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The COVID-19 pandemic led to heightened anxiety, distress, and burnout among healthcare workers and faculty in academic medicine. Penn Medicine launched Coping First Aid (CFA) in March 2020 in response to the pandemic. Informed by Psychological First Aid principles and therapeutic micro skills, CFA was designed as a tele-mental healthcare service for health system employees and their families delivered by trained lay volunteer coaches under the supervision of licensed mental health clinicians. We present an overview of the model, feasibility and utilization data, and preliminary implementation and effectiveness outcomes based on cross sectional coach (n = 22) and client (n = 57) self-report surveys with a subset of program users in the first year. A total of 44 individuals completed training and were certified to coach. Over the first 24 months of the program, 513 sessions occurred with 273 clients (119 sessions were no-shows or canceled). Follow-up appointments were recommended in 52.6% (n = 270) of sessions and 21.2% (n = 109) of clients were referred for professional mental health care. Client survey respondents reported CFA was helpful; 60% were very or extremely satisfied, and 74% indicated they would recommend the program. Our preliminary findings suggest that CFA was feasible to implement and most clients found the service beneficial. CFA provides a model for rapidly developing and scaling mental health supports during and beyond the pandemic.

The hospital workforce is experiencing overwork and burnout in response to COVID-19. It is imperative to identify those experiencing mental duress and determine protective factors to promote mental wellness and workforce retention. Our research aim was to identify the mental wellness and professional quality of life among hospital staff working during a global health pandemic, and to determine if age or years of experience served as protective factors. We electronically surveyed hospital staff in North Dakota during Summer 2021. Participants reported demographic data and completed clinically validated behavioral health screening tools assessing anxiety, depression, perceived stress, and work-related quality of life. The survey was administered to all 47 hospitals in North Dakota and received 771 complete responses. All hospital staff ages 18 and older were invited to participate. Age and years of experience were collected categorically in line with research on the topic. Years of experience had a significant influence (p < 0.05) on compassion satisfaction, burnout, and perceived stress. Compassion satisfaction was lowest for those who had worked 5-10 years, and then began to increase incrementally every 10 years thereafter. Hospital staff with 21-30 years of experience reported the highest mean score for both perceived stress and depression. Age had a significant influence (p < 0.05) on scores for anxiety, depression, compassion satisfaction, burnout, secondary traumatic stress, and perceived stress. Those closest to retirement (the oldest and those with the greatest years of experience) reported higher compassion satisfaction, while the youngest cohorts reported experiencing greater stress and burnout and may subsequently leave the profession. This may impact access to, and quality of, care. This study demonstrates the need to implement interventions with a focus on defending healthcare workers from the psychological effects of their caring profession.

INTRODUCTION: Clinicians that care for hospitalised patients face unprecedented work conditions with exposure to highly infectious disease, exceedingly high patient numbers, and unpredictable work demands, all of which have resulted in increases in stress and burnout. Preliminary studies suggest that increasing workloads negatively affect inpatient clinician well-being and may negatively affect job performance; yet high workloads may be prioritised secondary to financial drivers or from workforce shortages. Despite this, the correlation between workload and these negative outcomes has not been fully quantified. Additionally, there are no clear measures for inpatient clinician workload and no standards to define ideal workloads. Using the protocol described here, we will perform a scoping review of the literature to generate a comprehensive understanding of how clinician workload of medical patients is currently defined, measured in clinical settings and its impact on the workforce, patients and institutional outcomes. METHODS AND ANALYSIS: We will follow the methodology outlined by Joanna Briggs Institute and Arksey and O'Malley to conduct a comprehensive search of major electronic databases including Ovid Medline (PubMed), Embase (Embase.com), PsycINFO, ProQuest Dissertations and Google Scholar. All relevant published peer-reviewed and dissertaion grey literature will be included. Data will be extracted using a standardised form to capture key article information. Results will be presented in a descriptive narrative format. ETHICS AND DISSEMINATION: This review does not require ethics approval though all included studies will be screened to ensure appropriate approval. The synthesis of this literature will provide a better understanding of the current state of work for inpatient clinicians, associated outcomes, and will identify gaps in the literature. These findings will be used in conjunction with an expert Delphi panel to identify measures of inpatient clinician workload to then guide the development of a novel workforce mobile application to actively track clinician work. We aim to lay the groundwork for future workforce studies to understand the optimal workloads that drive key outcomes for clinicians, patients and institutions.

