from operating at scale within its borders
and American companies like Facebook
and Twitter are not welcome in China.
This sort of behaviour is spreading.
Consider India, which Silicon Valley had
hoped was an open market where it could
build the same monopolistic positions it
has in the West. On December 26th India
passed rules that clobber Amazon and Walmart,
which dominate e-commerce there,
preventing them from owning inventory.
The objective is to protect local digital and
traditional retailers. Draft rules revealed in
26 Briefing Slowbalisation The Economist January 26th 2019
2 July would require internet firms to store
data exclusively in India. A third set of
rules went live in October, requiring financial
firms to store data locally, too.
Furthermore, trade in services might
bring the kind of job losses that led manufacturing
trade to become unpopular.
Imagine, for example, if India’s it services
firms, experts at marshalling skilled workers,
doubled in size. Assuming each Indian
worker replaced a foreign one, then 1.5m
jobs would be lost in the West. And even the
flow of raw ideas across borders could be
slowed. The White House has considered
restricting Chinese scientists’ access to research
programmes. America’s new investment-
vetting regime could hamper venture-
capital activity. Technology services
will not evade the backlash against globalisation,
and may make it worse.
As globalisation fades, the emerging
pattern of cross-border commerce is more
regional. This matches the trend of shorter
supply chains and fits the direction of geopolitics.
The picture is clearest in trade. The
share of foreign inputs that cross-border
supply chains source from within their
own region—measured using value added—
has risen since 2012 in Asia, Europe
and North America, according to the oecd,
a club of mostly rich countries (see chart 2).
The pattern changes
Multinational activity is becoming more
regional, too. A decade ago a third of the
fdi flowing into Asian countries came
from elsewhere in Asia. Now it is half. If
you put Asian firms into two buckets—Japanese
and other Asian firms—each made
more money selling things to the other
parts of Asia than to America in 2018. In Europe
around 60% of fdi has come from
within the region over the past decade.
Outside their home region, European
multinationals have tilted towards emerging
markets and away from America.
American firms’ exposure to foreign markets
of any kind has stagnated for a decade
as firms have made hay at home.
The legal and diplomatic framework for
trade and investment flows is becoming
more regional. The one trade deal Mr
Trump has struck is a new version of
nafta, known as usmca. On November
20th the eu announced a new regime for
screening foreign investment. China is
backing several regional initiatives, including
the Asian Infrastructure Investment
Bank and a trade deal known as rcep.
Tech governance is becoming more regional,
too. Europe now has its own rules for the
tech industry on data (known as gdpr), privacy,
antitrust and tax. China’s tech firms
have rising influence in Asia. No emerging
Asian country has banned Huawei, despite
Western firms’ security concerns. The likes
of Alibaba and Tencent are investing heavily
across South-East Asia.
Both Europe and China are trying to
make their financial system more powerful.
European countries plan to bring more
derivatives activity from London and Chicago
into the euro area after Brexit, and are
encouraging a wave of consolidation
among banks. China is opening its bond
market, which over time will make it the
centre of gravity for other Asian markets.
As China’s asset-management industry
gets bigger it will have more clout abroad.
Yet the shift to a regional system comes
with three big risks. One is political. Two of
the three zones lack political legitimacy.
The eu is unpopular among some in Europe.
Far worse is China, which few countries
in Asia trust entirely. Traditionally,
economic hegemons are consumer-centric
economies which create demand in other
places by buying lots of goods from abroad,
and which often run trade deficits as a result.
Yet both China and Germany are mercantilist
powers that run trade surpluses.
As a result there could be lots of tensions
over sovereignty and one-sided trade.
The second risk is to finance, which remains
global for now. The portfolio flows
sloshing around the world are run by money-
management firms that roam the globe.
The dollar is the world’s dominant currency,
and the decisions of the Fed and gyrations
of Wall Street influence interest rates
and the price of equities around the world.
When America was ascendant the patterns
of commerce and the financial system
were complementary. During a boom
healthy American demand lifted exports
everywhere even as American interest
rates pushed up the cost of capital. But now
the economic and financial cycles may
work against each other. Over time this will
lead other countries to switch away from
the dollar, but until then it creates a higher
risk of financial crises.
The final danger is that some countries
and firms will be caught in the middle, or
left behind. Think of Taiwan, which makes
semiconductors for both America and China,
or Apple, which relies on selling its devices
in China. Africa and South America
are not part of any of the big trading blocks
and lack a centre of gravity.
Many emerging economies now face
four headwinds, worries Arvind Subramanian,
an economist and former adviser to
India’s government: fading globalisation,
automation, weak education systems that
make it hard to exploit digitalisation fully,
and climate-change-induced stress in
farming industries. Far from making it easier
to mitigate the downsides of globalisation,
a regional world would struggle to
solve worldwide problems such as climate
change, cybercrime or tax avoidance.
Viewed in the very long run, over centuries,
the march of globalisation is inevitable,
barring an unforeseen catastrophe.
Technology advances, lowering the cost of
trade in every corner of the world, while the
human impulse to learn, copy and profit
from strangers is irrepressible. Yet there
can be long periods of slowbalisation,
when integration stagnates or declines.
The golden age of globalisation created
huge benefits but also costs and a political
backlash. The new pattern of commerce
that replaces it will be no less fraught with
opportunity and danger. 7
Chain reaction
Source: OECD *Measured by value added
Share of cross-border supply-chain foreign inputs*
that are from the same region, %
2
30
35
40
45
50
55
60
2005 07 09 11 13 15 16
Asia
European Union
North America
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

Describe the places of employment of the public health workforce, how the workforce is trained, and who is licensed or certified.

/in /by

◄ ◄
◄
The Public Health Workforce
Matthew L. Boulton, MD, MPH • Edward L. Baker, MD, MPH • Angela J. Beck, PhD, MPH
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be
able to:
1. Identify professions comprising the public health
workforce and describe efforts to determine the public
health workforce size and composition.
2. Describe the places of employment of the public health
workforce, how the workforce is trained, and who is
licensed or certified.
3. Describe the efforts underway to ensure and measure
the impact of public health workforce development,
including leadership development.
4. Describe the essential public health services delivered
by the public health workforce.
5. Define leadership and be able to distinguish leadership
and management.
6. Understand theories of leadership practice a_nd
the related behaviors needed to practice effective
leadership.
7. Understand the needs for leadership development at
various career stages.
KEY TERMS
certification
competencies
enumeration
leadership
licensure
management
multidisciplinary teams
voluntary health organizations
workforce
workforce capacity
307
308
INTRODUCTION
. l forefront of the
Public health is increasmgly at t 1e d re-emergent
national and global response to new anf d adly infechealth
threats ranging from ~utbreak:ho in ~he obesity
tious diseases, to the explosive gro~ . . and vioepidemic,
to disturbing increases m mff1urt~ public
lence makm. g the nee d fo r a l1 1· ghly e ec 1ve f that
health system as vital as ever. Perhaps no part O
public health system is as important as th~ pheo~t1~
who work within it as members of the pubhc ea .
workforce. A well-trained and competent workforce is
essential to the practice of public health and. the successful
delivery of essential public health services. The
professionals and other workers who comprise the
public health workforce share a common awareness
of and commitment to improving health through a
population focus. These workers are uniquely diverse
in terms of the education, skills, and experience they
bring to the field, especially relative to other health
professions. However, unlike other health professions,
the public health workforce has actually become
smaller over the last two decades. At the same time the
variety of occupations comprising that workforce has
diversified and includes new positions such as health
informatics specialists, public health geneticists, and
emergency preparedness professionals which mostly
did not exist just a decade ago. The opportunities for
public health worker training and education have also
grown dramatically as schools and programs of public
health have undergone an unprecedented expansion.
This has been accompanied by a rapid development
of continuing education and other training, often using
distance modalities, offered through national networks
of federally funded workforce centers. These
efforts are creating an increasingly professionalized
workforce that has been reinforced and strengthened
through complementary initiatives aimed at development
of competency-based education and training
worker certification, and accreditation of public health
agencies.
Despite these exciting developments, many contemporary
c?allenges confront attempts to fully characterize
the pubhc health workforce-there is still too little known
about how many workers it contains, the disciplines they
represent, wh~re they d~liver services and how effective
they are at domg so, their demographic composition, the
reasons they enter and leave the workforce, and how th
adapt to unstable funding impacting their job security a~~
future caree~ prospects. And, we continue to wrestle with
the appropnate _benchmarks that define the ideal mix of
educ~tlon, expenence, and diversity needed to produce an
effecnve workfor~e an? how that mix contributes to overall
workforce capacity. F_mally, there is a clear need for more
research on the pubhc health workforce to address these
PART FOUR
ON OF PUBLIC HEALTH SERVICES
pROViSI
l ensure that, ultimately, we hav
. and to a so . h kill . e
many questions f eople with the ng t s s m the right
the right nu~ber ~ Pe to improve and protect the public’s
t the nght um
place a . .
health. ludes with an extensive discussion
The chapter cone ctice of leadership consists of speof
Jeaders~ip. ~~ r~ead to the realization of a shared
cific behaviors :
1
~ plementation of core strategies and
vision through t e imerational reality of specific tactics
I. tion to op . . ·
the app ica t” e of leadership consists of specific
f the prac 1c .