Undergraduate medical education (UGME) is the time when doctors' attitudes toward patients and their profession are formed. It is also a period of tremendous stress for future physicians, including high levels of negative stress. Such stress can be maladaptive and may sow the seeds of burnout and long-term dissatisfaction. We believe that the introduction of yoga practice in the 1st year of medical school could ameliorate the negative stressors to which undergraduate medical students are exposed. Although there are some studies in the U.S. and internationally that support the use of Yoga in UGME, they do not provide sufficient data to make a compelling case for widespread implementation of yoga programs in undergraduate curricula. We, therefore, wish to advocate for conducting a trial of the integration of yoga in the undergraduate medical curriculum to combine yoga's ancient health wisdom into the context of modern scientific medicine. Large, prospective, multicenter, and multi-method pilot projects are needed to identify how a program of yoga practice and theory could counter the UGME environment that ultimately produces depression, anxiety, and non-effective coping strategies among medical students. A curriculum for yoga for undergraduate medical students deserves serious consideration and a prominent place among efforts to improve UGME.

INTRODUCTION: In January 2020, a small, private school of nursing in a university in the pacific northwest, established the Initiative for Vital Practice (I4VP). The I4VP’s primary goal was to create a sustainable pathway for increasing vital practice through increasing resiliency and self-care practices. OBJECTIVES: The ensuing pathway’s objectives were to, (1) take previously identified factors related to perceived stress related to workloads, impacts on professional quality of life and psychosocial exposures during the COVID-19 pandemic; and (2) develop and pilot test a wellness intervention (i.e., wellness pods) for faculty and staff to build community and find new ways to enhance well-being through peer support. METHODS: Five focused Wellness Pods were developed on Microsoft Teams platform using the individual channels: (1) stress and mind–body exploration pod; (2) mindfulness in healthcare pod; (3) healing relationship pod; (4) environmental pod; and (5) physical activity pod. Faculty and staff self-selected into a Wellness Pod that interested them. The Wellness Pods met weekly in person over a period of two months. Quantitative and qualitative data was collected via cross-sectional surveys including: four sociodemographic items, one item on current stress level, one write-in item on current stress management at work, two write-in items focused on the cognitive reasoning for participation, the 7-item subjective vitality scale focused individual difference, the 7-item subjective vitality scale focused on the state level, the 10-item perceived stress scale, and one item ranking which wellness pod the individual wanted to participate in. There was one trained facilitator for the overall Wellness Pods operations and communication. RESULTS: The average score on the perceived stress scale was 22.3 (SD = 3.5), indicating moderate levels of perceived stress. The average score on the individual difference vitality score was 26.5 (SD = 7.6), whereas the state level vitality score was 21.4 (SD = 9.98), indicating moderate levels of subjective vitality. Two categories: stress management and wellness pods, were identified through content analysis. CONCLUSIOSN: Through pilot testing, this project demonstrated feasibility for future wellness pods interventions for faculty and staff at schools of nursing. Future research is needed to evaluate the effectiveness of the wellness pods intervention.