There ore, . h 1 d to the realizat10n of a shared vih
. s whic ea .
be avior h . plementation of core strategies and
sion thr~ug~ t ~~:perational reality of specific tactics.
the apphcatihon . s has developed regarding the skills
A oft eone
range a ct· leadership; one of the most compelneeded
for eue ive · · l d h’
. ublic health practice IS servant ea ers 1p. As
lmg for P 1 leadership development needs to change
leaders evo ve, h” d I
d b ddressed by formal leaders Ip eve opment
an can ea h’ · I
programs. In public health, leaders I•p • IS cendtr ad to a· ddressing
the challenges and opportumties nee e to improve
and protect the public’s health.
PUBLIC HEALTH WORKERS
The effective delivery of public health services is dependent
upon the availability of a skilled, competent
workforce (the population employed in a specified
occupation). A key challenge for governmental and
nongovernmental public health organizations is to
employ the appropriate number of workers who possess
the requisite skills which can be used where and
when they are needed.1 The public health workforce
c~mpri~es a_ highly varied group of professions. The
wide diversity of skills, education, and experiential
~ack~rounds that public health workers bring to the
field ~s a strength given the multitude of factors that
contribute to population health· however it also ere·
ates cha.l l.e n ges · ‘ . ‘ . lil accurately determimno the size,
composition 1• b f . 0 bl’
h I h ‘ 0 unction, and expertise of pu ic
eabtl. whorkers, both individually and collectively. The
pu ic ealth w kf
ways, wi. th a f or orce has been defined in many
the comm i°cus on population health serving as
Accord. on e ement to define a public health worker.
lie heal~~gp:~r:~:i~nstit~t~ of Medicine (IOM) , a pu?health
or a 1 n~l is a person educated in pubhc
re ated dis · 1· ·
prove health th cip me who is employed to 101·
~mportance of t~ough a_ population focus.”2 Given the
mg and protect” e p~bhc health workforce in promot·
to understand ~~~ ; health of populations, it is ke)’
ployed and what k”ll any Workers are currently et11·
gaps in Workfor s 1 s they possess as well as where
d . ce cap · . ‘ .
an retain the . h ac1ty exist and how to recruH
health settings. ng t types of Workers in all public
CHAI”‘ I t:K IO I Ht: PUBLIC HE
ALTH VvOR
KFORCE
WORKPLACE SETTIN
public health workers Gs
f
. b . . can be£
0 10 settmgs m both bl’ 0 unct in .
h
• pu 1c and a Wide
of t ese settmgs may not b private variety
as places where public h
1
e traditionally s~tors. Some
services carried out theree~! s~rvices are ~el:racterized
to the public’s health non th e important co v~red, but
· d · e eless AI h ntnbuti
summa~1ze m this chapter e · t ough the _ons
of public health workers mploy substantial settings
. , not all w k numbe
these settmgs are necessa .1 or ers em I rs
workforce. n Y part of the p u b~li co yheedal tinh
Governmental Public H ealth
The core public health workf
l
. orce is
ernm. enta settmgs ‘ includ’m g 5 9 st et mployed in g ovpubhc
heal~h agencies, nearly 3 0 a e and territorial
partments (mcluding tribal a : OO local health dedes
that contribute to a pubY~n~ies), and federal agenthe
Department of Health icd :;1th
mission such as
vironmental Protection Ao an uman Services, En-
. l oency, and D
Agncu ture, among others W’th’ epartment of
government, public health ~o k
1
m all three levels of
. f r ers are found · ‘d
vari.e ty o programs that focus on areas such m a w1 e
environmental protection c00. . , 1’ d sa1ce ty h ealth a· s energy,
(.m clud.m oo Medicaid) ‘ 1· mmum.z at1. ons’, controlm osfu irnafneccenous
dis.e ases, maternal and child health , mentaI h ealth
occupat10nal health and safety, substance abuse i
health , traffic safety, sexually transmitted infec,tir;:~:
~elfare, and zoning. Many of these programs, orig~
mally developed as part of a department or board of
?ealth, have since been relocated or combined as policy
makers shift preferences for relating programs and
people. For example, pesticide control programs now
housed in agriculture were once part of health departments,
and the function of assuring access to care for
the poor encompassed by Medicaid may have been a
part of the jurisdiction of a board of health. The IOM
described an ideal state health agency that encompasses
all of these programs. :1 However, no such agency exists,
nor is one likely to appear. Consequently, public health
professionals must work collaboratively across program
and agency lines and among public and private and
voluntary partners.
Nongovernmental Public Health
f d in a range of set-
Public health workers can be o~nhealth agencies. For
tings beyond governmental pu~l~~ . dual schools (pub~
xample, school distric~s ao<l
1
~
0
1
v~any public health
he, private, and parochial) em~ s~hool-aged children.
nurses to assure the he_a~th ~nd environmental health
They may also have nutntion_ . t wi’de level to assure
· t a d1str1c –
professionals working a
309
the healthf I Inde, pendeun tn Wesast and safet y o f sc h ool meal programs
tri c• t s also em lo er, sew. er ‘ or waste management dis-·
that standard: fo; ~~1ti’,1c :ealth professionals to assure
In addition I ic ealth protection are met.
(an industry co~ v~ _untary health organizations
fund raising for hns;;hg organizations that engage in
cation, and patiente: :related research, health edufor
public health w ekrv1ces) represent another setting
a speci.a l case of or 1e rs • The Am en·c an Red Cross is
h eal t h and care-g·a v. o untIa ry. a gency, gi.v en the public
ivmg ro e 1t pl d •
response in coord’ . ays urmg emergency
. mat1on with I I officials. It also prov· d ?ca ‘ state, and national
ti~n in many localittesesf~:tens1ve public health educash1p
of HIV/ AIDS ‘ . example, through sponsororganizations
wit/:es~ent10n trai?ing. Other voluntary
elude the A • rong pubhc health presence inCancer
_mencan Lung Association, the American
the S?c1ety, _the American Heart Association, and
th American Diabetes Association. Although each of
ese ~mploys public health personnel, they also use
extensive. networks of volunteers’ some of whom are
also fu~l-t1me public health workers in other agencies
For th~ir. volu~teers who are not public health workers:
~he trammg given for volunteer tasks results in expandmg_
the public health knowledge within communities.
To Illus~ate, few communities would be as strict in control
of mdoor tobacco smoke today were it not for the
thousands of public health volunteers workino through
voluntary associations. Local communities ltlso often
have nonprofit groups with public health and human
services missions who provide important outreach to
the population through health education, health advocacy,
and other public health efforts.
Hospitals and Healthcare Organizations
Many hospitals and health care organizations (including
staff-model and other health maintenance organizations)
employ public health professionals. Many of
the administrators of personal health care services have
earned graduate degrees in administration from programs
housed in schools of public health, and may have
developed a population focus on their work. Among the
most common public health workers in these settings
are health educators, outreach workers, and epidemiologists.
A large institutional system may have its own
sanitarians, environmental engineers, and occupational
health staff as well. Further, many localities expect that
the clinical portion of public health services, such as
immunizations or home-based education and outreach,
will be housed with other care services, and not solely
in the public health agency, and often are inc?rp?1:ate1d
seamlessly into daily practices such as a pediatncrnn s
ongoing care. Conversely, it should be remem~ered,
however, that just providing a health-related service or
PROVISION OF PUBLIC HEALTH SERVl():s
PART FOUR i;;
310
activity outside the walls of a hospital does not mak~ it
a public health activitv. The test for whether something
should be considerei part of public health is the pr~sence
of a focus on a population group or commumt!
and on a preventive strategy or a preventable outcoi~e.
As public health and health care organizations continue
to implement mandates of the Patient Protection and
Affordable Care Act of 2010 (ACA),5 some of the job
tasks of public health workers and hospital workers
may become more integrated and shared across worker
settings.
cal health departments? Enumerations
state n1ul_ lo unt the number of workers ernpl tuct.
( t dies to co · · 0 ies s u d t f agencies or orgamzations) have bY e·d
in a defined se tohe U.S. public health workforce s·een
con ducte o. n te i’ts size. More recent ef f orts esti”‘ ince
Occupational Health
For workforce and other strategic considerations, occupational
health is a subspecialty of public health practice
that may take workers into almost any other field as
a part of the organization’s infrastructure. These public
health professionals include physicians (some board certified
in occupational medicine by the American Board
of Preventive Medicine), nurses, epidemiologists, and industrial
hygienists, and are involved primarily with protection
of workers from hazardous working conditions.
Some also develop workplace-based health promotion
programs or even broader health programs for workers
and their families. Workers concerned about their
health and safety may also employ public health expertise
through unions or professional associations. For
example, occupational health advocates on the staff of
the American Nurses Association were leading activists
in supporting legislation protecting health care workers
from occupational exposure to blood-borne pathogens.
WORKER ENUMERATION
1908 to est1ma •11ated
ublic health workers per 10?,000 population in
220 p while a national enumeration_ study conducted
1. 98200,0 0 y1. e lded a total of approxim. ately 450 ,O oo 10 t· nally equivalent to a ratio of 158 pub\’ workers na 10 • 1 . 7 1c
k s per 100,000 popu at1on. These stud
health wor er f ” bl’ h ·
. d d’fferent definitions or pu ic ealth Worker”
1es use 1 d 11 t· ak’
d•ff t methods for ata co ec ion, m mg trend
and 1 eren . . 1 Th
. s over time d1fficu t. e most recent enu
comparison . 14 . 1 d .
merat.i on st udy , conducted m 20 , m· e u he s workers in
l l t te and federal health agencies w o are respono’bcla
‘ fs a th’e delivery of essent·i aI pub l1’ c h ea1t h services, s1 e or . . h d .
which is a narrower defimt10n_ t an use m previous
stu d1. es. In this study, approxim.a tely 291,000 pub- 1
.
lie health workers in 14 occupat10na categories were
enu merated using survey data collected by multiple 8 • organizations (see Table 18-1), eqmva1 ~ nt to a rate of
92/100,000 population. Half of the pubhc health workforce
worked in local health departments, which is not
surprising given that the majority of public health services
are provided at the local level; 30 percent worked
in state health departments and 20 percent at federal
health agencies. Additional detail on the recent trends
in governmental workforce data is provided in Chapter
8 (for state health departments) and Chapter 9 (for
local health departments). Enumeration studies provide
valuable information for assessing the size of the workforce,
but usually provide limited information on other
characteristics of the workforce, such as demographics,
Unlike for other health professions such as physicians
and nurses, the U.S. government does not employ a system
for continuously collecting data to count or characterize
the public health workforce. The U.S. Bureau of
Labor Statistics (BLS) produces employment and wage
estimates annually for over 800 professions. 6 Although
public health workers are included in these estimates,
most cannot be counted because they are grouped
within broader health care professions categories that
lack sufficient precision to specifically determine who is
a public health worker. As a result, public health professional
organizations and public health systems researchers
undertake national surveys and studies in an attempt
to collect information on different segments of the
workforce. Most studies are conducted with state and
local health departments because these agencies are easily
identifiable, have a clear public health mission, and
are often willing to participate in such research activities.
Among the most basic of research questions studied
is How many public health workers are employed ‘in
education and training background, and job function
because most data are collected from the organization,
rather than from individual workers.
Public Health Occupations
The occupational categories listed in Table 18-1 represent
the primary professions of public health workers.
The occupational diversity of the workforce is apparen~.
~everal disciplines, each with their own skills and
trammg requirements, work in multidisciplinary teains
t~ contribute to the overall delivery of public health services
· Ad mi·m ·s trat1·v e and clerical personnel, who in~Y
not have a degree in public health but support public
hhealth program activities in local state and federal
ealth. de partments, represent almo’s t 20 p’ ecr cent ofth e
;
0 ~~-fo~e. The largest proportions of workers trained in
(;6 ic ealth service delivery are public health nurses
ers (~ercent), followed by environmental health work-
0th percent), _and public health managers (6 percent).
er occupations w·th f l boratory workers b .1 ewer workers include ~ ‘ pu he health physicians, behav1ora
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
rJ\BLE 18-1 Public Health Workforce Occ .
upat,ons and Enumeration Estimates, 2014
occupation
Administrative/
Clerical
personnel
Public Health
Nurses
Environmental
Health Worker
Public Health
Manager
Laboratory
Worker
Public Health
Physician
Behavioral
Health
Professional
Job Description
Staff who work in bus· f·
d . . mess, inance, auditing, management,
~n accountin~; trained at a professional level in their
f1ehld of expertise before entry into public health · staff
w. o p.e rform support work ·1 n areas of busi.n ess a’ nd
financial operations; and staff who perform nontechnical
supf=’.ort wo_rk in all areas of management and program
adm1n1strat1on.
Wor~ers who plan, develop, implement, and evaluate
nursing and public h_ealth interventions for persons, families,
and_ f?0 Pu!at1o~s. at nsk for illness or disability. This includes
pos1~1ons 1dent1f1ed at the registered nurse (RN) level,
and include~ graduates of diploma and associate degree
programs with the RN license.
Staff who plan, develop, implement, and evaluate standards
and systems to improve the quality of the physical
environment as it affects health; manage environmental
health programs; perform research on environmental health
problems; and promote public awareness of the need to
prevent and eliminate environmental health hazards.
Health service managers, administrators, and public health
directors overseeing the operations of the agency or of
a department or division, including the senior agency
executive, regardless of education or licensing.
Staff who plan, design, and implement laboratory
procedures to identify and quantify agents in the
environment that might be hazardous to human health,
biologic agents believed to be involved in the e~iolo_gy of
diseases among animals or humans (e .g., bacteria, viruses,
or parasites), or other physical, chemical, and biologic
hazards; and laboratory technicians who plan, perform, and
I te laboratory analyses and procedures not elsewhere
eva ua . d ‘ I
classified, including performing routine tests 1n a me 1ca
laboratory for use in disease diagnosis and trea~ment;
prepari·n g v accines, biologics, and serums for disea. se
preven t’1 0n; preparing tissue samples for pathologists or
taking blood samples; and executing laboratory tests (e.g .,
urinalysis and blood counts).
Physicians who identify persons or groups at risk for illness
or d ‘1 sa b1T1 t y an d who develop ‘. implement, and evaluate
programs or · terventions designed to prevent, treat, or r in . . . . h risks· might provide direct medical services
ame ,orate sue , . • d ‘ I
. h’ h text of such programs, 1nclud1ng me 1ca
Wit In t e con r d . I’ d d d tor of osteopathy genera 1sts an spec1a 1sts,
octor an oc . • I h ·
f h have training in public hea t or preventive
some o w om
medicine.
h vide psychological support and assess,
Worke.r s w o pdr om onitor provision of communi·t y servi·c es f or
coo.r dinate, aI’n ts Includes soc1·a I work ers.
patients or c ,en ·
35,000
29,191
13,300
10,100
2,000
2,100
4,000
1: <
311
1 •
II I,
1· ,
I
,, 1
14,559 6,085 55,644
12,286 5,793 47,270
4,618 5,920 23,838
3,296 4,998 18,394
5,699 5,685 13,384
791 6,700 9,591
1,839 895 6,734
PART FOUR PROVISION OF PUBLIC HEALTH St1:1
“Vl~~S
TABLE lS-l (Continued)
Workers who design, organize, implement, communicate,
evaluate, and provide advice regarding the effect of
educational programs and strategies designed to support
and modify health-related behaviors of persons, families,
organizations, and communities.
Nutritionist
Epidemiologist
Emergency
Preparedness
Staff
Public Health
Dental Worker
Public Health
Informatics
Specialist
Public
Information
Specialist
Staff who plan, develop, implement, and evaluate programs
or scientific studies to promote and maintain optimum
health through improved nutrition; collaborate with
p~o~rams that have nutrition components; might involve
clm,cal practice as a dietitian.
Staff who investigate, describe, and analyze the distribution
and determinants of disease, disability, and other health
outcomes and develop the means for disease prevention
and control; investigate, describe, and analyze the efficacy
of programs and interventions.
Workers whose regular duties involve preparing for
(e.g., developing plans, procedures, and training programs)
and managing the public health response to all-hazards events.
Staff who plan, develop, implement, and evaluate dental
health programs to promote and maintain the public’s
optimum oral health, including public health dentists
who can provide comprehensive dental care and dental
hygienists who can provide limited dental services under
professional supervision.
Workers who systematically apply information and
computer science and technology to public health practice,
research, and learning (e.g., public health information
systems specialists or public health informaticists).
Staff who represent public health topics to the media and
public, act as a spokesperson for public health agencies,
engage in promoting or creating goodwill for public health
organizations by writing or selecting favorable publicity
material and releasing it through different communications
media, or prepare and arrange displays, make speeches,
and perform related publicity efforts.