BACKGROUND: We proposed that the behaviors that demonstrate compassionate care in the intensive care unit (ICU) can be self-assessed and improved among ICU clinicians. Literature showing views of intensivists about their own compassionate care attitudes is missing. METHODS: This was an observational, prospective, cross-sectional study. We surveyed clinicians who are members of professional societies of intensive care using the modified Schwartz Center Compassionate Care Scale® (SCCCS) about their self-reported compassionate care. A modified SCCCS instrument was disseminated via an email sent to the members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine between March and June 2021. RESULTS: Three hundred twenty-three clinicians completed the survey from a cohort of 1000 members who responded (32.3% response rate). The majority (54%) of respondents were male physicians of 49 (+ − 10 SD) years of age and 19 (12 + − SD) years in practice. The mean SCCCS was 88.5 (out of 100) with an average score of 8 for each question (out of 10), showing a high self-assessed physician rating of their compassionate care in the ICU. There was a positive association with age and years in practice with a higher score, especially for women ages 30–50 years ( P = 0.03). Years in practice was also independently associated with greater compassion scores ( p < 0.001). Lower scores were given to behaviors that reflect understanding perspectives of families and patients and showing caring and sensitivity. In contrast, the top scores were given to behaviors that included conducting family discussions and showing respect. CONCLUSION: Physicians in the ICU self-score high in compassionate care, especially if they are more experienced, female, and older. Self-identified areas that need improvement are the humanistic qualities requiring sensitivity, such as cognitive empathy, which involves perspective-taking, reflective listening, asking open-ended questions, and understanding the patient’s context and worldview. These can be addressed in further clinical and ICU quality improvement initiatives.

LEARNING OBJECTIVE: The goal of this study was to gain a deeper understanding of the personal and professional impact inter-physician conflict has on physicians’ well-being. BACKGROUND: Despite the recognized importance of collaboration and communication, interpersonal conflict amongst healthcare providers in different specialties remains a pervasive issue. Recent work elucidated some of the social conditions and processes that contribute to conflict between EM and IM physicians at the time of admission. However, little is known about the consequences that inter-physician conflict has on providers’ well-being. OBJECTIVE: The goal of this study was to gain a deeper understanding of the personal and professional impact inter-physician conflict has on physicians’ well-being. METHODS: In this study, the authors used constructivist grounded theory to explore themes related to the impact of conflict on individual providers. A purposive sampling approach was used to recruit participants (n=18), which included EM residents and attending physicians as well as IM attending physicians. Two authors conducted hour-long, semi-structured interviews and then coded the transcripts following Charmaz’s three stages of coding. The authors used constant comparative analysis until thematic sufficiency was reached. RESULTS: Participants described personal impacts of inter-physician conflict including emotional and moral distress which occurs in the context of feeling demoralized by colleagues. Conflict further impacted participants professionally by promoting cynicism, job dissatisfaction, and a negative view of their professional identity and professional accomplishments. Finally, participants described the ‘emotional residue’ that remained after conflict, which tended to perpetuate future conflict. CONCLUSIONS: Physicians attributed emotional exhaustion, cynicism, and reduced sense of personal accomplishment to conflicts arising during conversations around admission. In this way, inter-physician conflict is an under-recognized contributor to physician burnout that should be explored to support the well-being of trainees and attending physicians.

Burnout is common among physicians and physician leaders, including residency program directors (PDs). The effects of the COVID-19 pandemic and other stressors in 2020 on PDs is unknown.To measure the prevalence of burnout among internal medicine (IM) residency PDs 6 months into the COVID-19 pandemic.A total of 429 IM PDs, representing 83% of accredited residency programs, were surveyed from August to December 2020. Burnout, using a 2-item screening tool, and self-reported consideration of resigning in 2020, were compared to their annual prevalence since 2012 and tested for possible associations with pandemic stressors and program characteristics.The survey response rate was 61.5% (264 of 429). One-third (33.6%, 87 of 259) of PD respondents met burnout criteria, and 45.1% (110 of 244) reported considering resigning in the past year, which were within the range of preceding years. PDs who reported feeling highly supported by institutional leadership were less likely to meet burnout criteria and to have considered resigning. There were no associations between burnout or consideration of resigning and the amount of clinical time PDs spent in their roles, duration of maximum stress on programs, budget cuts to programs, or geographic region.The prevalence of burnout among PDs in fall 2020 was similar to the prevalence of burnout in pre-pandemic years despite uniquely extreme stressors. PDs' perception of being highly supported by institutional leadership was associated with lower prevalence of burnout and consideration of resigning. Perceived leadership support may be a protective factor against burnout during periods of high stress.