Other or
Uncategorized
Worker
Public health workers in occupations not listed in the
previous categories; workers who cannot be placed in a
category due to missing data
TOTAL
6,715
5,000 1,276 223 6.499
1,800 2,476 4,276
2,900 810 3,710
2,600 356 443 3,399
2,100 729 2,829
2,100 174 2,274
30,200 35,960 20,271 86,431
147,491 86,411 57,056 290,988 ==————– SOURCE: Beck, A.J. and Boulton, M.L.
h 1th professionals, health educators, nutritionists,
e~demiologists emergency preparedness staff, public
ep1 ‘ . . f . . . l
health dental workers, pubhc health _m ormat1cs ~pecia –
1· sts, an d publi· c information specialists. Approxunately
30 percent of the workforce in this study was repre·
sented by an undesignated occupation or was unas·
signed to a category due to underreporting of workforce
information. This further supports the need for n1ore
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
stan dardized metho. dologies for collecting workforce 1· 11-
ation on a national level.
forrn
public health workers who are often excluded from
st public health workforce enumeration studies are
rn’:nrnunity health workers, individuals who conduct
co treach for medical personnel or health organizations
ou . h
irnplement programs m t e community that pro-
:ote, maintain, and improve individual and community
health . 6 Community health workers, sometimes
called lay he~lth workers or ?romotoras, depending on
the community, are a growmg segment of the public
health work_forc_e; they may_ be volunteer or paid, are
found workmg m any pubhc health setting, and generally
do not have a formal educational background
in public heal~h, but are trained to help deliver public
health services to the population. The BLS recently
began collecting data on this segment of the workforce
and estimated that 45 ,800 community health workers
were employed in the United States in 2013, excluding
self-employed and volunteer workers for which
enumeration estimates are unavailable. The number of
employed, paid workers in this discipline is similar to
the number of public health nurses enumerated in oovemmental
public health settings. This diverse grou; of
public health workers could soon represent the largest
group of public health workers in the United States.
Workforce Taxonon-1y
One method for improving the quality of data related
to enumeration and other workforce characteristics is
to develop a common system for classifying workers.
A public health workforce taxonomy was developed
in 2014 by several public health professional groups
and federal agencies providing a framework for worker
classification that could lead to a much clearer picture
regarding workplace settings, type of employment, job
tasks, funding sources for workers, educational background
, licensure and certification , and worker demographics.
9 The taxonomy’s occupational categories,
which include far more than the 14 occupations used
in the most recent enumeration study, provide more
specificity on the types of disciplines represented in the
~ublic health workforce (see Table 18-2). Broadly, pubhe
health occupations can be grouped into four main
categories: management and leadership; professional
and scientific; technical and outreach; and support services.
The workforce taxonomy provides a mechanism
for standardizing the classification of public health occupations
across different workforce surveys, which has
been a persistent challenge for workforce researchers,
~ermitting more valid comparisons while also provid~
ng a framework for ensuring collection of a set of minimum
data elements on all workers in the public health
Workforce.
313
TRENDS IN PROFESSIONALIZATION
The field of public health has been aptly described
as a “loose confederation of professions” because t~e
breadth of skills and experience needed by pubhc
health workers requires highly diverse back~round_s
representing many different disciplines. Histoncally, it
was commonplace for workers in health d~part~ents,
for example, to be primarily trained on the Job w~th no
public health degree and little or no formal educat10n or
even training in public health. However, that began to
change with the IOM’s 1988 report, The Future of Public
Health, which prominently acknowledged th~ need
for significant changes in the training and educat10n of
the national public health workforce, including acces_s
to more educational offerings. That need was dramatically
highlighted and reinforced in the follow-on 2003
IOM report, Who Will Keep the Public Healthy in the
21st Century?, which recommended that the CDC and
Health Resources and Services Administration (HRSA)
“periodically assess the preparedness of the public
health workforce, to document the training necessary to
meet basic competency expectations and to advise on
the funding necessary to provide such training.” These
ongoing efforts to further develop the skills and competence
of the existing public health workforce have increased
substantially since 2000, with greater emphasis
on certification and licensure of public health workers,
and accreditation of governmental public health departments.
Although it may have been true at one time that
public health workers learned most skills on the job and
that any worker in the health department could perform
almost any job task in a pinch, even without any training
or education in that area, that is rapidly becoming
an outmoded perspective and no longer true nor feasible
in the modern public health workforce. As several
enumeration and other workforce studies have revealed
the public health workforce is becomino increasinol~
professionalized as workers are charged
0
with carryhi~
out more complex, specialized, and technical tasks tha~
c~ll for an appropriate level of educational and profess10nal
background training. This has been driven, in
part, b! the enormous changes occurring in health informat10n
technology with the advent of advanced webbased
com?1′:1nicab~e disease surveillance systems, ever
more sophisticated immunization information systems
the ?evelo~ment of large and complex health registries:
the tncreastng use of electronic health records and th
need_ to u~ilize “big data” to improve health, all ,of whic~
r~qmre high levels of technical and professional expertise.
For example, a 2002 national study found that
over 40 percent of epidemiologists in state health depa~
tme?ts lacked any education or formal training in
ep1dem~ology;10 similarly a state health department reported
m 2006 that over 60 percent of their workforce
I 1
………
l I ,
I I
I I
314 PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
TABLE 18-2 A Taxonomy for the Public Health Workforce
1.4. Management and Leadership
1.4.1. Public Health Agency Director
1.4.2. Health Officer
1.4.3. Department or Bureau Director
(subagency level)
1.4.4. Deputy Director
1.4.5. Program Director
1.4.6. Public Health Manager or Program Manager
1.4. 7. Other Management and leadership
1.4. 7. 1 . Coordinators
1.4.7.2. Administrators
1.5. Professional and Scientific
1.5.1. Behavioral Health Professional
1.5. 1.1 . Behavioral Counselor
1.5.2. Emergency Preparedness Worker
1.5.3. Environmentalist
1.5.3.1 . Sanitarian or Inspector
1.5.3.2. Engineer
1.5.3.3. Technician
1.5.4. Epidemiologist
1.5.5. Health Educator
1.5.6. Information Systems Manager
1.5.6.1. Public Health Informatics Specialist
1.5.6.2. Other Informatics Specialist
1.5.6.3. Information Technology Specialist
1.5.7. Laboratory Worker
1.5. 7. 1. Aide or Assistant
1.5.7.2. Technician
1.5.7.3. Scientist or Medical Technologist
1.5.8. Nurse
1.5.8.1. Registered Nurse Unspecified
1 .5.8.1.1. Public Health or
Community Health Nurse
1 .5.8.1.2. Other Registered Nurse
(Clinical Services)
1.5.8.2. licensed Practical or Vocational
Nurse
1.5. 9. Nutritionist or dietitian
1.2.
1.3.
1.5
1 _ 1.1. Oral Health Professional
1.1 .1.1. Public Health Dentist
1.1.1 .2. Other Oral Health Professional
1.1.2. Physician
1.1.2.1. Public Health or Preventive
Medicine Physician
1.1.2.2. Other Physician
1.1.3. Medical Examiner
1.1.4. Physician Assistant
1.1.5. Public Information Specialist
1.1.6. Social Worker
1.1 .6.1 . Social Services Counselor
1. 1. 7. Statistician
1.1.8. Veterinarian
1.1.8.1. Public Health Veterinarian
1.1.8.2. Other Veterinarian
1.1. 9. Other Professional and Scientific
1.1.1 O. Student Professional and Scientific
Technical and Outreach
1.2.1 . Animal Control Worker
1.2.2. Community Health Worker
1.2.3. Home Health Worker
1.2.4. Other Technical and Outreach
Support Services
1.3.1 . Clerical Personnel
1.3.1.1 . Administrative Assistant
1.3.1 .2. Secretary
1.3.2. Business Support
1.3.2.1. Accountant or Fiscal
1.3.2.2. Facilities or Operations
1.3.2.2.1. Custodian
1.3.2.2.2. Other Facilities or
Operations Worker
1.3.2.3. Grants or Contracts Specialist
1.3.2.4. Human Resources Personnel
1.3.2.5. Attorney or Legal Counsel
1.3.3. Other business support services
Other
SOURCE: Boulton, M.L. , Beck, A.J., Coronado, F., Merrill, J., Friedman, C. et al.
Jacked a college degree of any type. 11 However, just a
decade later a repeat of the national epidemiology assessment
revealed over 60 percent of epidemiologists
working in health departments possessed a public
health or epidemiology degree and almost 90 percent
had received at least some formal training in epidemiology
(although this may constitute just a single epidemiology
course12). The Jack of formal training within the
workforce resulted in workers who were cross-trained to
fulfill many types of duties: a public health nurse may
have also performed duties of an epidemiologist, such
as outbreak investigation; a health educator may have
also assisted with health facility inspection. Although
the public health professionals continue to work in
multidisciplinary teams (work groups composed of
or combining several usually separate fields of expertise)
and are cross-trained to some extent, public health
disciplines have become much more specialized as t~e
number of accredited schools and programs of public
health have increased in the United States (Figure 18-1).
PUBLIC HEALTH EDUCATION
The first U.S. school of public health was founded in
1916 but the process of formally accrediting these
schools did not begin until the 1940s; two decades
later, the first program of public health (outside of~
school of public health) was accredited. The number 0
schools and programs grew steadily until the 2000S nt
◄
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE 315
70 en
E e en 60
£ 50
“O
C ca en 40
0 ——
0 ~ 30 u —– 50
(/) – 0 20
.! E 10
:::I z
0
—— – – – 31
0 —- 5 — 17
9 13
6 6 5 7
1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s
Decade
\ D Programs D Schools \
FIGURE 18-1 The Growth of Schools and Programs of Public Health in the United States, 1940s-201 Os
which point a dramatic and rapid expansion occurred
(see Figure 18-1). The increased availability of public
health degree programs at the graduate level and, more
recently, at the undergraduate level, in on-campus and
distance learning formats has greatly improved the accessibility
of public h ealth education. Not all public
health graduates choose to work in public health practice;
however, it seems reasonable to expect increases
in the percentage of public health workers with formal
public health education in future years.
The academic core of a public health Master’s (MPH)
degree program, which is the most common type of public
health degree, includes courses in the following five
areas: biostatistics, epidemiology, environmental health
sciences, health services administration/policy, and social
and behavioral sciences, described in Table 18-3. All
schools and programs of public health accredited by the
Council on Education for Public Health (CEPH), the main
national accrediting body, are required to offer courses
in these areas; many also offer courses in areas such as
global public health, health information/informatics, public
health genetics, health disparities, and maternal and
child health, among other specialty areas. Some of these
areas have more recently been developed into formal degree
offerings; in particular global public health, public
health preparedness, and health information technology
are offered as MPH concentrations through a number of
schools and programs of public health.
TABLE 18-3 Knowledge Areas of the Core Academic Components of Accredited Master of Public Health Programs
Biostatistics
Epidemiology
Environmental Health Sciences
Health Services Administration
Social and Behavioral Sciences
………
SOUR.c E: C-oun-cil on Educatt. on for p u blic Health
l
Collection, storage, retrieval, analysis, and interpretation of health data;
design and analysis_ o’. health-related _surveys and experiments; and concepts
and practice of stat1st1cal data analysis
Distributions and determinants of d isease, disabilit ies and death in human
populations; the c~aracteristics and dynamics of human populations; and the
natural history of d isease and the biolog ic basis of health
Environmental factors including biolog ical , physical, and chemical factors that
affect the health of a community
Plann ing, organization, ad1;1 inistration , management, evaluation, and policy
analysis of health and public health programs
Concepts and methods of social and behavioral sciences relevant to the
identification and solution of publ ic health problems
I
316
Continuing Education
Beyond educatin_g students for future work in public
health, substantial resources have been invested by
schools of public health and other public health organizations
to train current public health workers.
The !OM reported that schools of public health have
a responsibility to ensure that appropriate, quality
education and training are available to public health
professionals, other members of the public health
workforce, and health professionals who participate in
public health activities. 2 As a result, federally funded
training centers were developed at schools of public
health across the country to train the existing public
health workforce in foundational public health skills.
A large national network of Public Health Training
Centers (funded by the HRSA) and CDC-funded Preparedness
and Response Learning Centers have offered
trainings using distance learning and a variety
of other modalities to offer instruction which is provided
by public health professionals and faculty covering
a diverse array of public health topics ranging
from short courses related to the five academic core
areas of public health, to emergency preparedness and
response. These trainings tend to be more applied in
nature in order to provide knowledge and skills that
the public health worker can integrate into his or her
daily job tasks immediately and often provide continuing
education credit to meet certification or licensure
requirements.
Licensure and Certification
In keeping with trends of greater professionalization
and training of the public health workforce, there has
been a concurrent increase in the requirement for and
monitoring of worker licensure and certification.
There are several methods for verifying that workers
are adequately trained and capable of performing the
duties required by their positions. Some health professionals
are required to obtain a state license by passing
an examination in order to practice their profession. Examples
common among public health workers include
M.D. licenses for physicians, R.N. licenses for nurses,
R.S. licenses for sanitarians, and R.D. licenses for dietitians.
Maintaining licensure generally requires the
worker to complete training courses to achieve a minimum
number of continuing education credits within
specific time intervals and then report those credits periodically
to a state licensing board. Licensure may be
an effec.tive way to ensure workers continue to hone and
maintain their skills; however, only a minority of the
overall public health workforce is eligible for licensure,
as there is no license for most disciplines within the
public health workforce.
◄
PART FOUR PROVISION OF PUBLIC HEALTH SERVICES
Worker certification is another common method f
encouraging workforce development. Unlike licensu~r
certification is usually voluntary, ~!though_ some Pub:
lie health organizations _and a_ge?c1es m~y mdividual!y
require worker certification. Su~ilar to hcen_sure, Workers
achieve certification by pass!~g a~ ex~mmation and
maintain certification by part1c1patmg m continuin
education opportunities. _Ther~ are many examples 0~
public health worker cert1ficat10n; however, a cenification
open to public health workers of all educational
backgrounds and disciplines does not yet exist. Perhaps
the closest example of a uniform certification for public
health workers is the Cert!fied in Public Heal~h (CPH)
credential. In 2005, a Nat10nal Board of Pubhc Health
Examiners, comprising representatives from academic
and practice organizations,. was _formed to develop and
administer a voluntary cert1ficauon exam for graduates
of public health schools and programs. The CPH is intended
to distinguish public health workers who have
“mastered knowledge and skills relevant to contemporary
public health.”13 Eligibility for certification was
expanded in 2013 to include public health professionals
who have taken core public health courses at an accredited
institution and have relevant job experience or
other education. The CPH is the field’s only certification
for which all public health disciplines are eligible.
Other examples of certification in public health are
discipline specific. Physicians and nurses may achieve
board certification in public health through a combination
of completing clinical or preventive medicine
residency programs, successfully passing board examinations,
and enrolling in other advanced training
or fellowship programs. Workers with a degree and/
or substantial experience in health education are eligible
to sit for a Certified Health Education Specialist
(CHES) exam, which is also offered at a Master’s level
for advanced health educators. Finally, public health
laboratory workers are eligible for a variety of generalist
and specialist certifications within their field.
WORKFORCE COMPETENCIES
Public health education and training, whether provided
by a school of public health or through a training
center’s online offerings, is increasingly being guided
by the development of competencies. Competencies
form the cornerstone of efforts by schools and pro·
grams of public health, governmental public health
agencies, and many public health professional groups
to more systematically ensure that public health work·
ers are equipped with the appropriate level of skills
and knowledge to competently and effectively carry out
their work.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
public health workforce competencies are the
foundational_ knowledge, ski!ls , and abilities necessary
for pubhc_ health profe~s10nals to efficiently and
ffectively deliver the services deemed essential to
;ublic h~alth . Competencies the~selves should be
action-oriented and clearly describable, observable,
and measurable. The CDC, IOM, and the Association
of Schools and Programs of Public Health (ASPPH)
have all strongly endorsed competency development
in order to strengthen the public health workforce.
Competencies improve the workforce by providing a
framework for developing educational and training
programs, delin_ea:ing worker roles and responsibilities
, and perm1ttmg a means for assessing worker
performance and organizational capacity. The first
public health workforce competencies were developed
in the 1980s; more recently many national public
health worker specialty groups including the Council
of State and Territorial Epidemiologists (CSTE) , the
Association of Public Health Laboratorians, the Quad
Council of Public Health Nursing Organizations, the
TABLE 18-4 Public Health Workforce Competency Sets
317
National Commission for Health Education Credentialing,
and the CDC, among others, have develope_d
comprehensive worker competencies specific to their
profession (see Tobie 18-4). 14-18 These practitioner and
profession-specific competencies are complemented by
more general public health competencies such as the
Core Competencies for Public Health Professionals d~veloped
by the Council on Linkages Between Academ~a
and Public Health Practice-developed for all public
health workers19-and the more academically oriented
public health core competencies for MPH students enrolled
in academic degree programs, developed by the
ASPPH Education Committee. For educational accreditation
, CEPH requires academic programs to clearly
identify the competencies expected of their graduates
and to indicate how course-specific learning objectives
will lead to the acquisition of these competencies.