Burnout is defined as a syndrome of emotional exhaustion, depersonalisation and reduced efficacy (Maslach & Jackson, 1981). With burnout becoming increasingly prevalent within policing, this study aimed to expand awareness by exploring the lived experience of this syndrome for serving officers. Utilising a qualitative approach, data was derived from five participants using semi-structured interviews and an interpretative phenomenological methodology (IPA) for analysis. Six categories of themes emerged: perceived causes, personal impact factors, experiencing burnout, changed feelings and behaviour, the underlying meaning, and learning derived from the experience. Participants perceived organisational issues as the main cause of their burnout. They also described other aspects of their experience which contributed towards their long-term suffering. The relationship between burnout and spiritual crisis is discussed, an area rarely explored, but one that provides rich material for those focused on burnout research. It is hoped that this study will help inform work-based solutions and provide a platform for future investigation.

OBJECTIVE: Pandemics negatively impact healthcare workers' (HCW's) mental health and well-being causing additional feelings of anxiety, depression, moral distress and post-traumatic stress. A comprehensive review and evidence synthesis of HCW's mental health and well-being interventions through pandemics reporting mental health outcomes was conducted addressing two questions: (1) What mental health support interventions have been reported in recent pandemics, and have they been effective in improving the mental health and well-being of HCWs? (2) Have any mobile apps been designed and implemented to support HCWs' mental health and well-being during pandemics? DESIGN: A narrative evidence synthesis was conducted using Cochrane criteria for synthesising and presenting findings when systematic review and pooling data for statistical analysis are not suitable due to the heterogeneity of the studies. DATA SOURCES: Evidence summary resources, bibliographic databases, grey literature sources, clinical trial registries and protocol registries were searched. ELIGIBILITY CRITERIA: Subject heading terms and keywords covering three key concepts were searched: SARS-CoV-2 coronavirus (or similar infectious diseases) epidemics, health workforce and mental health support interventions. Searches were limited to English-language items published from 1 January 2000 to 14 June 2022. No publication-type limit was used. DATA EXTRACTION AND SYNTHESIS: Two authors determined eligibility and extracted data from identified manuscripts. Data was synthesised into tables and refined by coauthors. RESULTS: 2694 studies were identified and 27 papers were included. Interventions were directed at individuals and/or organisations and most were COVID-19 focused. Interventions had some positive impacts on HCW's mental health and well-being, but variable study quality, low sample sizes and lack of control conditions were limitations. Two mobile apps were identified with mixed outcomes. CONCLUSION: HCW interventions were rapidly designed and implemented with few comprehensively described or evaluated. Tailored interventions that respond to HCWs' needs using experience co-design for mental health and well-being are required with process and outcome evaluation.

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Stress/Trauma & Resilience).

Managing the uncertainty of clinical practice represents a significant source of stress for clinicians, including medical students transitioning into the clinical workplace. Self-compassion, a strategy to better cope with stress and burnout, may represent a skill that can be leveraged to better prepare learners for the uncertainty inherent in clinical practice. A negative correlation between intolerance of uncertainty and self-compassion has been demonstrated in undergraduate students and in the general population. An examination of this relationship in medical students may help inform future curricular development for addressing burnout in undergraduate medical education. We electronically administered the Intolerance of Uncertainty Short Scale and the Self-Compassion Short Form to 273 third-year medical students from a single institution and analyzed data via regression. A significant negative correlation was found between intolerance of uncertainty and self-compassion (p?