2° Competencies are further addressed in detail in
Appendix B.
A common basis for many of these public health
worker competencies is the 10 Essential Services of Public
Competency,~~:~ Lead Organization -·=• ‘ -· ·~ ·’ · · – –~ ., Date’· Notes ·
Bioterrorism and Emergency Readiness: Columbia University School of Nursing 2002
Competencies for All Public Health Center for Health Policy & Centers for
Workers Disease Control and Prevention
Applied Epidemiology Competencies Council of State and Territorial 2006 Three tiers: Beginner,
Epidemiologists Midlevel, and Senior
Epidemiologist
Master’s Degree in Public Health Core Association of Schools of Publ ic Health 2006
Competency Development Project (v. 2.3)
Competencies for Public Health Centers for Disease Control and Prevention & 2009
lnformaticians University of Washington Center for Public
Health Informatics
Areas of Responsib ility, Competencies, National Commission for Health Education 2010
and Subcompetencies for Health Credentialing, Inc.
Education Speciali sts
Ouad Council Competencies for Public Quad Council of Public Health Nursing 2011
Health Nurses Organizations
Guidel ines for Biosafety Laboratory Centers for Disease Control and Prevention 2011
Competency
Competency Guidelines for Publ ic Health Centers for Disease Control and Prevention & 2014
Laboratory Professionals Association of Publ ic Health Laboratories
Core Competencies for Pub lic Health The Council on Linkages Between Academia 2014 (This is the newest
Professionals and Public Health Practice version)
/’ I I’
I’ I
• I
I
318
Health (ESPH) (Tobie 18-5), described earlier in this text?
ook (see, e.g., Chapters 1, 2, and 11). First formulated
m_ 1994 by the Public Health Functions Steering Com’.~
ttee, these 10 key services summarize the major activities
of ~he workforce in carrying out the responsibilities
of pubhc health and form the core from which necessary
worker knowledge, skills, and abilities are derived. For
example, the CSTE Applied Epidemiology Competencies
and the six national capacity assessments based on those
competencies focus on them largely in the context of carrying
out just four ESPH which are perceived to have a
significant epidemiological focus: ESPH 1 (Monitoring),
2 (Investigate), 9 (Evaluate), and 10 (Research).
PUBLIC HEALTH WORKFORCE
CAPACITY
There have been an increasing number of researchers,
practitioners, and policy makers acknowledging the
need to identify factors that contribute to workforce
capacity, or the ability of the public health workforce
to perform the necessary tasks to effectively deliver the
essential public health services. Deficiencies in organizational
capacity have been theorized to negatively impact
TABLE 18-5 The 10 Essential Public Health Services
1. Monitor health status to identify community health
problems.
2. Diagnose and investigate health problems and
health hazards in the community.
3. Inform, educate, and empower people about health
issues.
4. Mobilize community partnerships to identify and
solve health problems.
5. Develop policies and plans that support individual
and community health efforts.
6. Enforce laws and regulations that protect health and
ensure safety.
7. Link people to needed personal health services, and
assure the provision of health care when otherwise
unavailable.
8. Assure a competent public health and personal
health care workforce.
9. Evaluate effectiveness, accessibility, and quality of
personal- and population-based health services.
1 O. Research for new insights and innovative solutions to
health problems.
SOURCE: Centers for Disease Control and Prevention
PART FOUR PROVISION OF PUBLIC HEALTH SERV1ces
the ability to sustain public health programs and i
ventions 21 -22 an d work fo rce capac1• t y contri.b utesn te.r –
nificantly to the overall capacity of an organizatio sig.
deliver services. ~~ny f actors can contn’b u te to Wno rtko.
force capacity. Ind1v1dual factors such as educational
training background , J.O b experi.e nce, an d J. o b satisfactain d
may play a role, as well as organizational factors such on
whether the organization suppor.t s c.o ntinu. ing educati· oans
for employees. Workforce capacity 1s an ~mportant concept
that needs further research to determme how it m
h t t . . ay
be enhanced and to w at ex en orgamzational performance
may be improved as a result. Consensus amon
public health systems and services researchers and publi~
health practitioners as to how and what to measure in order
to most accurately assess workforce capacity remains
elusive although interest in this area continues to grow.
Public Health Department
Accreditation
Accreditation is the process by which health department
performance is assessed against a set of nationally recognized,
practice-focused and evidence-based standards
that are continually developed and revised. Ultimately,
the goal of the national accreditation program is to improve
and protect the health of the public by advancing
the quality and performance of tribal, state, local,
and territorial health departments while also increasing
value and accountability to public health stakeholders.
The Public Health Accreditation Board (PHAB), a
nonprofit entity charged with developing accreditation
standards and measures as well as evaluating health departments’
abilities to achieve them, strongly supports
development of the nation’s governmental public health
workforce. In addition to the various standards and
measures that detail tasks and responsibilities expected
of public health workers, there are also accreditation criteria
that focus on ensuring that a sufficient number of
workers are staffing health departments, and that those
workers are well-qualified. PHAB encourages the development
of a competent workforce by requiring health
departments to regularly assess staff competencies and
address gaps through training opportunities. 23-24 The
PHAB standards and measures include a domain focused
on maintaining a competent public health workforce.
The two standards within this domain require
health departments to: encourage the development of
a sufficient number of qualified public health workers;
and, ensure a competent workforce through assess·
me_nt_ of staff competencies, the provision of individu~
t~ammg and professional development, and the pr~vi·
s1on of a supportive work environment. 24 Accreditation
measur~s such as these promote the development of _a
well-tramed workforce that can effectively deliver public
health services in health departments.
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
WORKFORCE RESEARCH
Research on the public health workforce is typically inJuded
under the broader umbrella of public health sere.
es and systems research (PHSSR) which is defined as
VlCfi eld of study t h at exami.n es t h e organization, finance,
and delivery of public health services in communities
:nd the impact of these service~ on public health.
In the last few years especially, numerous national
workgroups have been convened, meetings held, and papers
written on public health workforce research needs.
Recently, a number of central themes have been developed
to guide the public health workforce research agenda25
and public health workforce has been specifically identified
as one of the four main thematic areas of PHSSR in
a 2012 journal supplement (as shown in Tobie 18-6).2<>
The progress in the conduct of research on these themes
varies and, for example, while the evidence base on public
health worker enumeration and competency development
have both rapidly advanced, in contrast we have
made very little headway in examining issues around (the
Jack of) workforce diversity and disparities, or in addressing
the clear lack of diversity in the current public health
workforce, especially in leadership positions. Nonetheless,
these themes provide a research roadmap that hopefully
will establish a basis for guiding future efforts to develop
a competent, sustainable, and diverse public health workforce
through evidence-based training, career and leadership
development, and strategic workforce planning to
improve population health outcomes.
LEADERSHIP
Leadership is the “process of persuasion or example by
which an individual influences a group to act toward a
common goal.”27 In this definition emphasis is placed
on the processes associated with the practice of leadership
(rather than the personality of the leader)• It
then follows that effective leadership is characterized by
TABLE 18-6 Public Health Workforce Research
Priority Areas
Worker enumeration
Demand, supply, and shortages
Diversity and disparities
Recruitment and retention
Workforce competencies
Educational methods and curricula
SOlJR.CE: Consortium from Altarum Institute, CDC: th~ Robert
Wood Johnson Foundation, and the National C00rdmat1ng Center
for Public Health Services and Systems Research
319
adherence to certain behaviors which can contribute to
improved performance by “followers” and to increased
organizational effectiveness.
In this section, some of the theoretical resea_rch
on leadership practice will be reviewed with a parti_cular
emphasis on applicabilit~ to publ_ic heal~h pract1
::~
Since an emphasis on practice and 1mprovn1:g lea~
ship behaviors flows from that research, a d1scuss10n
of various programs desigi:ied to enh_ance p~blic healt~
leadership development will be provided. Fmall~, som
guiding principles and best practices will be delmeated
as a guide for future leader development.
Leadership versus Management
The processes of leadership and manage~e~t ar~ different.
The process of leadership has been d1stmgm~hed
from the process of management by the aphons~:
“leadership is doing the right thing, management 1s
doing things right.”28 Perhaps the most useful framework
for distinguishing the two processes came from
Kotter. 29 In his formulation, management is designed
to provide order and consistency; leadership is designed
to provide change and movement. To accomplish these
goals, management consists of planning and budgeting,
organizing and staffing, and controlling and problem
solving. Leadership is about providing direction, aligning
people, and motivating and inspiring. 29
Another approach to distinguishing the practices
of management and leadership30 focused on the role
of leaders as providing a compelling vision and core
strategies while management involved translating strategies
into operational reality using specific tactics. In
this formulation, a vision should be “something you can
see”-a visualizable mental picture that is easily communicated
to others. Strategies provide the logic and limited
details for how the vision can be achieved. In public
health, programs are created to operationalize the strategies
and apply concrete tactical solutions to problems.
Theories of Leadership Practice
The commonly used statement that “leaders are born
and not made” derives from a trait perspective toward
leadership.27 As a result of this emphasis, early research
on leadership practice focused on the personal attributes
of effective leaders, leading to the erroneous view
that a basic set of unique traits could be delineated and,
as a result, aspiring leaders should be assessed with respect
to those ideal traits. Selection for leadership positions
then utilized an assessment and matching process.
In the mid-twentieth century, this point of view
was called into question as an era of leadership development
began. Since the trait theory of leadership provides
a very static view of what a leader is and should
I
320
be, ~ystematic development of leadership skills and be~
aviors was devalued. Once this static view was called
mto question, the research field expanded to consider
a range of theoretical foundations that led into formal
approaches to developing leaders.
The Skills Approach
Seminal research31 •32 in the mid- to late-twentieth century
created a useful framework for the elucidation of
the skills needed for effective leadership. Katz’s 1955
paper considered the skills needed at various levels
of an organization. At the supervisory level, technical
and human skills are needed to a greater degree than
con~~ptual skills. As one moves “up” into a managerial
position, ~II ~h~ee skill areas take on equal importance.
Once_ an m~1vidual reaches a top leadership position,
techmcal skill becomes less important while human and
conceptual skills are paramount.
. Mui:nfo_r~ went further by focusing on the relationship
of md1V1dual attributes and competencies as they
relat~ to leadership outcomes, such as effective problem
solvmg and enhanced performance. 32 In his formulation,
there are four key individual attributes:
► General Cognitive Ability
► Crystallized Cognitive Ability
► Motivation
► Personality
These attributes contribute to specific leadership
competencies:
► Problem-solving skills-especially when dealing
with novel and ill-defined problems
► Social Judgment skills-the capacity to understand
people and social systems
► Knowledge-the accumulation of information
needed to apply skills to a particular situation,
along with the ability to mentally structure and
communicate that knowledge
This skills-based framework has fostered the use of a
range of educational approaches designed to enhance
creative problem solving, conflict resolution, listening,
and teamwork. 27
The Situational Approach
Building upon the skills approach, research then evolved
to consider ways in which leadership styles should be
adapted to different situations, particularly as they relate
to the developmental level of the follower. 33 This approach
takes into account the degree to which leaders should focus
energy and attention on tasks versus the development
of relationships. For example, in situations where the “follower”
is less developed, a directive is called for; whereas,
more developed followers can be supported or delegated
to. A central challenge of this approach lies in the ability
PART FOUR PROVISION OF PUBLIC HEALTH SERViqs
of the leader to correctly assess the developmental le
hi /h ve 1o r another person and to adapt s er style according! y.
Transformational Leadership
A more popular, recent theory of leadership practi· .
transformational lea de rs h1. p, wh 1′ c h .ts contrasted wce· ihs
transactional leadership. As described by Burns :J.1, t It . . ‘ ransformational
leadership taps the motives of followers
establishes an interactt.o n be tween Ie a de rs and followaenrds
toward achieveme.n t of .a common goal. In contrast , tr~” nsactional
leadership rehes on the exchange of some ty
of contingent reward from the leader in order to elicitpc
behavior on the part of t_h e 1c 0I I ower:’ lo Tr ~nsformationaal
leadership is seen as evoking a more endunng level of motivation
and a level of performance beyond expectations
Kouzes and Posner36 articulated a set of five fund~mental
practices which p~ovide strategies for practicing
transformational leadership:
► Model the Way
► Inspire a Shared Vision
► Challenge the Process
► Enable Others to Act
► Encourage the Heart
This practice-oriented approach emphasizes that certain
behaviors can lead to better organizational outcomes
and can be learned by the developing leader.
Servant Leadership
Robert Greenleaf in his classic book, Servant Leadership,37
articulated a view of leadership that has resonated for
many:
Servant leadership begins with the natural feeling
that one wants to serve, to serve first … . The
best test is: do those served grow as persons and
will the least privileged in society benefit. 37
Servant leadership behaviors can then be described as
including listening, showing empathy and awareness,
committing to the growth of others, and building com·
munity. 38 Within the context of public health practice,
the servant leadership philosophy has had particular
resonance as a foundation for various approaches to
the development of public health leaders.
Leadership Development
in Public Health
As theories of leadership evolved and an emphasis on developing
leaders increased, organized programs were created
to develop public health leaders beginning in 1990,
The National Public Health Leadership Institute
Following the IOM report on The Future of Public
Health, 3 the CDC, under the leadership of Director
j
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
or. William Roper, c~n~mitted to an extensive effort
to strengthen the pub~ic mfrastructure in 1990. Within
this conte~’t, leadership de~elopment_was identified as
top priority and the National Pubhc Health Leader-
31 •p Institute (PHLI) was formed in 1991. The mission
s1f1 the PHLI was to provi’ d e top pub h. e health leaders 0 ‘th a high-quality development opportunity in which
M .
they were exposed to new perspectives related to the
ractice of leadership within the public health system.
i’he pHLI program was initially designed and managed
by a team of California public health leaders; the proaram
was later managed out of the University of North
0 Carolina.
Over the 20 years of its existence (1991-2011),
the Public Health Leadership Institute included nearly
1,000 scholars in top public health leadership positions,
including a former U.S. Surgeon General, top
CDC and other federal health agency leaders, numerous
state and local health directors, the National Association
of County and City Health Officials (NACCHO)
and Association of State and Territorial Health Officials
(ASTHO) presidents, the current Food and Drug Administration
commissioner, the CEO of CARE, a senior
vice president of a major health foundation, presidents
and executive directors of the American Public Health
Association, Association of Schools of Public Health,
Public Health Foundation, Association of Public Health
Laboratories, deans and professors in schools of public
health, and leaders in many other major health
organizations. 39
An evaluation40,41 of the impact of the PHLI prooram
revealed that 81 percent of PHLI graduates de:
eloped a better understanding of leadership principles
and practices; 73 percent developed ne~ o~ better
leadership skills and behaviors, such as skills m leading
collaborations and managing teams; 82 percent developed
an enhanced awareness of their own personal
leadership behaviors through the use o~ 360 de~re~
assessment, team interaction, and executive coachi?g,
55 percent developed a professional knowle~ge-shar~ng
network focusing on public health leadership practice,
which continued for many years after gradu~t.wn; and
19 percent obtained new or higher level positions as a
result of PHLI participation. PHLI grad_u~tes also led
the creation of new policies and laws gmdmg the practice
of public health such as increasing cigarette taxes,
developing a state trauma registry system, and passage
of a smoke-free workplace act. Finally, gra_duates
increased funding for public health programs mcludi.
n g legislation providing $ 1. 9 mi·1 1·i on for loca.l pu.b –
11.c health departments and an ·m creas e in funding for
school nurses. was the
Another benefit of the PHLI prof~ H alth
creation of an alumni network, the u hic e h
Le adership Society (PHLS), w hi. c h broug t toget er
321
PHLI alumni and alumni of other similar prog~am~ to
enhance lifelong learning. An important contnbutwn
of the PHLS was the creation of a Public Health Code
of Ethics,42 which is discussed in greater detail in
Chapter 5.
The National Public Health Leadership
Development Network
In 1994 the National Public Health Leadership Network
(le’d by the Saint Louis University College for
Public Health and Social Justice) was formed to share
information and to develop collaboration across the
growing number of state, regional, and national public
health leadership institutes. The network of leade_rship
institutes ultimately expanded through academ~c
and practice collaboration among schools of pubhc
health and state public health departmen~s, ~esulting
in the establishment of 1~ state~ba~ed mst1tutes,
10 regional institutes, 6 national mst1tutes, and 3
international institutes. As a result, 4 7 states plus the
District of Columbia and Puerto Rico had access to
a state, regional, or national public health leadershi_P
program. These programs graduated over 6,000 pubbc
health practitioners from across the world. A full report
on these public health leadership programs can be accessed
through http://www.heartlandcenters.slu.edu.
Furthermore, the network created a competency
set which guided the design and development of public
health leadership institutes for over a decade. -i-3
The National Leadership Academy
for the Public’s Health
The National Leadership Academy for the Public’s
Health (NLAPH) began in 2011 to provide training to
four-person multisector teams from across the country
to advance their leadership skills and to achieve health
equity in their communities. The program, managed by
the Public Health Institute in Oakland, California, uses
an experiential learning process that includes webinars,
a multiday retreat, coaching, peer networking, and an
applied population health project.