Home healthcare (HHC) nurses are experiencing stress and burnout related to high workloads, isolation on the job, and COVID-19 restrictions. A literature review found numerous interventions effective in reducing nurse burnout through building resiliency and decreasing moral distress. The purpose of this evidence-based project was to improve resiliency and decrease the risk of burnout in HHC nurses through the introduction of a resiliency bundle. The following resiliency bundle interventions were implemented: a) gratitude strategies, b) connecting with co-workers, c) storytelling, and d) resiliency training. Duffy's Quality-Caring Model and Neal's Theory of Home Health Nursing Practice framed the project. The interventions were implemented in an HHC department at a large Midwestern pediatric hospital. Outcomes were measured using a pre- and postimplementation resiliency and burnout survey, which used a Likert scale to allow for quantitative analysis. Fourteen nurses completed the presurvey, 11 completed the postsurvey, and 10 completed both pre- and postsurveys. Results showed no statistically significant change in resiliency or burnout after implementation; however, nurses expressed desire to continue using the bundle pieces, especially the gratitude strategies, connecting with co-workers, and sharing stories. Leadership should take burnout risk in HHC nurses seriously and look for innovative ways to promote resiliency.

Cynicism and burnout are well-described among new medical school graduates. At the new medical school in Washington state, the trend toward placing importance on wellness and creating a culture of healing was present from the outset. To encourage reflective practice, Balint groups were introduced as a method to teach students to think deeply about patient relationships and to address particular curricular objectives, including to demonstrate empathy for healthcare trainees and for patients, and to practice active listening skills in the context of the student Balint groups. The approach presented here will focus on the introduction of Balint groups into the pre-clerkship curriculum as a longitudinal tool to prepare students to use the method with more facility in their clerkships. The presentation at the 2022 American Balint Society Annual Meeting highlighted the introduction of Balint groups to the clinician faculty using the Intensive on the Road format, the introduction of Balint groups to pre-clerkship medical students, and the use of Balint groups in the pre-clerkship curriculum. The operational aspects, including faculty recruitment and retention, as well as student groupings and scheduling, were addressed in the context of the overall theme of monitoring student progress toward open communication about their challenging patient relationships. Programmatic evaluation and current trends were emphasized, along with the anticipated evolution and future directions of the program at our community-based medical school.

OBJECTIVE: Past literature establishes high prevalence of burn-out among intensive care unit (ICU) nurses, and the influence of the COVID-19 pandemic in intensifying burn-out. However, the specific pandemic-related contributors and practical approaches to address burn-out have not been thoroughly explored. To address this gap, this work focuses on investigating the effect of the COVID-19 pandemic on the burn-out experiences of ICU nurses and identifying practical approaches for burn-out mitigation. DESIGN: Semistructured focus group interviews were conducted via convenience sampling and qualitatively analysed to identify burn-out contributors and mitigators. Maslach Burnout Inventory for Medical Personnel (MBI-MP) and Post-traumatic Stress Disorder Checklist (PCL-5) were employed to quantify the prevalence of burn-out of the participants at the time of study. SETTING: Two ICUs designated as COVID-19 ICUs in a large metropolitan tertiary care hospital in the Greater Houston area (Texas, USA). PARTICIPANTS: Twenty registered ICU nurses (10 from each unit). RESULTS: Participants experienced high emotional exhaustion (MBI-MP mean score 32.35, SD 10.66), moderate depersonalisation (M 9.75, SD 7.10) and moderate personal achievement (M 32.05, SD 7.59) during the pandemic. Ten out of the 20 participants exhibited post-traumatic stress disorder symptoms (PCL-5 score >33). Regarding contributors to burn-out in nurses during the pandemic, five thematic levels emerged-personal, patient related, coworker related, organisational and societal-with each factor comprising several subthemes (eg, emotional detachment from patients, constant need to justify motives to patients' family, lack of staffing and resources, and politicisation of COVID-19 and vaccination). Participants revealed several practical interventions to help overcome burn-out, ranging from mental health coverage to educating public on the severity of the pandemic and importance of vaccination. CONCLUSIONS: By identifying the contributors to burn-out in ICU nurses at a systems level, the study findings inform the design and implementation of effective interventions to prevent or mitigate pandemic-related burn-out among nurses.