In its first year, NLAPH was successful in advancing
participants’ leadership skills, strengthening team functioning,
increasing intersectoral collaboration, and helping
teams make progress on their community health
improvement project. Through 2014, 69 teams from 33
states along with two national teams have participated
in the NLAPH pmgram.
Schools of Public Health and Academic
Public Health Programs
Some schools of public health and academic public
health programs have included courses in the curriculum
related to leadership theory and practice. Often ,
I
322
graduate public health students may have access to
leadership development experiences through business
schools within their own university. Some schools (e.g.,
University of North Carolina at Chapel Hill, University
of Illinois at Chicago, and Harvard) have developed
doctoral programs in public health leading to DrPH
degrees that focus on leadership practice and provide
opportunities to develop leadership skills as part of a
fom1al degree program.
In 2009, the Association of Schools of Public
Health developed a set of competencies for DrPH
programs which included specific leadership competencies
to develop the ability to create and communicate
a shared vision for a positive future; inspire trust
and motivate others; and use evidence-based strategies
to enhance essential public health services. (More information
can be found at http://www.aspph.org by
searching “DrPH Model.”) Graduates of such DrPH
programs are expected to acquire the following leadership
skills:
► Communicate an organization’s mission, shared
vision, and values to stakeholders.
► Develop teams for implementing health initiatives.
► Collaborate with diverse groups.
► Influence others to achieve high standards of
performance and accountability.
► Guide organizational decision making and planning
based on internal and external environmental
research.
► Prepare professional plans incorporating lifelong
learning, mentoring, and continued career progression
strategies.
► Create a shared vision.
► Develop capacity-building strategies at the individual,
organizational, and community level.
> Demonstrate a commitment to personal and
professional values.
These competencies now provide a basis for curriculum
development and course creation in schools of public
health and academic public health programs.
Lea~ership Development Programs Sponsored by
National Public Health Organizations
PRovisioN OF PUBLIC HEALTH SERVicl:’. .. l· PART FOUR Q
. h lth directors in a mentoring relationshi’
with new ea d J h d p.
d
. f m the Robert Woo o nson an de Beau
Fun mg ro · l ·
mont Fo un d a ti·ons has been essentla to support the se
programs.
Leadership Development Needs at Stages
of Career Development
As leaders develop, they may evolve through a series
of stages in which devel?pmental needs differ.44 The
emerging leader (sometimes refe~red ~o as a “rising
star”) needs to be identifie? an~ assisted m developing a
personal awareness of their umque talents and abilities.
Further these emerging leaders benefit from exposure
to lead~rship concepts and theories ~as noted above)
and involvement in a formal mentormg relationship.
Emerging leaders should seek out a mentor, rather than
hoping one will come along.
At a later stage, often when a young leader enters a
full-time job situation, needs evolve as she/he enters the
stage of the “early leader.” In this stage, technical skills
are often central in public health occupations (e.g., epidemiology);
however, leadership development must
also advance skills in adaptive change. At this stage, formal
360 degree assessments are useful along with participation
in formal leadership development programs
of the type noted above. Peer networks are also of great
value as ways to share lessons learned and promote lifelong
learning.
As leaders progress to becoming established leaders,
they will continue to benefit from activities noted
at earlier developmental stages and should take note
of the need for ongoing peer-to-peer interaction with a
struc~red approach to formal executive coaching. Often,
established leaders fail to commit to leadership develop·
~~°:t as the? _bec~me saddled with increasing responsi·
bihties. Pa~c1pat10n in some type of formal development
program swted to their needs can offset the tendency to
procr~stinate with regard to ongoing leadership learning.
Fmally, as leaders enter the emeritus stage of their ca·
reers, they may be uniquely qualified to serve as coaches
and m_ent?r~ to those at early career stages. In this way,
these mdividuals may pass on the wisdom of experi·
ence tha.t goes b eyon d fo rmal courses or programs ·in
leadership.
Both ASTHO (http://www.astho.org) and NACCHO
(~ttp://www.naccho.org) have sponsored programs designed
to enhance leadership skills in directors of state
or local health departments. ASTHO has also created
a leadership development experience designed for senior
deputies. Each of these programs relies on a competency-
based format and a cohort model in which
peer learning and network development is enhanced.
The NACCHO program-the “Survive and Thrive
Program”-pairs experienced local health directors
PROFILES IN PUBLIC HEALTH
LEADERSHIP
Many of the princi 1 exemplified d .
1
. P es and practices noted above arc
Two example:
1
(f;:~he work of public health lea~ersd
here) are useful . many hundreds not describe
practice of publicm h p roviding 1 f the 1 h concrete examp es o .
Exhibit 18-1. eat leadership, as shown beloW 111
CHAPTER 18 THE PUBLIC HEALTH WORKFORCE
tXlllBIT 18-1 Leadership Profiles
f c•j=• § liii) # ;l =!M: ~
As Director of the Massachusetts Commission of Public
Health, John Auerbach led efforts to capture and codify
the role of public health in the Massachusetts Health Reform
effort that has served as a national model for health
system change. In an article titled: “Lessons From the
Front Line: The Massachusetts Experience of the Role
of Public Health in Health Care Reform,” 45 he stated five
key principles that enabled public health contributions to
landmark health policy change:
1. Get a Seat at the Table
2. Take an Open Minded and Critical Look at What Public
Health Does Now
As Director of the Kane County (Illinois) Health
Department, Paul Kuehnert was faced with a daunting
challenge during the Great Recession of 2008. Budget
cuts prompted an in-depth reassessment of the role
of the public health agency that ultimately led to the
transfer of personal health services out of the health
agency into three federally qualified health centers and
SUMMARY
The public health workforce comprises a diverse group
of health professionals who are uniquely varied in terms
of the education, skills, and experience they bring to the
job, although all share a common awareness of and commitment
to improving health through a population fo~s.
Over the last decade the public health workforce, unhke
?ther health professions, has grown smaller while also
increasing in occupational diversity to encompass n_ew
fields such as health informatics, public health genetics,
~nd emergency preparedness. The opportunities for public
health training and education have never been greater
as the number of programs and schools of publ~c health
have rapidly expanded along with more o~tions for
continuing education. The result is an increasmgly p~ofessionalized
public health workforce that has been further
~trengthened by enhancements to co~pe~ency-basecl
t~ainings, worker certification, and accred1tatJOn °_f pu~hc
health agencies. Despite these advanc~s, too httle 18
known about the number and type of pubhc healt~ workers
and the reasons they enter and leave ~he workfo~ce. ,
. A key concept related to workfare~ is that of lea~ership,
defined as the “process of persuaswn or example by
Wh1· ch an m. d1. v1. dual i. nfluences a gr oup to act tow. ard. a
cornrnon goal.” Leadership is essential to the reahzat10n
323
3. Defend the Traditional Public Health Approach When
Called For
4. Keep on the Lookout for Opportunities
5. Envision a Better Model and Take Steps to Make It
Real
These principles, which were instrumental in leading
the Massachusetts Health Reform effort, reflect the
leadership attributes described in this section and are
broadly applicable to other public health challenges and
opportunities.
a reduction in the agency workforce by 50 percent.46
This case study exemplifies the practice of front line
leadership within a public health agency (in addressing
major organizational changes) as well as leadership outside
the agency (to navigate major political challenges
related to accomplishing unprecedented organizational
change).
of a shared vision, and a number of theories have been
developed regarding the skills required for effective leadership,
although “servant leadership” is an especially
compelling model. Outstanding leadership for the public
health workforce will be needed to successfully address
the challenges and opportunities to improve and
protect the public’s health in the twenty-first century.
REVIEW QUESTIONS
1. What are some of the professions that comprise
the public health workforce and what do they share
in common’?
2. What are some of the key trends in public health
worker professionalization ‘?
3. What are competencies and why are they valuable’?
What are some of the public health professions
which have developed profession-specific
competencies’?
4 . How does the practice of leadership differ from the
practice of management’?
5. What are the key feahires of servant leadership’?
6. What do “early leaders” need to enhance their own
leadership skill development’?

How do free cash flows available for debt and equity stakeholders differ from free cash flows available for common equity shareholders?

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Explain “free” cash flows. Describe which types of cash flows are free and which are not. How do free cash flows available for debt and equity stakeholders differ from free cash flows available for common equity shareholders?
Suppose you are valuing a healthy, growing, profitable firm and you project that the firm will generate negative free cash flows for equity shareholders in each of the next five years. Can you use a free-cash-flows-based valuation approach when cash flows are negative? If so, explain how a free-cash-flows approach can produce positive valuations of firms when they are expected to generate negative free cash flows over the next five years.