Resident physician burnout and well-being are increasingly important and salient topics in medical training. Unfortunately, limited research exists regarding the efficacy of various burnout and wellness interventions for resident physicians. Better characterization of the causes of burnout and the components of well-being must necessarily precede implementation and evaluation of interventions. The authors advocate for an increased role for technology in implementing and studying wellness programming for resident physicians. In addition, they describe an intervention under development at the University of Colorado School of Medicine that uses a "Gratitude Journal" smartphone app to support trainee wellness.

Succinct clinical documentation is vital to effective twenty-first-century healthcare. Recent changes in outpatient and inpatient evaluation and management (E/M) guidelines have allowed neurology practices to make changes that reduce the documentation burden and enhance clinical note usability. Despite favorable changes in E/M guidelines, some neurology practices have not moved quickly to change their documentation philosophy. We argue in favor of changes in the design, structure, and implementation of clinical notes that make them shorter yet still information-rich. A move from physician-centric to team documentation can reduce work for physicians. Changing the documentation philosophy from "bigger is better" to "short but sweet" can reduce the documentation burden, streamline the writing and reading of clinical notes, and enhance their utility for medical decision-making, patient education, medical education, and clinical research. We believe that these changes can favorably affect physician well-being without adversely affecting reimbursement.

BACKGROUND: Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey. METHODS: The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics. RESULTS: Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics. CONCLUSION: Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

One way to increase the number of RNs during a global nursing shortage is to recruit those currently not working in health care to rejoin the workforce. The goal of this project was to assess the attitudes and perceived learning needs of nurses who are not working in health care. An online survey was distributed via social media nursing groups to a self-selected sample of nurses not working in health care for the previous 2 years. Although the response rate was low (n = 18), there was interesting discussion on re-entry to nursing practice. Top reasons stated for not re-entering the workforce included burnout/stress, workplace conditions, lack of education/skills, and pay. Pharmacology, skills, and technology were the top three self-identified learning needs of the participants. Limited programs offer education for re-entry to practice. Nurse educators should develop learning materials to meet the needs of this special population. [J Contin Educ Nurs. 2022;53(11):486-490.].

Self-compassion has previously been shown to buffer healthcare professionals from burnout and other forms of mental distress, yet research is lacking on how self-compassion can be developed and integrated into the healthcare work environment. The purpose of this pilot study was to examine the potential precursors, mechanisms, and outcomes of change regarding how healthcare professionals learned self-compassion from attending a 6-week Self-Compassion for Healthcare Communities (SCHC) training. Social connections at work enhanced the trustworthiness of the program and helped participants learn to apply self-compassion within the healthcare context. Participants described practicing self-compassion with ?small daily gifts? and by offering themselves ?grace.? They felt their relationships with patients, coworkers, and family members had improved as a result of the emotion regulation and self-care skills they had gained. Findings suggest the SCHC program may address HCP burnout and empathy fatigue by providing tools that help individuals replenish their energy throughout the day and emotionally separate from others? experiences of pain. Situating programs within healthcare settings may help to reinforce and contextualize self-compassion concepts and facilitate the implementation and benefits of these tools and skills.

Limited research is available on the COVID-19 response experiences of local, state, and federal public health workers in the United States. Although the response to COVID-19 is still presenting challenges to the public health workforce, public health systems must also begin to consider lessons learned that can be applied to future disasters. During July and August 2021, a random sample of participants from a cross-sectional study of the public health workforce was invited to participate in interviews to obtain information on the current state of public health operations, the ongoing response to the COVID-19 crisis, and takeaways for improving future preparedness and response planning. Interviews were transcribed and inductively coded to identify themes. Twenty-four initial interview invitations were sent, and random substitutions were made until thematic saturation was reached when 17 interviews were completed. Four thematic categories were identified, including challenges related to (1) ongoing lack of political support or policy guidance; (2) fluctuations in, and uncertainty about, future funding and associated requirements; (3) job expectations, including remote work and data-sharing capabilities; and (4) the mental health toll of sustained response and related burnout. As the public health response to the COVID-19 pandemic continues in its third year, it is crucial to identify lessons learned that can inform future investment in order to sustain a public health workforce and a public health preparedness and response system that is resilient to future disasters.